Nutritional plan: matching diet to disease

Institution of appropriate, timely nutritional support in the anorexic or critically ill patient has become accepted medical practice in people and animals. This article focuses on the benefits of appropriate nutrient intake in critically ill animals, recommended nutrient requirements for dogs and cats receiving enteral feeding, and mechanics of food preparation and delivery for a variety of feeding tubes. General nutrient requirements for all patients, specific recommendations for certain illnesses such as renal failure, pancreatitis, and hepatic disease, and nutritional alterations for critical illness are reviewed. Commercial liquid diets manufactured for people and pets, and pet-food diets practical for formulation of gruel are presented. Institution of and weaning from feeding are explained.     

Effects of nutritional support on hospital outcome in dogs and cats

Objective – Investigate the effects of assisted nutritional support on hospital outcome in dogs and cats, and the relationship between hospital outcome and energy intake, body condition score (BCS), physical status score, and type of nutritional support used. Design – Retrospective analysis of hospitalized animals. Setting – Teaching Veterinary Hospital. Animals – Four hundred and sixty‐seven dogs and 55 cats. Interventions – Routine clinical nutritional support. Measurements and Main Results – The following variables were recorded for each animal: energy intake, body weight at admission and discharge, BCS, physical status score, and type of nutritional support used. Disease severity was negatively associated with hospital outcome and energy intake (P=0.009). Energy intake was positively associated with hospital discharge (P<0.001). Outcome may be related to BCS, with discharge rates of 73% for animals with low BCS, and 84.7% for those at an ideal BCS or overweight (P=0.04). Sixty‐four percent of animals showed voluntary food intake (92.9% were discharged), 19.0% received enteral support (71.8% were discharged), 7.0% were forced fed (75.0% were discharged), 6.0% received parenteral support (61.9% were discharged), and 4.0% did not receive calories (38.4% were discharged), suggesting a possible relationship between the type of nutritional support, energy intake, and outcome (P=0.009). Conclusions – Energy supply, even if modest and close to resting energy requirements appears to be positively associated with hospital discharge. However, disease severity was the main negative factor on outcome and also had a negative effect on energy intake, making it difficult to separate the effects of both factors when interpreting hospital discharge. Thin animals with low BCS had greater mortality.     

Owner experiences and complications with home use of a replacement low profile gastrostomy device for long-term enteral feeding in dogs

The purpose of this study was to evaluate complications and owner impressions of a low profile gastrostomy device (LPGD) for enteral feeding in dogs. Medical records of dogs that had placement of a percutaneous endoscopic gastrostomy tube followed by a LPGD between 1995 and 2003 were reviewed. Fifteen dogs had 29 devices placed for a variety of disease states in which enteral nutritional support was indicated. The individual tubes were placed for a median duration of 212 d. Most complications occurred more than 15 d after placement and were of no health risk to the animals. The most common reason for LPGD replacement was leakage through the 1-way antireflux valve. Fourteen of 15 owners that were contacted were supportive of the device. Based on its durability, ease of placement, minor complications, and positive owner impressions, we conclude that the LPGD is a valuable device for long-term enteral nutritional support of dogs.     

Limited approach to the right flank for placement of a duodenostomy tube

A new enterostomy tube placement technique is described for provision of nutrients into the duodenum. Placement of the duodenostomy tube (d-tube) is performed through a limited right flank approach under sedation and local anesthesia. Seven client-owned animals (three dogs and four cats) requiring enteral nutritional support were selected for d-tube placement. Patients were fed via the d-tube for two to 28 days. Complications included discomfort when manipulating and exteriorizing the duodenum, discomfort with bolus feedings, local cellulitis, and tube site infection. All complications resolved without further incident. This technique should be considered in patients that are not good candidates for prolonged general anesthesia or esophageal or gastric feeding, or patients being mechanically ventilated.     

Improved nasogastric intubation technique for administration of nutritional support in dogs.

Established procedures for nasogastric intubation are difficult to perform in dogs because of anatomic variation of nasal passages and turbinate structures. Twenty-five clinically normal dogs were used to improve and refine the technique of nasogastric tube placement, and 13 clinical patients at our teaching hospital were evaluated for malnutrition and were considered candidates for nutritional support by nasogastric tube feeding. An improved method for the placement of nasogastric tubes in dogs was used. By pushing the external nares dorsally while advancing the tube in a caudoventral, medial direction, the tube passed through the ventral meatus and into the oropharynx and esophagus easily. The procedure does not require chemical restraint, and the complication of epistaxis was not observed in any dog. Materials required to perform this technique are inexpensive, and the method can be used for the administration of nutritional support, fluids, drugs, or contrast material.     

