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COM PA N I O N A N I M A L PR ACT I CE

Body condition can be assessed by palpating an animals ribs

Nutritional support for the hospitalised small animal patient

MARGE CHANDLER

UNLIKE healthy animals, which can metabolise fat even when they are not eating, sick or traumatised patients catabolise lean body mass when they have insufficient calories, thus compromising cardiac, respiratory and immune functions. The need for nutritional support should therefore be recognised and initiated early during the course of hospitalisation, with the number of calories required calculated carefully to prevent under- or overfeeding. This article discusses the options available for the nutritional support of hospitalised small animal patients.

Marge Chandler qualified as a doctor of veterinary medicine from Colorado State University in 1984. She is currently a senior lecturer in internal medicine and clinical nutrition at the Royal (Dick) School of Veterinary Studies, Edinburgh. She holds a masters degree in animal nutrition and is a diplomate of the American College of Veterinary Internal Medicine, the European College of Veterinary Internal Medicine (Companion Animal) and the American College of Veterinary Nutrition, and a member of the Australian College of Veterinary Scientists.

MALNUTRITION

Malnutrition is a general term for a medical condition caused by an improper or insufficient diet. While it most often refers to undernutrition resulting from inadequate consumption, poor absorption or excessive loss of nutrients, it can also relate to overnutrition due to excess consumption of food. Malnutrition, particularly undernutrition, compromises the immune system, slows healing, contributes to increased intestinal permeability, and increases morbidity and mortality. In human hospitals, it is estimated that 30 to 50 per cent of patients suffer from malnutrition at admission, and a survey by the University of Edinburgh showed a similar rate in canine and feline patients admitted to the Internal Medicine Service. While healthy animals primarily metabolise fat when they are not eating, animals that are sick or traumatised catabolise protein from their lean body mass (including

skeletal muscles, cardiac muscle and visceral proteins) when they have insufficient calories. The lean body mass. Catabolism of lean body mass provides the liver with gluconeogenic precursors for glucose production and amino acids for the acute phase protein response. This shift to utilisation of protein results in a negative nitrogen balance or net protein loss. All of the protein in the body is functional, so the breakdown or catabolism of endogenous protein compromises many systems, including cardiac, respiratory and immune functions. Thus, sick or traumatised animals may retain body fat while losing lean tissue.

PATIENT ASSESSMENT

WHO TO FEED
A dietary history should be taken for all hospitalised patients and should include what the animal has been fed, how much and when. Any patient that has been anorectic for three to five days or more is a candidate for nutritional support. In human hospitals with a nutrition service, supplemental nutrition is provided to patients who have not been receiving at least two-thirds of their estimated requirements. A human or small animal patient that has unintentional weight loss of over 10 per cent of its bodyweight acutely or more than 20 per cent over a longer period should be given nutritional support. The assessment of body condition includes thorough palpation and visual assessment. Using a body condition scoring (BCS) system with either a 1 to 5 or a 1 to 9 scale (in which higher numbers relate to fatter animals) adds some objectivity to the assessment. Pictorial sheets depicting such systems are helpful in teaching clients about ideal body condition (see box on page 443).
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Nutritional goals
The main goals of nutritional support are to prevent or slow down the use of endogenous protein for gluconeogenesis (sometimes termed proteinsparing) and to try to maintain a patients weight. In thin animals, weight gain may seem preferable, but in an animal that is in a catabolic metabolic state due to stress this may not be a realistic goal during acute illness. Overfeeding can also be detrimental due to the increased metabolic rate, heart rate, production of carbon dioxide, increased risk of hepatic lipidosis, and the potential risk of refeeding syndrome (see box at the top of page 447).

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Body condition scoring systems in cats and dogs

EMACIATED. Ribs visible on shorthair cats. No palpable fat. Severe abdominal tuck. Lumbar vertebrae and wing ilia easily palpated

EMACIATED. Ribs, lumbar vertebrae, pelvic bones and all bony prominences evident from a distance. No discernible body fat. Obvious loss of muscle mass

VERY THIN. Shared characteristics of body condition scores 1 and 3

VERY THIN. Ribs, lumbar vertebrae and pelvic bones easily visible. No palpable fat. Some evidence of other bony prominence. Minimal loss of muscle mass

THIN. Ribs easily palpable with minimal fat covering. Lumbar vertebrae obvious. Obvious waist behind the ribs. Minimal fat

