An Assignment on

Nutritional Support
to
Veterinary Surgical Patients

Submitted to
Dr. Manoj Kumar Shah
Lecturer
Department of surgery and pharmacology
IAAS, Rampur campus, Chitwan

Submitted by
Suraj Subedi
B.V.Sc & A.H 7th semester
Roll no 29
IAAS, Rampur campus, Chitwan

September, 2010
 Nutritional Support to Veterinary Surgical Patients
Introduction
Nutrition is the process by which an organism assimilates materials and uses them for normal
growth and maintenance of life. Nutrition provides the substrates essential for living creatures
to use for protein synthesis, cellular function, and metabolic processes.

When an animal is ill or injured and is recommended for surgical intervention, it faces a
substantial decrease in the normal intake of protein and energy at a time when more energy is
being utilized for metabolic fuel and cell turnover. A negative energy and protein balance exists,
and providing adequate nutrition is essential to avoid malnutrition. Extensive research and
clinical studies have shown a close relationship between morbidity and mortality rates and
nutrition in the animal having critical conditions. Consequences of malnutrition include
increased susceptibility to infection, shock, delayed wound and fracture healing, muscle
weakness, impaired immunity, major organ failure and death.

Tissue synthesis and wound healing depend on local and whole body nutrition. Amino acids and
carbohydrates are needed for collagen and ground substance synthesis while fibroblasts require
energy to synthesize RNA, DNA and ATP necessary for proteins. The liver and bone marrow
require energy and protein for glucose, complement, platelet, and leukocyte and monocyte
production. Studies show that post operative patients that are fed demonstrate a much higher
rate of protein synthesis versus protein degradation while those that are not fed demonstrate
higher protein degradation.

The immune system is particularly susceptible to the effects of poor nutrition and post surgical
patients depend on a healthy immune system to ward off infection. In animals, decreased
protein-calorie intake is the most common cause of secondary immunodeficiency.

There are other factors that make adequate nutrition following surgery even more critical and
these are in response to the injury itself. Following trauma, metabolic and physiologic changes
occur in response to the release of catecholamines, adrenocorticoids, glucagons, and a number
of other hormones associated with the "fight or flight(emergency)" response. The result of this
hormonal surge is:

Suppression of insulin secretion

Hyperglycemia
Increased proteolysis
Increased cardiac output

This metabolic alteration must be met with a supply of adequate nutrition that meets the
requirements of the body.

In summary, the benefits of nutritional support are

• Preservation of nutritional status

• Prevention of complications of protein malnutrition
• Decreased post-operative complications

Role of Nutrition in Peri-operative Patients

 Enhances wound healing
 Enhances immunocompetance
 Speeds onset of therapeutic effects from other treatments
 Serves to meet the metabolic demands of the patient
 Improves survival rate of critical care patients
Goals of Nutritional Management and Support
Provide enough calories to aid the body in healing from surgery and underlying disease.
Prevent atrophy of the gut, which predisposes the patient to ulceration, bacterial
translocation, and potential for sepsis.
Ensure adequate glucose levels and avoid large fluctuations.
Maintain neutral PH.
Provide organs with nutritional support to prevent organ failure as a result of
malnutrition.
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)0·75
Alternatively, for animals weighing between 2 and 30 kg, a linear formula may be used:
RER (kcal) = (30 x Current bodyweight in kg) + 70
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, 1·6 to 1·8 x RER for
dogs and 1·2 to 1·4 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.

Methods of assessment of nutritional status

Accumulation of lean body mass is the principal objective of nutritional support; thus
determination of lean body mass is the most appropriate means of nutritional assessment. The
methods used are:
History and physical examination

Weight loss, anorexia or a disease process that interferes with intake (such as esophageal
carcinoma) should alert the examiner to the possibility of malnutrition. On physical
examination, muscle wasting; loss of thenar eminence muscles; loose flabby skin; edema of
hypoproteinemia; weakness; loss of body fat and pallor are the key signs that confirm the
malnutrition.

