Enteral Critical Care Nutrition M • ARK ORRIS NSTITUTE I

Diets/diet management Enteral Critical Care Nutrition The need to feed The enteral route Diets/diet management

Histortic perspectives Clinical/metabolic perspectives The Need To Feed Histortic perspectives Clinical/metabolic perspectives Patient selection

Eel skin nasoenteral tube 1990’s $ billion industry Historic Perspectives 1793 John Hunter Eel skin nasoenteral tube 1990’s $ billion industry

Equation for nutritional support: Clinical/Metabolic Perspectives Equation for nutritional support: Food Deficit Disease/Injury Hypermetabolism Accelerated Starvation + =

Endocrine Cytokines Clinical/Metabolic Perspectives Cortisol Catecholamines Insulin: glucagon Thyroxine Growth hormone TNF Prostaglandins Increased metabolic rate

Resting Metabolism (%) Clinical/Metabolic Perspectives Metabolic Rate During Clinical Conditions Major burn Maintenance energy requirement 160 Resting Metabolism (%) Sepsis Trauma, cancer Resting energy requirement 100 Total partial Food deprivation: Days 0 10 20 30 40 50 60

Equation for nutritional support: Clinical/Metabolic Perspectives Equation for nutritional support: Food deficit Disease/injury hypermetabolism Accelerated starvation + = Accelerated starvation Compromised host defenses Compromised wound healing + =

Provides 1/5 patient’s energy requirement Clinical/Metabolic Perspectives 1 liter = 170 kcal Provides 1/5 patient’s energy requirement No protein or micronutrients 5% Dextrose I.V.

Predictive Indicators Patient Selection History & exam Laboratory tests Predictive Indicators

Poor food intake for > 3 days Patient Selection Weight loss of > 10% Poor food intake for > 3 days Increased nutrient demands (Trauma, surgery, infection) Increased nutrient losses (Vomiting, diarrhea, wounds) Laboratory parameters (Albumin, creatine kinase)

Patient selection = common sense When in doubt: feed Feed early

Advantages of enteral nutrition (EN) Appetite stimulation The Enteral Route Advantages of enteral nutrition (EN) Appetite stimulation Forced feeding Tube feeding

The golden rule of critical care nutrition: Advantages of Enteral Nutrition (EN) The golden rule of critical care nutrition: When the gut works, use it.

EN feeds intestine as well as patient Advantages of Enteral Nutrition (EN) EN feeds intestine as well as patient Decreased bacterial translocation Glutamine - enterocyte nutrient Enhanced enteric immunity

Highly palatable, balanced diets Assure optimal olfaction Appetite Stimulation Highly palatable, balanced diets Assure optimal olfaction Warm food to body temperature

Effect of Food Temp on Preference in Cats Appetite Stimulation Effect of Food Temp on Preference in Cats 80 60 40 20 80 60 40 20 Food preference (%) Food preference (%) Food temperature (ºC) Sohail, Nutr Abst Rev, 1983 10 20 30 40 50 Food temperature (ºC) Sohail, Nutr Abst Rev, 1983 10 20 30 40 50

Highly palatable, balanced diets Assure optimal olfaction Appetite Stimulation Highly palatable, balanced diets Assure optimal olfaction Warm food to body temperature Avoid K, Zn, & B vitamin def. Drugs

Diazepam 1 - 2 mg PO cat 0.1 - 0.2 mg/kg PO dog 0.05 - 0.1 mg/kg IV Appetite Stimulation Diazepam 1 - 2 mg PO cat 0.1 - 0.2 mg/kg PO dog 0.05 - 0.1 mg/kg IV Oxazepam (Serax ) 0.3 - 0.4 mg/kg PO dog 2.5 mg (1/4 tab) PO cat Fluazepam (Dalmane ) 0.1 - 0.5 mg/kg PO dog 0.1 - 0.2 mg/kg PO cat ® ®

Orogastric Nasoesophageal Pharyngostomy Esophagostomy Gastrostomy Tube Feeding Orogastric Nasoesophageal Pharyngostomy Esophagostomy Gastrostomy Enterostomy Indwelling

Nutrient requirements Diet selection Feeding protocols Cost analysis Diets/Diet Management Nutrient requirements Diet selection Feeding protocols Cost analysis