THIN. Ribs easily palpated and may be visible with no palpable fat. Tops of lumbar vertebrae visible. Pelvic bones becoming prominent. Obvious waist and abdominal tuck

UNDERWEIGHT. Shared characteristics of body condition scores 3 and 5

UNDERWEIGHT. Ribs easily palpable with minimal fat covering. Waist easily noted when viewed from above. Abdomen tucked up when viewed from the side

IDEAL. Well proportioned. Observe waist behind the ribs. Ribs palpable with slight fat covering. Abdominal fat pad minimal

IDEAL. Ribs palpable without excess fat covering. Waist observed behind the ribs when viewed from above. Abdomen tucked up when viewed from the side

OVERWEIGHT. Shared characteristics of body condition scores 5 and 7

OVERWEIGHT. Ribs palpable with slight excess fat covering. Waist discernible when viewed from above, but not prominent. Abdominal tuck apparent

HEAVY. Ribs not easily palpated with moderate fat covering. Waist poorly discernible. Obvious rounding of abdomen. Moderate abdominal fat pad

HEAVY. Ribs palpable with difficulty due to heavy fat cover. Noticeable fat deposits over lumbar area and base of the tail. Waist absent or barely visible. Abdominal tuck may be absent

OBESE. Shared characteristics of body condition scores 7 and 9

OBESE. Ribs not palpable under very heavy fat cover, or palpable only with significant pressure. Heavy fat deposits over lumbar area and base of the tail. Waist absent. No abdominal tuck. Obvious abdominal distension may be present

GROSSLY OBESE. Ribs not palpable under heavy fat cover. Heavy fat deposits over lumbar area, face and limbs. Distension of abdomen with no waist. Extensive abdominal fat deposits

GROSSLY OBESE. Massive fat deposits over thorax, spine and base of the tail. Waist and abdominal tuck absent. Fat deposits on the neck and limbs. Obvious abdominal distension

Reproduced, with permission, from Nestl Purina. From Laflamme (1993), Laflamme and others (1994a, b)

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BCS systems do not take into account muscle wasting, and many ill animals show loss of muscle that is disproportionate to the loss of fat due to the metabolic changes of stressed starvation. Bilateral loss of muscle mass over the temporal and epaxial muscles can indicate muscle wasting. A muscle mass scoring system has also been developed, based on palpation of skeletal muscle over the skull, scapulae, spine and pelvis, to describe the amount of muscle wasting. Animals are scored as follows: SCORE 3. No muscle wasting; SCORE 2. Mild muscle wasting; SCORE 1. Moderate muscle wasting; SCORE 0. Severe muscle wasting. Overweight patients are difficult to manage. In cats, fasting is well known to predispose the animal to hepatic lipidosis. In dogs, it may seem that an overweight animal can support itself nutritionally from its own body fat. However, if a dog is ill or injured, it has the same metabolic changes and the same protein catabolism as a leaner one; even though the animal is fat, it will be losing functional proteins. Therefore, a weight-loss diet should only be instigated in healthy dogs. The use of laboratory analyses to determine nutritional status is not commonly practised in veterinary medicine, and is not consistently predictable in human medicine. Serum concentrations of proteins such as albumin, transferrin, thyroxine-binding protein, retinal-binding protein and fibronectin have been examined as markers of nutritional status in human patients. These have not been evaluated in veterinary patients and include some acute phase reactants that may be increased or decreased due to disease. Serum creatine kinase concentration has been used in cats as a marker of nutritional status, but is also subject to changes due to disease states. Serum insulin-like growth factor I (IGF-I) has been evaluated in research cats and dogs but, while it did show a correlation with nutritional status, it has not been used in clinical patients. Lymphopenia can be caused by malnutrition but, again, is influenced by many disease states. Immune system function tests, such as delayed hypersensitivity testing via intradermal antigen injection, immunophenotyping of T cells and measurement of the phagocytic capabilities of monocytes, have been examined experimentally in veterinary patients. Gene expression testing and measurement of the activities of specific enzymes, cell receptors and gene signalling pathways have also been carried out in fasting and refed animals, but are not practical in the clinical setting.

be initiated after hydration status, acidbase balance and electrolyte disturbances have been corrected, and haemodynamic stability has been achieved. The aim is to initiate nutrition supplementation in critical patients within 24 hours, and to reach target nutrition delivery within 72 hours. Early nutritional support has been documented to result in improved outcomes in human and animal studies.

