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Enteral Critical Care Nutrition

•. M. M. M. M. I. ARK. ORRIS. NSTITUTE. Enteral Critical Care Nutrition. Enteral Critical Care Nutrition. The need to feed The enteral route Diets/diet management. The Need To Feed. Histortic perspectives Clinical/metabolic perspectives Patient selection. Historic Perspectives.

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Enteral Critical Care Nutrition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  19. Appetite Stimulation • Diazepam1 - 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 ® ®

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

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

  22. Nutrient Requirements • Water • Energy • Protein • Minerals & vitamins

  23. Nutrient Requirements • Resting energy requirement (RER) • 1000 kcal/m2 • 70 (Wt kg0.75) • 30 (Wt kg) + 70* Dogs & Cats * > 2 kg and < 45 kg

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

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

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

  27. Nutrient Requirements • Protein quantity • At least maintenance amounts 4g protein/100 kcal16% of energy as protein Dogs 6g protein/100 kcal24% of energy as protein Cats

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

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

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

  37. 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. Diet Selection • Diameter of tube • Location of tube • Functional status of GI tract

  39. Feeding Protocols • Bolus - maximal amount/feeding30-45 ml/kg • Bolus - minimal feeding frequency3-5/day • Gradual transition1/3 day 1, 2/3 day 2, full feeding day 3

  40. Cost Analysis Daily cost ($) Diet10 kg septic dog Canine/Feline a/d 2.77 Clinicare Canine 10.62 Levity 5.12 Peptamen 13.82

  41. Due to Due to Due to 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

  42. 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

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