Factors associated with adverse outcomes during parenteral nutrition administration in dogs and cats

Background: Parenteral nutrition (PN) is increasingly used to support hospitalized dogs and cats. Published assessments of outcome are limited. Objective: Evaluate type and prevalence of complications and risk factors for death and complications in dogs and cats receiving PN. Animals: Three hundred and nineteen dogs and 112 cats that received PN at a teaching hospital between 2000 and 2008. Methods: Retrospective case review. Diagnosis, duration of PN administration, concurrent enteral feeding, death, and mechanical, septic, and metabolic complications were abstracted from medical records. Association of each parameter with complications and death was analyzed by binary logistic regression. Results: Pancreatitis was the most common diagnosis (109/319 dogs, 34/112 cats), and 137/319 dogs and 51/112 cats died. Dogs and cats received 113 ± 40% and 103 ± 32% of resting energy requirement, respectively. Mechanical (81/319 dogs, 16/112 cats) and septic (20/319 dogs, 6/112 cats) complications were not associated with death (P > .05). Hyperglycemia was the most common metabolic complication (96/158 dogs, 31/37 cats). Hypercreatininemia in dogs (8/79) was the only complication associated with death (P < .01). Chronic kidney disease in dogs, hepatic lipidosis in cats, and longer duration of inadequate caloric intake before PN in both species were negatively associated with survival (P < .05). Factors positively associated with survival included longer duration of PN administration in both species, enteral feeding in cats with any disease, and enteral feeding in dogs with respiratory disease (P < .05). Conclusions and Clinical Importance: PN can be effectively used to provide the energy requirements of most critically ill dogs and cats. Most complications accompanying PN administration do not affect survival.     

Nutritional support for patients

A good intake of fluids and essential nutrients in the first fourteen days is of vital importance to recuperating animals. Moreover, it is important to encourage cats and dogs to eat after illness or surgery, in order to promote optimal functioning of the gut and the immune system. Enteral nutrition is to be preferred to nasogastric feeding or parenteral nutrition. In the first stage of recovery, during the first 24 to 48 hours, it is important to feed the gut' with nutrients, and thereafter, in the second stage of recovery (after day 3), the calorie intake can be increased. Timely nutritional support with nutraceuticals, such as arginine, glutamine, taurine, long-chain polyunsaturated omega-3 fatty acids, and prebiotic fibres, can considerably shorten the recovery period of cats and dogs after illness or surgery     

Nutritional support of hospitalised dogs and cats

SUMMARY Nutritional support of hospitalised dogs and cats improves recovery from illness, reduces mortality, and improves responses to trauma and stress. The primary goal of nutritional support is to prevent use of tissue protein. This is accomplished by the provision of sufficient calories and dietary protein in optimal proportions. For nutritional support, calorie intake is adjusted according to the patient's metabolic rate so that the animal may be fed above or below its usual intake. Nutritional support should always be started gradually, no matter what the final calorie goal may be. For many sick dogs fed enterally, diets provide about 30% of calories from fat and at least 27% of calories from protein. Carbohydrates in nutritional support diets should not include maize, wheat or, especially, soy. Sick cats fed enterally should receive at least 30% of calories from both fat and protein.     

A quantitative summary of nutrition support services in a veterinary teaching hospital

A full-time nutrition support service provided 1,133 consultations in a small animal teaching hospital from July 1986 to June 1988, consisting of 840 dogs, 260 cats, 23 exotic species, and 10 consultations with incomplete information. The dog and cat consultations represented 2.1 and 3.7% of canine and feline admissions, respectively. Consultations involved the determination of nutritional goals which led to recommendations of specific dietary regimens. Most frequent requests were for diet evaluation and diet formulation to meet estimated calorie and protein needs during illness and stress (23%), for specific calorie or nutrient modification given a working diagnosis (23%), and for avoidance of tissue utilization or weight loss (23%). Frequently involved single organ systems were gastrointestinal (16%), liver (12%), kidney (9%), and pancreas (4%), but multiple system involvement was more common (19%). Most frequent diagnostic categories were metabolic disorders (17%), chronic organ failure (17%), and neoplasia (12%). Enteral nutrition was preferred for 98% of consultations. Voluntary consumption was deemed adequate in 81% of consultations, and highly palatable balanced homemade diets and specialty products were recommended in 74% of these. Human hospital liquid enteral products were used in 95% of consultations recommending involuntary feeding, either fed alone, blended with petfoods, or supplemented with modules of protein or fat. The service demonstrated that full-time nutrition support can be utilized effectively in a small animal teaching hospital. Further development of such services will depend on research focused especially on determination of case-specific nutritional goals, patient responses, and cost effectiveness.     