HOW MUCH TO FEED

The basal energy requirement (BER) is the energy needed for a healthy resting animal in a postabsorptive (unfed) state in a thermoneutral environment. Resting energy requirement (RER) is BER plus the energy needed for assimilation of food and recovery from physical activity. In humans, RER is estimated to be about 10 per cent greater than BER, but this difference is unlikely to have any clinical significance. The RER is the same as resting energy expenditure (REE). The most widely used allometric formula for RER in cats and dogs of any weight is:
RER (kcal) = 70 x (Current bodyweight in kg) 075

Alternatively, for animals weighing between 2 and 30 kg, a linear formula may be used:
RER (kcal) = (30 x Current bodyweight in kg) + 70

WHEN TO FEED
In most cases, it is better to provide nutritional support earlier rather than later; however, nutrition should only

Maintenance energy requirement (MER) is the energy required by an animal with a moderately active life. It is usually estimated to be a multiple of RER; for example, 16 to 18 x RER for dogs and 12 to 14 x RER for cats. It does not include energy needed for growth, gestation, lactation or work. A dog (or less likely a cat) with a very active lifestyle may need more energy than is supplied by the estimated MER. Previously, some clinicians multiplied the RER by a factor of 12 to 20 for an illness energy requirement (IER) to increase the calories thought to be necessary for the hypermetabolism associated with illness or injury. However, when caloric requirements were determined using indirect calorimetry in hospitalised dogs, most of them were found to have energy requirements close to the RER. Human patients caloric needs are now estimated to be at or near RER, with adjustments made based on clinical assessment, and this is a reasonable and safe approach for most veterinary patients. Human patients whose needs are known to be above RER include those with head trauma and severe burns. In patients that have not been eating for several days, enteral or parenteral supplementation should not be started at the full RER. A common approach is to provide one-third of the calories on the first day, divided into several small meals or tube-fed boluses, or as a constant

Dog with a body condition score of 2

Cat with diabetes mellitus that has lost epaxial muscle mass but retained body fat

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rate infusion. If this is well tolerated, the amount can be increased to two-thirds of the calories on the second day and a full feed on the third day.

METHODS OF FEEDING

WHAT TO FEED
Many formulations for enteral nutritional support in cats and dogs are high in fat, as it provides the most calories per gram. This is appropriate for many patients, but may cause diarrhoea in animals with impaired fat assimilation. The administration of a highly digestible, low residue liquid diet may also result in soft stools but in animals with a functional intestinal tract this should resolve within several days. Provision of a fibre source in the enteral formula may improve stool consistency in some patients. Recent studies have evaluated the use of glutamine, arginine and omega-3 fatty acids in various feeds. Glutamine is an important energy source for enterocytes and the immune system, and may improve survival, although studies in dogs and cats have not shown consistent results. An increase in intestinal requirements for glutamine in the first week postoperatively has been shown in dogs, and so supplementation may be helpful. Glutamine supplementation given parenterally has been found to have the most consistent positive effect. Arginine supplementation in the veterinary setting has been shown to reduce the catabolic response to trauma, sepsis and injury, and improves immune response and wound healing in elective surgical patients. However, it has also been associated with increased mortality in dogs with sepsis, so it should be used with caution. Omega-3 fatty acids reduce inflammatory response by providing a substrate for the less inflammatory eicosanoids and lipoxygenase products. In theory, it may take a couple of weeks before the plasma phospholipids are significantly changed, so they may be more important in convalescent rather than acute stages of inflammation. They have, however, been shown to benefit people with acute respiratory distress syndrome and, when combined with antioxidants, improve the outcome for patients with sepsis or septic shock, so there may also be more acute benefits. The use of omega-3 fatty acids in critically ill or traumatised veterinary patients has not been reported, but they may be helpful. Some enteral formulations available for dogs and cats have increased amounts of arginine and omega-3 fatty acids.

An animals gut function and the length of time that nutritional support is anticipated to be needed will determine the method of feeding selected (see box below).

