Nutritional Support of the Critically Ill Small Animal Patient

2024 AAHA Fluid Therapy Guidelines for Dogs and Cats

Fluids are drugs used in veterinary patients capable of producing beneficial therapeutic or inadvertent harmful effects within the body's intravascular, interstitial, and intracellular fluid spaces. The individualized design of a fluid therapy plan requires careful patient assessment and targeted selection of proper fluid types, administration routes, and rates, along with adjustments during therapy tailored specifically as per the individual patient's fluid requirement and therapeutic response. Personalized fluid prescriptions and vigilant patient monitoring help avoid patient morbidity from body fluid deficiencies, fluid excess, and electrolyte derangements and support better patient outcomes. These guidelines provide an overview of fluid dynamics within the fluid spaces of the body, describe various types of fluids and their uses, and outline recommendations for fluid administration for resuscitation, rehydration, and maintenance purposes. The guidelines also outline approaches to fluid therapy for anesthetized patients and reiterate the recommendations of reduced fluid rates in this population of patients. Additionally, the guidelines include practical fluid therapy strategies for patients with various common disorders. The goal of these guidelines is to help veterinary professionals safely and effectively prescribe and administer fluid therapy for canine and feline patients.

High carbohydrate is preferable to high lipid parenteral nutrition in healthy dogs undergoing prolonged sedation

Parenteral nutrition (PN) is commonly used in intensive care units (ICUs) and is associated with earlier hospital outcome. However, there is scarcity of information about the metabolic effects of PN caloric distribution for dogs. Considering the high tolerance of dogs to lipids and, also, that hospitalized animals usually present insulin resistance, PN formulation with high fat instead high glucose can provide metabolic benefits in this specie. This study evaluated two PN protocols, based on high lipid or high carbohydrate in 12 healthy dogs under sedation/ventilation during 24 h. For baseline data, blood samples were collected 24 h before the study beginning. After fasting, the dogs were anesthetized and put under mechanical ventilation without energy support for 12 h to obtain: daily energy expenditure (DEE), respiratory quotient (RQ), oxygen consumption (VO2), carbon dioxide production (VCO2), lactate, glucose, cholesterol, and triglycerides concentrations. After, the dogs were allocated into two groups: lipid-based energy group (LEG) and carbohydrate-based energy group (CEG). Both groups received the PN infusions at a rate of 3 mL/kg/h for 12 h. Blood tests were performed 12, 24, and 48 h after infusion's completion. VO2 increased after PN in LEG, increasing energy expenditure compared to CEG. RQ remained close to 1 in CEG, indicating carbohydrate preferential consumption. Triglycerides increased in both groups after propofol infusion, remaining higher in LEG until the end of the evaluation. Glycaemia increased in CEG compared to baseline. In conclusion, both PN protocols can be used in healthy animals undergoing prolonged sedation protocols. However, high lipid PN had higher VO2 and DEE, and resulted in higher triglycerides concentrations and lower glycaemia indexes than carbohydrate, making high carbohydrate PN preferable to high lipid PN. Therefore, for use in critically ill patients, the data obtained in this study should be extrapolated, taking into consideration the specificity of each case.

Tolerability of naso-esophageal feeding tubes in dogs and cats at home: Retrospective review of 119 cases

BACKGROUND

The use of naso-esophageal feeding tubes (NFT) at home could represent an alternative way to reduce the costs for owners and facilitate enteral feeding until recovery of a spontaneous appetite.

OBJECTIVE

To describe the use of NFT at home in dogs and cats and evaluate the satisfaction of owners and their capacity to handle the device.

ANIMALS

One hundred nineteen client-owned animals (90 cats and 29 dogs) which remained anorexic during hospitalization and were discharged with NFT for at least 24 hours after placement.

METHODS

Medical records were reviewed retrospectively, and owners were contacted by telephone calls. Complications were reported according to their relative severity (minor and major). Owners were asked to report their experience and comfort with NFT management.

RESULTS

Naso-esophageal feeding tubes were kept in place at home for a median of 6 days (range, 1-17) and 62.2% (95% confidence interval [CI]: 53.3-70.7) of animals recovered a spontaneous appetite while wearing NFT, 60% (95% CI: 44.4-75.6) of the remaining animals recovered a spontaneous appetite after removal. Overall complication rate was 65.5% (95% CI: 57.0-74.0), but only 18.5% (95% CI: 11.5-25.5) required a consultation and no life-threatening complication occurred. Owners were satisfied in 94.1% (95% CI: 89.9-98.3) of cases.

CONCLUSION AND CLINICAL IMPORTANCE

Although most animals discharged with NFT at home presented complications, no major adverse effects were reported and NFT were easily handled by owners. This study provides evidence that NFT can be well tolerated at home.