Complications with non-endoscopic percutaneous gastrostomy in 31 cats and 10 does: a retrospective study

Percutaneous gastrostomy tubes were placed non-endoscopically in 31 cats and 10 dogs using either a rigid insertion tube (n=13) or an Eld gastrostomy tube applicator (n=28). Tubes were placed successfully in 38 of the 41 animals and the consequent feeding was of therapeutic benefit to 31 of the animals. Six of 41 died or were euthanased for reasons unrelated to gastrostomy. In four cases (10 per cent), gastrostomy failed with respect to correct tube placement or tube feeding. Overall complications occurred in 18 of 41 animals. Severe procedural complications occurred in two cats; a cardiorespiratory arrest during pharyngeal manipulation and erroneous tube placement through the distal oesophagus. Moderate late complications included peristomal food leakage (n=2), peristomal abscess (n=2) and pyloric outflow obstruction by a migrated tube (n=1). Complications associated with the feeding procedure, nausea and vomiting (n=3), led to aspiration pneumonia in one case.     

Nutritional support of hospitalized patients

Effective nutritional support requires sound knowledge of both basic and clinical nutrition of dogs and cats as well as familiarity with products and delivery systems. Case management includes assessment of nutritional status and estimation of fuel sources. Most starved or stressed patients use fatty acids for over 70 per cent kcalME and protein for over 20 per cent kcalME. Approximate kcal needs are calculated from maintenance energy equations. Most patients respond best to enteral nutrition. Meat-based pet foods, liquid enteral products, and nutrient modules are offered in slurries or are tube-fed. Management includes careful monitoring of patients and gradual transitions to diets with more complex nutrient sources.     

Enteral nutrition by tube

When oral intake is unsatisfactory or contraindicated, maintenance of nutrition by tube feeding is an alternative to the parenteral route. A large volume of research data supports the decision to use the enteral route whenever possible. Entry of food into the alimentary tract is a stimulus to structural and functional maintenance of that tract. Enteral nutrition can be given via indwelling nasoesophageal, pharyngostomy, esophagostomy, percutaneous or surgical gastrostomy, or enterostomy tube. Use of an appropriate catheter, familiarity with the technique used, and careful patient selection and monitoring are important factors in successful tube feeding. Blenderized pet food diets should be fed whenever possible; commercially available liquid diets provide an alternative when tube caliber or patient factors preclude the use of blenderized foods.     

Esophagostomy Feeding Tube Use and Placement in Exotic Pets

Providing enteral nutrition to injured or ill exotic animal patients by means of assisted feedings minimizes catabolism and gastrointestinal morbidity associated with anorexia, while optimizing immune system and organ function, and providing nutritional precursors necessary for healing. When determining the nutritional needs of a debilitated animal, it is important to account for both metabolic rate and energy requirements. Providing enteral nutrition via a feeding tube utilizes the functional gastrointestinal tract in patients that cannot or will not eat. Additionally, administration of food through a feeding tube is significantly less stressful for patients than restraint and syringe feeding. Feeding tube placement should be considered in any animal where the stress associated with syringe feeding is likely to result in significant morbidity or when the need for an extended period of assisted feeding is required.     

The risk of salmonellae shedding by dogs fed Salmonella-contaminated commercial raw food diets

Twenty-eight research dogs were enrolled to determine the prevalence of salmonellae shedding after consumption of 1 Salmonella-contaminated commercial raw food diet meal. Sixteen dogs were exposed to Salmonella-contaminated commercial raw food diets and 12 to Salmonella-free commercial raw food diets. Seven of the exposed dogs shed salmonellae 1-7 days after consumption of Salmonella-contaminated raw food diets. None of the dogs fed Salmonella-free diets shed salmonellae. No clinical signs were observed in either group. Five of the 7 dogs shed the same serotypes as those recovered from food samples used for feeding. Results showed the same serotypes and antimicrobial resistance pattern in 2 of the 7 shedders. Dogs fed Salmonella-contaminated raw food diets can shed salmonellae and may, therefore, be a source of environmental contamination potentially leading to human or animal illness.     