ORAL
Voluntary oral feeding is the easiest method of feeding for both animal and clinician. Cats may be encouraged to eat by providing moistened food with a high protein and high fat content, warming the food to just below body temperature or using foods with a strong odour (eg, oily fish). Many cats prefer a flat dish to a bowl, and some have a preference for porcelain or glass over plastic or metal. Some animals like to be petted during feeding or hand-fed small amounts; some patients will eat only a small amount when a new food is introduced. Some dogs like sweeter foods or flavourings. Products with onion or garlic should be avoided, even in powdered form, to prevent the risk of haemolysis. Many critical care diets are highly palatable, but other foods, such as cat food, cooked chicken or hot dogs, may be given to encourage dogs to eat. While these latter foods do not constitute a balanced diet and are not appropriate for long-term feeding, they will supply some calories and can encourage patients to start eating before a more appropriate diet is initiated. Drugs that have been used to entice cats to eat include diazepam, zolazepam and oxazepam. Diazepam given intravenously often works but only for a very short time (minutes), and oral medications run the risk of causing hepatic necrosis. Oral cyproheptadine is also effective in many cats, although it has been suggested anecdotally that it may very occasionally cause haemolytic anaemia.

Decision making for nutritional support

Nutritional support indicated

Functional gastrointestinal tract

Pancreatitis

Non-functional gastrointestinal tract

Enteral feeding

Jejunostomy tube

Parenteral nutrition

No vomiting or gastric function is OK? Yes Appetite stimulants helpful? No

No

Central catheter feasible? Yes Debilitated patient/ long-term support No

Yes

Intake inadequate Long term Short term Central total parenteral nutrition

Short-term support (days) Gastrostomy tube

Offering a selection of foods may encourage an animal to eat

Naso-oesophageal tube Peripheral parenteral nutrition

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Corticosteroids and anabolic steroids may increase food intake, but are unlikely to encourage an anorectic animal to eat. B vitamins have been rumoured to be useful appetite stimulants, but this has never been proven. Many ill or anorectic animals, especially cats, are deficient in B vitamins, so supplementation may be worthwhile but may not result in a change in appetite. Some anorectic animals may be nauseous, even if not vomiting, so antiemetic medication, such as maropitant (in dogs) or mirtazapine (in cats), may be helpful. Despite the use of appetite stimulants, many patients will not meet their RERs. The amount actually eaten should be measured and the percentage of requirements met calculated. Hospital records often only note that an animal has eaten and do not record the amount consumed.

feeding is usually employed, although continuous feeding is possible in a monitored situation. Patients should not be left alone when using continuous naso-oesophageal tube feeding because, if they vomit and cause the tube to be displaced into the pharyngeal area, they may aspirate the feeding formula. Syringe drivers can be used to deliver feed in animals that are well monitored.
Oesophagostomy tubes

Oesophagostomy tubes are usually larger than nasooesophageal tubes, so liquid food or slurries of food may be given. Placement requires anaesthesia and is relatively easy in cats and smaller dogs. The tubes are usually well tolerated and do not require any special equipment. They have completely replaced the use of pharyngostomy tubes as they are much easier and safer to place.
Gastrostomy tubes

TUBE FEEDING
Naso-oesophageal tubes

Naso-oesophageal (nasogastric) tubes may be placed in animals that need nutritional supplementation for less than a week. Some clinicians feel that the end of the tube should be in the distal oesophagus so as not to compromise the gastro-oeosophageal sphincter. Tubes can usually be inserted without general anaesthesia (and sometimes without sedation) using topical anaesthesia. They may be secured in place using Chinese finger cuff sutures with a preplaced suture lateral to the nares; Elizabethan collars may be fitted to prevent animals from interfering with the sutures. Tissue glue often causes dermatitis and makes tube removal difficult. Tube placement can be checked by: Aspiration (if the tube has been placed correctly in the oesophagus, little or no air will be expelled; conversely, lots of air will be expelled if it has been placed in the trachea); Inserting a small amount of air into the tube and listening over the stomach for gastric borborygmi; Radiographing the thorax, which is the best way of confirming correct tube placement. Checking for a cough after the administration of a small amount of sterile fluid is not reliable. It is worth remembering that there is no magical way of retaining a naso-oesophageal tube in a cat that is determined to remove it. Due to the small diameter of naso-oesophageal tubes, only liquid formulas can be administered. Slow bolus

Gastrostomy tubes may be placed at surgery or using an endoscope. When placed using an endoscope, the tube is referred to as a percutaneous endoscopically placed gastrostomy (PEG) tube. This procedure requires anaesthesia and is usually considered a specialist technique. Blind placement of gastrostomy tubes is possible using special instruments, but there is a risk of the tube exiting via the oesophagus or traversing the spleen. Tubes can be used for long-term feeding for months or even years. A low-profile tube may be placed in animals that need long-term support. Pet food slurries or liquid formulas may be fed. Bolus feeding is usually employed, although continuous feeding with a pump can be used if the patient tolerates feeding well or is constantly monitored.
Jejunostomy tubes