 Nitrogen balance  Neuron activation analysis

 Indirect calorimetry  Magnetic resonance imaging
 Functional studies of muscle function  Delayed cutaneous hypersensitivity or
 Displacement of water volume allergy
Some indications of surgical nutrition:
 Paralytic ileus more than 4 days.  Trauma:
 Surgical sepsis. • Mainly maxillofacial.
 Intestinal fistula. • Multiple trauma.
 Massive intestinal resection. • Burns
 Pancreatitis.  Organ failure: renal, liver, cardiac.
Approaches to feeding the surgical patient
Enteral
Force feeding/appetite stimulation
Nasoesophageal tube
Nasogastric tube
Percutaneous endoscopic gastrostomy tube
Esophagestomy tube
Gastrostomy tube
Jejunostomy tube
Parenteral
Partial parenteral nutrition (PPN)
Total parenteral nutrition (TPN)
Total parenteral nutrition (TPN)
A mixture of dextrose, amino acids, and lipid solution providing 100% of the patient’s
nutritional requirements in a central vein.
Partial parenteral nutrition (PPN)
• Dextrose solutions that provide minimal calories to the patient
• Free amino acid solutions (FreeAmine, Aminosyn, Travasol) with balanced electrolytes added.
• Amino acid and dextrose solutions (Clinimix, Quick Mix, ProcalAmine)
• Dextrose, amino acids, and lipid mixtures that provide 50% of the patient’s caloric
requirements
Major complications in enteral and parenteral nutrition delivery
Mechanical: Blocked enteral tubes and kinked catheters can present physical difficulties
Metabolic: Alterations in electrolyte balances, hyperglycemia, acid-base disturbances, and
hyperlipidemia occur. It is not uncommon to see diarrhea or soft stool from enteral nutrition.
Septic: Parenteral solutions are an ideal growth medium for bacteria (aseptic technique is
essential when administering parenteral solutions).
Monitoring of Patients during nutritional support
Patients should be weighed daily. Temperature, pulse, and respiration can be monitored
four times a day. A minimum database of packed cell volume, total protein, glucose, and blood
urea nitrogen should be performed twice a day. Monitoring electrolyte imbalances, albumin,
hypertriglyceridemia, hypercholesterolemia, hyperammonemia, and urine dipstick for glucosuria
and ketones is recommended. The patient should be monitored for volume overload.

 RER (Resting energy requirement)

amount of calories to maintain minimal metabolism;
RER = 30× body weight (kg) + 70 = kcal/day (for patients weighing 2-35 kg)
 IER (Illness energy requirement)
amount of calories required to feed an ill patient;
IER = RER × illness factor (illness factors = cage rest [1.25], postsurgery [1.30], trauma [1.5])

 PER (Partial energy requirement)

amount of calories required to supply 50% of the IER
Calculations of the nutrition
1. Calculation of protein requirement:
• Dogs - Approximately 4-6 gram/100kcal
• Cats - Approximately 6 + grams/100kcal
But it should be kept in mind that increased protein is needed in animals with severe burns and
restriction of protein for patients in renal failure. Protein requirement is typically provided by an
8.5% amino acid solution.

2. Calculation of the non protein requirement:

Non-protein calories are typically provided as a 50/50 mixture of lipid and dextrose.
Carbohydrate requirement is provided by 5% dextrose solution and lipid requirement is
provided by 20% lipid solution.
Calculation of the volumes of each nutrient solution:
• 5% dextrose solution = 0.17 kcal/ml
• 8.5% amino acid solution = 0.085 g/ml = 0.34 kcal/ml
• 20% lipid solution = 2 kcal/ml

What to Feed
As mentioned previously, a patient recovering from surgery requires protein and calories
at a higher level than its normal resting energy requirement. This can be supplied in many
forms but the easiest way is to use one of the many veterinary critical care diets available. A
syringable diet high in fat, low in carbohydrate (to combat insulin resistance) and high in omega
fatty acids, amino acids and glutamine are prescribed. The diet is very palatable and well
received by many patients. There are several other veterinary diets available and homemade
diets can also be formulated.
It is important to remember that some patients, especially cats, may develop food
aversions. When forced to eat a food when in pain or unwell, the patient may refuse to eat the
same food once forced feeding is discontinued. Always offer other alternatives so that the
patient can resume eating on its own as soon as possible. It is important to remember that a
successful surgical outcome depends heavily on post operative care and nutrition is one of the
key components.
Types of diets
Polymeric diets (Clincare, Osmolite, Jevity) contain nutrients that require digestion
before absorption can occur and are generally preferred over monomeric diets (Vivonex HN,
Vital HN ), which are composed predominately of simple molecular substrates, including mono-
and oligosaccharides and amino acids. Polymeric diets are less expensive and more physiologic
than monomeric diets, however monomeric diets are used when polymeric diets are not
tolerated such as short bowel syndromes, pancreatitis, parvovirus, pancreatic abscess, exocrine
pancreatic insufficiency and extreme IBD.
Feeding pattern of animals