Nutritional support of hospitalised animals

Effective nutritional support requires a sound knowledge of both basic and clinical nutrition of dogs and cats as well as familiarity with products and their administration. Management includes the assessment of a patient's nutritional status and estimation of fuel sources. Most starved or stressed patients utilise fatty acids at over 70 per cent kcalME (metabolisable energy) and protein at over 20 per cent kcalME; appropriate diets contain at least 30 per cent kcalME from protein as well as fat. Approximate calorie needs are based on maintenance energy requirements. Enteral nutritional support is superior to parenteral support in most patients as gastrointestinal integrity and enterocyte viability are maintained. Meat-based pet foods, liquid enteral products and nutrient supplements are offered in slurries and via tubes. Management includes careful monitoring of patients and the gradual transition to diets with more complex nutrient sources.     

Nutritional considerations for horses with colitis. Part 1: Nutrients and enteral nutrition

The equine colon is the primary site of fibre digestion and water absorption. It is therefore not surprising that colitis and associated colonic dysfunction can result in severe nutritional derangements, which can be exacerbated by reduced feed intake in affected horses. Dietary management of colitis is important for optimum recovery. In broad terms, it should prioritise provision of nutrients to horses that otherwise have reduced appetites. In some forms, such as right dorsal colitis, as well as those with chronicity, nutritional recommendations include restricting or eliminating long‐stem roughage from the diet and feeding a complete pelleted diet. Voluntary enteral nutrition is preferred, but horses that are not ingesting enough to meet the minimum recommended requirements as outlined, should be fed via nasogastric tube (if tolerated – no reflux, no ileus and no colic present; faecal output present). Parenteral nutrition may be necessary in some cases, as some colitis cases do not tolerate enteral feeding for reasons such as colic, intestinal dysmotility or abdominal distension. Timing and constitution of nutritional intervention is vital and should be tailored to the individual patient to prevent further complications of the disease process.     

Nutritional Support In Pancreatitis: A Retrospective Study

The medical records of animals with pancreatitis that received nutritional support were evaluated. Over a five year period (1989–1994), 16 patients with pancreatitis (14 dogs and 2 cats) received nutritional support. Affected animals commonly exhibited vomiting, diarrhea, and weight loss, as well as multiple clinicopathological abnormalities.
Total parenteral nutrition (TPN) was used in 13 of the cases, while two animals received partial parenteral nutrition (PPN), and one was fed through a jejunostomy tube. The duration of nutritional support ranged from one to 13 days, with a mean of 6.6 days. Three of the animals receiving TPN had complications resulting from the nutritional support, including hyperglycemia, hyperammonemia, and hyperlipidemia. The survival rate for all 16 cases was 56% (9 of 16).
A variety of nutritional support techniques can be successfully used in animals with pancreatitis and are associated with few complications, most of which can be managed with adjustments in treatment regimen.     

Retrospective evaluation of partial parenteral nutrition in dogs and cats

The purpose of this retrospective study was to evaluate the use of partial parenteral nutrition (PPN) in dogs and cats. The medical records of all dogs and cats receiving PPN between 1994 and 1999 were reviewed to determine signalment, reasons for use of PPN, duration of PPN administration, duration of hospitalization, complications, and mortality. Complications were classified as metabolic, mechanical, or septic. One hundred twenty-seven animals (80 dogs and 47 cats) were included in the study, accounting for 443 patient days of PPN. The most common underlying diseases were pancreatitis (n = 41), gastrointestinal disease (n = 33), and hepatic disease (n = 23). Median time of hospitalization before initiation of PPN was 2.8 days (range, 0.2-10.7 days). Median duration of PPN administration was 3.0 days (range, 0.3-8.8 days). Median duration of hospitalization was 7 days (range, 2-20 days). In the 127 animals receiving PPN, 72 complications occurred. These included metabolic (n = 43), mechanical (n = 25), and septic (n = 4) complications. The most common metabolic complication was hyperglycemia (n = 19), followed by lipemia (n = 17) and hyperbilirubinemia (n = 6). Most complications were mild and did not require discontinuation of PPN. Ninety-three (73.2%) of the 127 patients were discharged. All 4 animals with septic complications were discharged from the hospital. The presence, type, and number of complications did not impact the duration of hospitalization or outcome. However, animals that received supplemental enteral nutrition survived more often than those receiving PPN exclusively. Although PPN seems to be a relatively safe method of providing nutritional support, future studies are warranted to determine its efficacy.