Jejunostomy tubes (J tubes) are placed surgically when the upper gastrointestinal tract is non-functional (eg, gastric surgery or intractable vomiting). The author also places J tubes in patients with pancreatitis or those undergoing anaesthesia for other procedures. A more rapid recovery from pancreatitis has been noted in humans fed via a J tube. Only liquid formulas of fairly low viscosity can be fed using a J tube, and continuous or very, very slow bolus feeding must be used as there is no reservoir capacity within the small intestine and distension can cause painful cramping and diarrhoea.

MICROENTERAL NUTRITION
Microenteral nutrition is the enteral delivery of small amounts of water, electrolytes and easily absorbed nutrients (eg, maltodextrins or glucose and peptides), via any of the methods discussed above, by slow constant rate infusion (eg, 025 ml/hour) or small boluses every two to three hours. Commercial oral rehydrating solutions can be used. The aim of microenteral nutrition is to feed the gastrointestinal system rather than meet a patients nutritional needs, and it can often be used in animals that cannot be fully fed enterally. The presence of nutrients in the gut increases gastrointestinal blood flow, improves gastrointestinal immune function, helps to prevent down regulation of brush border enzymes, decreases the risk of gastrointestinal ulcers and helps to prevent increases in intestinal permeability. It also facilitates a more rapid return to full enteral feeding, and can be used in conjunction with parenteral nutrition.
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PARENTERAL NUTRITION
Parenteral nutrition is appropriate for patients that have a non-functional gastrointestinal tract or in cases where it is undesirable to use the tract for nutritional support (eg, in animals with severe malassimilation or prolonged ileus, or after some gastrointestinal surgeries). Total parenteral nutrition (TPN) solutions are generally administered via a central vein to prevent peripheral vein thrombosis. The disadvantages of using TPN include cost, the need to place and maintain a central venous catheter, the risk of infection or central vein thrombus, and metabolic disturbances. These problems sometimes limit the use of TPN in general veterinary practice. Peripheral parenteral nutrition (PPN) is the provision of nutritional supplementation via a peripheral vein using a standard intravenous catheter. The aim of PPN is to spare endogenous protein by providing an energy source (eg, glucose or lipids), and amino acids, which are used for protein synthesis and may also be catabolised for energy. Often, only part of an animals nutritional needs can be met using a peripheral vein due to the lower caloric density of the solution used. This is sometimes termed partial parenteral nutrition, although, confusingly, partial parenteral nutrition is also sometimes delivered via a central vein. Delivery of PPN can be combined with partial enteral nutritional support.

Refeeding syndrome
When a previously starved individual is fed, the body shifts from a catabolic to an anabolic state and insulin levels are increased. Refeeding syndrome, which may be caused by the intracellular shift of phosphorus and potassium due to glucose-induced insulin release, occurs in individuals that are provided with excess nutrition when they are in a severely anorectic and malnourished state. It is characterised by weakness, cardiac disorders, haemolytic anaemia and death due to respiratory or cardiac failure, and has been documented in cats. Haemolytic anaemia due to hypophosphataemia is a particular risk in cats due to their more fragile red blood cells. Hypomagnesaemia and vitamin deficiencies may also occur, and respiration may increase due to the production of increased carbon dioxide from carbohydrate metabolism. The risk of this syndrome supports the practice of slow initiation of full nutritional support, monitoring of electrolytes and glucose, and addition of vitamins (especially thiamine) to the nutritional formula.

POTENTIAL COMPLICATIONS

Potential complications of enteral or parenteral nutritional support include metabolic disturbances (eg, hyperglycaemia, electrolyte abnormalities, hypertriglyceridaemia) or refeeding syndrome (see box, above right.) Hyper-

glycaemia may occur in animals with glucose intolerance, but the clinical relevance of this is not fully understood. In some human critical care facilities there is concern about patients with sepsis-induced stress hyperglycaemia, who have a poorer prognosis compared with those who are normoglycaemic. Hyperglycaemia in critically ill non-diabetic dogs has been shown to correlate with longer hospitalisation times and an increased risk of death. In animals with renal insufficiency or hepatic encephalopathy due to liver disease, the amount and/or type of protein given may need to be adjusted. Complications of tube feeding include mechanical problems relating to the tubes, such as removal or breakage by the animal and blocking, kinking or migration of the tube. Abnormalities of the stoma (ie, the opening

