Companion animal Critical Care Nutrition P Mandigers Companion animal Critical Care Nutrition V. Biourge DVM PhD Dipl ACVN&ECVCN Health and Nutritional Sciences Director R&D, Royal Canin SAS, Aimargues, France Thanks to D. Elliott and Y. Queau

Research & Development Confidential information - Mars Inc Malnutrition Introduction Human hospitals US: 30-50% of patients are malnourished and 73 are never assessed for nutrition status. Europe: 80 % of surgeons believe that nutrition is an important part of the management of surgical patients, yet only 20% do a nutritional assessment. ASPEN CNW 2012: « Patients are fed too late, do not get enough calories, the sicker the patient the lower the intake of calories. Nutrition gets no respect » Veterinary hospitals 73 % of hospitalized dogs achieved a positive energy balance (Remillard et al 2001). Only 7 % of dogs and cats that could benefit from dietary management, actually do ! Research & Development Confidential information - Mars Inc

Research & Development Confidential information - Mars Inc Malnutrition The WSAVA 5th Vital Assessment Group (V5) 1. Temperature 2. Pulse 3. Respiration 4. Pain assessment 5. Nutritional assessment Research & Development Confidential information - Mars Inc

Research & Development Confidential information - Mars Inc Malnutrition Acute weightloss > 10% No intake for >3 d Research & Development Confidential information - Mars Inc

Conditions associated with malnutition Esophageal dysfunction Facial Trauma Neurotoxin Post-op PDA Prostatic abscess

Clinical consequences of malnutrition Impaired immune function Increased susceptibility to infection Delayed wound healing Decreased strength and vigor Altered gastrointestinal mucosal barrier Bacterial translocation Decreases muscle mass and strength Predictor of morbidity and mortality in humans J of Online Hepatology, 2011

Anorexia Common manifestation of disease Manifestation of pain Particularly the GIT, pancreas, liver Manifestation of pain Side-effect of medications Central alterations in appetite, hunger or satiety Unbalanced body fluids, electrolytes, pH

Candidates for Nutritional Support Patients which… Have a poor body condition score 5-10% weight loss Reduced oral intake for > 3 days

Providing Nutritional Support If the animal is willing to eat feed it. If the gut works, use it! Assisted feeding Warm, wet, odiferous, palatable foods Positive reinforcement Pharmacological stimulants Benzodiazepines Serotonin antagonists Megestrol acetates Androgens Impossible to provide enough calories

Routes of Administration Gastrostomy tubes Nasoesophageal tubes TPN & PPN Jejunostomy tubes Esophagostomy tubes

Nasoesophageal tubes Shorter term support Local anesthesia (Lidocaine) <7 days to several weeks Elizabethan collar Local anesthesia (Lidocaine) Small diameter tubes Liquid diets only Clog easily 5-8 F cats and small dogs 8 F medium to large dogs PVC vs red rubber vs Polyurethane

Esophagostomy and gastrotomy tubes Medium - long term support Well tolerated, easy (eso) to moderately easy (gastro) to place Larger diameter Cats and small dogs 12-20 Fr Medium to large dogs 24 Fr Slurries Requires general anesthesia Indications Any nutritional support Mandibular, maxillary, nasal, and nasopharyngeal disease Inability to prehend or masticate

Jejunostomy tubes Medium term support Liquid “purified” diet Continuous infusion Indications Unable to tolerate gastric feeding Normal distal intestinal and colon function Surgical placement Needle catheter jejunostomy Small bowel pexied to wall Percutaneous endoscopic jejunostomy

Placement complications Splenic laceration Gastric hemorrhage Pneumoperitonium Peritonitis Tube displacement Tube extraction Epiphora Armstrong et al JVIM 1990;4:202-6 Mason et al JAVMA 2000; 216:1096-1099 DeBowes et al JAVMA 1993;202:1963-5 Bright et al AJVR 1988;49:629-33

Stoma Complications Complications Management Pain Tissue swelling Discharge Erythema Abscess formation Ulceration Management Warm antiseptic soaks Daily cleaning Antimicrobial ointment Avoid patient licking Consider post- placement antibiotics

Tube clogging Minimized by Treatment Adequate liquefaction Strain food Flush with water after use Treatment Small syringe (2 mL) Simultaneous massage, flushing and aspiration Instill carbonated drinks, meat tenderizer, pancreatic enzymes

Nutritional management Pathophysiology Diet Energy Protein ARG, GLU, BCAA Fat EFA: n-3/n-6 Fiber Minerals, Vitamins Nutritional plan Metabolic complications Aversion

Pathophysiology Royal Canin Encyclopedia, 2004 Modern nutrition in Health & diseases 2006

Pathophysiology Modern nutrition in Health & diseases 2006

Canine & Feline convalescence diets Energy Dogs & cats Protein: 30-50 % ME Fat: 35-70% ME Carbohydrates: 20-30 % ME Complete and balanced, highly digestible, easy to pass through a tube RER = 70 Kcal/kg0,75

Protein High levels (30-50%ME) Glutamine Branched chain aas (BCAA) Energy substrate To sustain wound recovery To minimize negative nitrogen balance Glutamine Main energy substrate for the gut. Nucleotide synthesis Branched chain aas (BCAA) Leucine, isoleucine, valine To sustain muscle mass Arginine Urea cycle Immune function, wound healing Precursor of NO To avoid when excessive inflammation

Fat Efficient source of energy (30-70%ME) N-3 Fatty acids Low volume Palatibility N-3 Fatty acids EPA-DHA. Anti-inflammatory benefits Resolvins, protectins Γ-linolenic acid Borage oil Anti-inflammatory Dogs 7% Cats 0% PGE3 Tx3 Lt5 Anti-inflammatory Resolvins Protectins

Others Dietary fibers Nucleic acids Minerals Vitamins 15-25 g/1000 kcal Soluble Vs Insoluble Transit – colonic health Nucleic acids DNA, RNA precursors Immunity, dividing cells Minerals Ca, P, K, Na, Cl Fe, Cu, Zn, Mn Vitamins Antioxidants: Vit E, Vit C, Lutein, Taurine Vitamin B12 Vitamin K Cellulose Psyllium

Nutritional management Calculate resting energy requirements RER = 70(BW Kg)0.75 Daily volume to feed = RER/energy density Initially provide ¼ to ½ daily energy Increase over several days Weigh daily and adjust intake as needed in order to maintain or gain weight

Nutritional Management Warm food to room temperature Give drugs prior to food Except phosphate binders which must be mixed with food Administer food over 10-15 minutes Salivation and discomfort suggests nausea Slow the rate of feeding and/or reduce the volume Flush tube with warm water following use

Nutritional management Complications Tube clogging Vomiting/diarrhea Metoclopramide 2.2 mg/kg 15 min before meal Maropitant citrate Aspiration/pneumonia Metabolic abnormalities Hypokalemia Hyperglycemia Hypophosphatemia

Nutritional management Food aversion Diet & GI upset Food aversion Do not expose to all the diets before tube-feeding Do not give food to eat for the first 10 d Appetite stimulants not found useful

Conclusions Malnutrition is common in hospitalized patients 5 Vs Most critical patients are catabolic Enteral nutrition is preferred Nutritional support will facilitate recovery ↑protein ↑fat ↓carbohydrates GLN, EPA/DHA, Nucleotic acid AntiOx complex Begin within 24 hours or immediately following stabilization Monitor regularly to optimize patient needs

If you want to know more … www.ivis.org Obrigado …

Questions? % fat ?