1. Enteral Critical
Care Nutrition M •
ARK
ORRIS
NSTITUTE I

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

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

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

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

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

7. 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

8. 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 + =

9. 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.

10. Predictive Indicators
Patient Selection
History & exam
Laboratory tests
Predictive Indicators

11. 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)

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

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

14. 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.

15. 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

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

17. 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
Food temperature (ºC) Sohail, Nutr Abst Rev, 1983

18. 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

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

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

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

22. Nutrient Requirements
Water
Energy
Protein
Minerals & vitamins

23. 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

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

25. 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

26. Injury (surgery, trauma) Energy requirement (IER)
Energy Requirements
Infection
Illness (cancer)
Injury (surgery, trauma)
Energy
requirement
(IER)
IER =

27. 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

28. 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)

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

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

31. 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

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

33. 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

34. 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) ÷ =

35. 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) ÷ =

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

37. 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

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

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

40. 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

41. 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

42. 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

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