Nutrient Requirements Water Energy Protein Minerals & vitamins

Resting energy requirement (RER) Nutrient Requirements Resting energy requirement (RER) 1000 kcal/m2 70 (Wt kg 0.75) 30 (Wt kg) + 70* Dogs & Cats * > 2 kg and < 45 kg

Maintenance energy requirement (MER) Nutrient Requirements Maintenance energy requirement (MER) MER dogs = 1.6 RER MER cats = 1.2 RER

Resting Metabolism (%) Clinical/Metabolic Perspectives Metabolic Rate During Clinical Conditions Major burn Maintenance energy requirement 160 Resting Metabolism (%) Sepsis Trauma, cancer Resting energy requirement 100 Total partial Food deprivation: Days 0 10 20 30 40 50 60

Injury (surgery, trauma) Energy requirement (IER) Energy Requirements Infection Illness (cancer) Injury (surgery, trauma) Energy requirement (IER) IER = 1.0 - 1.25

Protein quantity Dogs Cats At least maintenance amounts Nutrient Requirements Protein quantity At least maintenance amounts 4g protein/100 kcal 16% of energy as protein Dogs 6g protein/100 kcal 24% of energy as protein Cats

Protein quality Digestibility/availability Amino acid profile Nutrient Requirements Protein quality Digestibility/availability Amino acid profile EAA’s (extra arginine, branched chains) Glutamine (conditionally essential) Taurine (cat)

Minerals and vitamins Maintenance/growth levels Nutrient Requirements Minerals and vitamins Maintenance/growth levels Micronutrient def. common

Nutrient Requirements Concept: When a diet is properly formulated, the nutrients are balanced to the energy density of the diet

Nutrient Requirements Thus, when such a diet is fed to meet a patient’s energy requirements, the requirements for the non-energy nutrients are automatically met

÷ = Patient’s Diet Daily Daily energy Energy Diet Clinical/Metabolic Perspectives Patient’s Diet Daily Daily energy Energy Diet Requirement Density Dosage ÷ =

Example 10 kg dog with septic bile peritonitis Nutrient Requirements Example 10 kg dog with septic bile peritonitis RER = 30 Wt kg+ 70 = 30(10) + 70 = 370 kcal IER = 1.25 RER = 1.25(370) = 463 kcal/day

Canned pet food = 675 kcal/can Nutrient Requirements Canned pet food = 675 kcal/can Patient’s Diet Daily Daily energy Energy Diet Requirement Density Dosage (463 kcal/day) (675 kcal/can) (2/3 can/day) ÷ =

Liquid diet = 1 kcal/ml ÷ = Patient’s Diet Daily Nutrient Requirements Liquid diet = 1 kcal/ml Patient’s Diet Daily Daily energy Energy Diet Requirement Density Dosage (463 kcal) (1 kcal/ml) (463 ml/day) ÷ =

Defined formula diets Meal replacement (polymeric, intact protein) Diet Selection Defined formula diets Meal replacement (polymeric, intact protein) Elemental (monomeric)

Blenderized diets - follow recipe Diet Selection Blenderized diets - follow recipe 15 oz. Can (recuperative type) cat food 1½ cup water Blend - high speed 1 minute Strain through kitchen strainer > 8 Fr

Functional status of GI tract Diet Selection Diameter of tube Location of tube Functional status of GI tract

Bolus - maximal amount/feeding 30-45 ml/kg Feeding Protocols Bolus - maximal amount/feeding 30-45 ml/kg Bolus - minimal feeding frequency 3-5/day Gradual transition 1/3 day 1, 2/3 day 2, full feeding day 3

Daily cost ($) Diet 10 kg septic dog Canine/Feline a/d 2.77 Cost Analysis Daily cost ($) Diet 10 kg septic dog Canine/Feline a/d 2.77 Clinicare Canine 10.62 Levity 5.12 Peptamen 13.82

Diet- & feeding-related complications: Feeding Protocols Diet- & feeding-related complications: Vomiting, Overly-aggressive administration, cramping, excessive diet osmolality, diarrhea improper diet composition, GI alterations Airway Regurgitation, aspiration not checking for proper tube placement Plugged Inadequate tube maintenance tube Due to Due to Due to

Critically ill animals are in a hypermetabolic state Summary Critically ill animals are in a hypermetabolic state When it comes to nutritional support, the sooner the better When the gut works, use it Use RER rather than MER for calculation of energy needs in the critically ill patient

Summary Veterinary products are more suitable than human preparations for use in critically ill patients