Enteral nutrition a case study

Signalment Two-year-old neutered male Bengal cat. History The cat returned home with blood on its face and jaw four days after escaping from the back garden. On initial presentation, the animal was dehydrated. This was corrected with intravenous fluids. The cat was diagnosed with mandibular fractures, which were repaired by bonding, so it was unable to eat normally or open its mouth. The animal had to stay in hospital during its early convalescence. Patient assessment The cats body condition score was 4 on a scale of 1 to 9, and it weighed 40 kg. It had lost an unknown amount of weight, but was healthy other than its inability to eat due to trauma. Its previous diet was a combination of commercial dry and canned food, and its last known meal was six days previously. Possible feeding techniques and rationale for the ultimate choice As the cats gastrointestinal tract was functional, it could be fed enterally. As its jaws had been wired together, placement of a percutaneous gastrostomy tube (PEG) would be challenging. If a PEG had been placed before surgery, this would have been a feasible option. The use of a naso-oesophageal tube is an option for short-term support (one week or less) and may usually be placed with no or only light sedation; however, cats sometimes remove the tube, and only liquid foods can be fed by this method. The final option, an oesophagostomy tube, would require a short period of anaesthesia for placement. These tubes allow thicker foods to be fed, and animals are less likely to remove them. In addition, they can be used for longer-term support. Caloric requirements The cat was kept in a cage, so it should initially be fed at its resting energy requirement (RER) for its current weight. If the initial regimen is tolerated well, the amount of food given could be increased subsequently to provide for weight gain. At a bodyweight of 4 kg, the cats RER was 70 x 4 075 = 198 kcal. Alternatively, the formula of (30 x 4) + 70 = 190 kcal may be used. Feeding regimen (food type and amount, frequency of feeding) for nutritional support An oesophageal feeding tube was placed and a commercial moist homogenised recovery formula chosen (Hills a/d), which is balanced for cats and may be administered through this type of tube. As the cat had probably not had any food for six days, its initial intake should be low to ensure that it can tolerate enteral feeding. The common protocol of administering one-third of the RER on the first day, twothirds on the second day and the full feed on the third day if no adverse events occur was followed. On the first day, the patient was given 66 kcal of the formula, which equates to about 60 ml, divided into three 20 ml feedings. This was increased over the next two days to three 60 ml feedings (or 198 kcal) as the animal tolerated the feed well. The cats pharyngeal trauma healed in about a week and it was able to lap soft food, so the oesophagostomy tube could be removed. The jaw healed fully in two months and the animal was back to normal, with its time spent outdoors now supervised!