Continuous versus intermittent enteral nutrition in hospitalised dogs and cats using a new scoring system: A prospective clinical study

Nutrition is an important part of the critical care. The goals of this prospective clinical study were to create a scoring system for the assessment of patient nutritional status and to compare continuous and intermittent bolus feeding of enteral nutrition (EN). A total of 38 patients (21 dogs and 17 cats) were divided into Group C (continuous feeding; 23 patients) and Group I (intermittent feeding; 15 patients). The following variables were recorded for each patient in both groups: gastrointestinal (GI) complications, changes in body weight (BW), body condition score (BCS), muscle condition score (MCS), veterinary nutritional status score (VetNSS), length of hospitalisation and outcome. The normality of the data was assessed using the Shapiro-Wilk test. Fisher's exact test, Mann-Whitney, Wilcoxon signed-rank tests, and the t-test were used in statistical analyses. Significant changes were found in VetNSS and BW between the 1st and 5th day in Group C. The VetNSS seems to be useful for monitoring the nutritional status of hospitalised patients. Anorectic dogs and cats can be successfully supported with either continuous or intermittent feeding methods with a similar risk of GI complications and outcomes.

Nutritional Management of Cats and Dogs with Diabetes Mellitus

This article reviews the nutritional assessment and management of diabetic dogs and cats. It discusses how to determine appropriate nutritional goals for individual patients, including comorbid patients with diabetes. Considerations for macronutrient and micronutrient modifications will be reviewed.

2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat

PRACTICAL RELEVANCE

Inappetence may have many origins and, as a presenting sign or observation in the hospitalised patient, is common in feline practice. Nutritional assessment of every patient is encouraged, to identify the need for, and appropriate type of, intervention indicated. The impact of malnutrition may be significant on the feline patient, perpetuating illness, delaying recovery, slowing wound healing and negatively impacting gut health and immunity. Delayed intervention may result in the cat's deterioration; hence prompt control of contributing factors such as the underlying illness, pain, nausea, ileus and stress is vital to optimise voluntary food intake. Management is multimodal, comprising reduction of stress, medications and assisted nutrition in the form of tube feeding or parenteral nutrition. Use of antiemetic, analgesic, prokinetic and appetite stimulant medications may restore appetite, but placement of feeding tubes should not be delayed. Feeding tubes are generally well tolerated and allow provision of food, water and medication with minimal stress, although clinicians must be aware of complications such as stoma site infections and refeeding syndrome.

CLINICAL CHALLENGES

Cats are vulnerable to malnutrition owing to their unique metabolism and specific nutritional requirements. Moreover, their nature as a species means they are susceptible to stress in the hospital environment, which may result in reduced food intake; previous negative experiences may compound the problem. In particular, an inappropriate clinic environment and/or handling may cause or exacerbate inappetence in hospitalised patients, with negative impacts on recovery. Postponing interventions such as feeding tube placement to await improvement, owing to clinician or caregiver apprehension, may hinder recovery and worsen nutritional deficits.

EVIDENCE BASE

The 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat have been created by a panel of experts brought together by the International Society of Feline Medicine (ISFM). Information is based on the available literature, expert opinion and the panel members' experience.

Feline cholangitis/cholangiohepatitis complex - what have we learned?

Cholangitis/cholangiohepatitis complex in cats is commonly encountered in clinical practice worldwide. Diagnosis and management of cats with this complex is difficult because of the ambiguity of clinical signs, diagnostic test results and commonality of comorbid disorders. These impediments can delay disease identification and treatment, which can increase morbidity and mortality. ​In this narrative review, we aimed to provide a thorough review of the unique physioanatomic features of the biliary system as well as clinically relevant updates on cholangitis/cholangiohepatitis complex in cats.

Repurposing medical devices as "button" esophagostomy tubes for extended nutritional support

Background

Esophagostomy tubes (E‐tubes) are widely utilized for extended nutritional support in dogs and cats. Problems associated with their use include the unwieldy excess (10‐20 cm) of external tubing, constant need for neck wraps and necessity for skin sutures, suture tract infection, and tube loss if sutures fail.

Objectives

To evaluate 2 different, low profile (LP) “button” products intended for use in people as enteral (jejunostomy [J] and gastrojejunostomy [G‐J]) feeding tubes for suitability as LP E‐tubes in dogs and cats.

Animals

A young giant breed dog that required extended (>6 months) nutritional and fluid support during recovery from severe neurological illness with protracted adipsia, anorexia, and dysphagia.

Methods

Prospective evaluation of 2 commercially available LP feeding devices after placement of a standard E‐tube. An LP J‐tube and an LP G‐J tube were assessed in consecutive 4‐week trials, for tube retention, patient comfort, stoma health, and functionality.

Results

Both products performed extremely and equally well as LP E‐tubes in this clinical patient, enhancing patient freedom and comfort by eliminating external tubing, skin sutures, and bandaging. The dual port G‐J tube allows medication delivery (eg, sucralfate) to the entire esophagus, but for safety alone (ie, to avoid aspiration), the single port J‐tube appears the best device for client‐owned patients.

Conclusions and Clinical Importance

The LP enteral feeding tubes from the human medical field can be successfully used as LP E‐tubes in dogs and cats, offering superior patient comfort, with no obvious detriment to the patient and main drawback of higher cost.