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CHANDLER, M. L., GUILFORD, W. G. & PAYNE-JAMES, J. (2000) Use of peripheral parenteral nutritional support in dogs and cats. Journal of the American Medical Association 216, 669-673 CHANDLER, M. L. & GUNN-MOORE, D. A. (2004) Nutritional status of canine and feline patients admitted to a referral veterinary internal medicine service. Journal of Nutrition 134 (Suppl), 2050S-2052S KOGA, Y., IKEDA, K. & INOKUCHI, K. (1975) Effect of complete parenteral nutrition using fat emulsion on liver. Annals of Surgery 181, 186-190 LAFLAMME, D. P. (1993) Body condition scoring and weight maintenance. Proceedings of the North American Veterinary Conference. Orlando, USA, January 16 to 21. pp 290-291 LAFLAMME, D. P., KEALY, R. D. & SCHMIDT, D. A. (1994a) Estimation of body fat by body condition score. Journal of Veterinary Internal Medicine 8, 154 LAFLAMME, D. P., KUHLMAN, G., LAWLER, D. F., KEALY, R. D. & SCHMIDT, D. A. (1994b) Obesity management in dogs. Journal of Veterinary Clinical Nutrition 1, 59-65 MAXWELL, A., BUTTERWICK, R., YATEMAN, M., BATT, R. M., COTTERIL, A. & CAMACHO-HBNER, C. (1998) Nutritional modulation of canine insulin-like growth factors and their binding proteins. Journal of Endocrinology 158, 77-85 McCLAVE, S. A., CHANG, W. K., DHALIWAL, R. & HEYLAND, D. K. (2006) Nutrition support in acute pancreatitis: a systematic review of the literature. Journal of Parenteral and Enteral Nutrition 30, 143-156 McCLAVE, S. A., GREENE, L. M., SNIDER, H. L., MAKK, L. J., CHEADLE, W. G., OWENS, N. A., DUKES, L. G. & GOLDSMITH, L. J. (1997) Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. Journal of Parenteral and Enteral Nutrition 21, 14-20 MAXWELL, A., BUTTERWICK, R., BATT, R. M. & CAMACHOHBNER, C. (1999) Serum insulin-like growth factor (IGF)-I concentrations are reduced by short-term dietary restriction and restored by refeeding in domestic cats (Felis catus). Journal of Nutrition 129, 1879-1884 MICHEL, K. E. (2004) Preventing and managing complications of enteral nutrition support. Clinical Techniques in Small Animal Practice 19, 49-53 PRITTIE, J. & BARTON, L. (2004) Route of nutrient delivery. Clinical Techniques in Small Animal Practice 19, 6-8 PYLE, S. C., MARKS, S. L. & KASS, P. H. (2004) Evaluation of complications and prognostic factors associated with administration of total parenteral nutrition in cats: 75 cases (1994-2001). Journal of the American Veterinary Medical Association 225, 242-250 QIN, H. L., SE, Z. D., HU, L. G., DING, Z. X. & LIN, Q. T. (2002) Effect of early intrajejunal nutrition on pancreatic pathological features and gut barrier function in dogs with acute pancreatitis. Clinical Nutrition 21, 469-473 REMILLARD, R. L., ARMSTRONG, P. J. & DAVENPORT, D. J. (2000) Assisted feeding in hospitalized patients: enteral and parenteral nutrition. In Small Animal Clinical Nutrition, 4th edn. Eds M. Hand, C. Thatcher, R. Remillard and P. Roudebush. Topeka, Mark Morris Institute. pp 351-400 WOHL, J. S. (2003) Nutritional intervention in the critically ill patient. Proceedings of the American College of Veterinary Internal Medicine Forum. Charlotte, USA, June 4 to 8. pp 816-818 ZSOMBOR-MURRAY, E. & FREEMAN, L. M. (1999) Peripheral parenteral nutrition. Compendium on Continuing Education for the Practicing Veterinarian 21, 512-523

of the tube through the body) can include erythema or infection. Removal of gastrostomy tubes too early may result in gastric contents leaking into the peritoneum. If an ill patient is vomiting or regurgitating, there is a risk of aspiration pneumonia with enteral feeding. If patients are fed a larger volume than they can tolerate (eg, due to poor gastric emptying), vomiting is more likely, so residual volumes left in the stomach should be checked before feeding. Overfeeding may also result in diarrhoea, especially when using jejunal tubes. With TPN provided via a central intravenous line, potential problems include mechanical problems associated with the catheter and lines, and septic complications. The primary disadvantage of PPN is the limited number of calories that can be provided due to reduced energy density resulting from the decreased osmolality that is thought to be necessary to prevent peripheral vein thrombophlebitis. Nutritional solutions are good media for bacterial growth and are therefore easily contaminated, so catheters must be handled as aseptically as possible. In particular, central catheters should be labelled to avoid inadvertent administration of oral feeding solutions. The intestine is at an increased risk of villous atrophy, bacterial translocation and adynamic ileus when using parenteral nutrition without some enteral feeding. Careful monitoring is important to reduce the risk of complications. At the very least, heart rate, respiratory rate, temperature, bodyweight, glucose level, attitude of the animal and position of the catheter or tube should be noted daily in all animals receiving nutritional support. Monitoring of other parameters (eg, electrolytes, complete blood cell count, serum biochemistry profile) may also be beneficial depending on the requirements of the individual patient.
Further reading BARTGES, J. W. (2001) Identifying and feeding patients that require nutritional support. Veterinary Medicine 96, 60-72 CHAN, D. L. & FREEMAN, L. M. (2006) Nutrition in critical illness. Veterinary Clinics of North America: Small Animal Practice 36, 1225-1241 CHAN, D. L., FREEMAN, L. M., LABATO, M. A. & RUSH, J. E. (2002) Retrospective evaluation of partial parenteral nutrition in dogs and cats. Journal of Veterinary Internal Medicine 16, 440-445

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Nutritional support for the hospitalised small animal patient

Marge Chandler In Practice 2008 30: 442-448

doi: 10.1136/inpract.30.8.442

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