Many non-injured patients do not eat well in the hospital so those recovering from surgery may
be even more challenging due to factors such as anesthetic effects and pain. Proper attention to
analgesia and comfort will make your patients more likely to regain their appetite. Depending
on the type of surgery, in most cases you will want to start feeding your patients as soon as the
noticeable effects of anesthesia have worn off. It is best to select a food with high palatability
and it may be necessary to warm the food above room temperature to increase its
attractiveness. Hand feeding may be required in some cases combined with some tender loving
care (TLC). This seems to be particularly important with cats who we all know can be extremely
finicky when it comes to food.
If the patient does not respond within 24 hours of surgery it is time to consider some assisted
feeding techniques which can range from simple to quite complicated. Some pharmacological
agents will increase appetite in cats and can be tried before physical intervention. These include
cyproheptadine (2-4 mg per cat) and diazepam (dosage varies).

Forced feeding involves using a syringe to place a semi-solid food into the pharyngeal area to
stimulate the swallowing reflex. This can be met with resistance and care must be taken to
avoid injury to the patient or the nurse. In dogs, it is best to place the syringe between the
cheek and the molars with the head held in a normal position. For cats the syringe is placed
between the four canine teeth. Some animals will refuse to swallow a bolus of food and you
must be careful not to be too aggressive or aspiration may result.

The next level of intervention is the use of an orogastric tube and should only be used on
cooperative patients that require such feeding for 2-3 days. A lubricated soft rubber tube is pre-
measured to the ninth rib and introduced gently with the head held in the normal position. Once
the patient swallows, pass the tube to the pre-measured mark and instill some sterile water to
ensure proper placement before feeding. There is some mouth gags designed to prevent the
patient from chewing on the tube.

For patients that require assisted feeding for a prolonged period it is best to place a fixed
feeding tube as this will reduce the stress on the patient and ensure proper delivery.
Naso-esophageal Tubes
Nasoesophageal tubes can be left in place for prolonged periods of
time (usually 1-2 weeks) and are generally well tolerated if
properly inserted. As noted by the term, these tubes are best
placed in the distal esophagus rather than the stomach to prevent
reflux. A number of different tube types can be used and vary in
size from 5-Fr for cats to 8-Fr for most dogs. These tubes can be
placed without anesthesia or sedation (in most cases) and are thus
preferable for patients considered anesthetic risks. After some
drops of local anesthesia, the tube is directed ventromedially to
avoid the ethmoturbinate bones and advanced to the pre-
measured mark once the swallowing reflex is initiated. Sterile water should be used to ensure
proper placement and the tube can be fixed to the skin with a couple of sutures or tissue glue
followed by a protective buster collar.

Pharyngostomy/Esophagostomy Tubes
For patients with oral trauma or for those that need a longer term of tube placement (weeks to
months), pharyngostomy or esophagostomy tubes can be used. These procedures require
anesthetic and complications include infection, hemorrhage and aspiration. Owners can
maintain these tubes at home and due to their larger size (8-16 Fr) they can tolerate a wider
range of food types than nasogastric tubes.
Gastrostomy Tubes
Gastrostomy tubes have become more popular for enteral
feeding now that different placement techniques have been
developed. The most common method employs an endoscope
but there are blind methods that can be used and special kits
that make this much easier. Food is placed directly into the
stomach and as in the other tube techniques, the patient is able
to eat on its own if it desires.
Jejunal feeding and jejunostomy

This assisted-feeding method is indicated in animals

that are unable to tolerate gastric feeding but have
normal jejunal, ileal and colonoic function. Placement
of jejunostomy tubes may be indicated in animals with
gastric outflow or proximal small-intestine obstructions
and severe pancreatitis. These tubes are most
commonly placed surgically (jejunostomy), but newer
percutaneous endoscopic gastrojejunal tube (J-G) and
fluroscopically guided nasaljejunal tube techniques
have been evaluated in dogs and cats and may play a
role in the management of hospitalized animals in the
future.

Jejunostomy tubes must be placed under general

anesthesia and are again limited in diameter (5-8 Fr). Fig: jejunostomy tube
Because nutrients delivered into the jejunum have
bypassed the major steps in digestion that occur in the stomach and duodenum, liquid
elemental diets are preferred with this feeding type and should be delivered as a constant rate
infusion over 12 to 16 hours to prevent complications, such as abdominal cramping and
diarrhea.

Surgical placement of jejunostomy tubes also carries the risks of tube displacement and
subsequent peritonitis. Jejunal feeding through a J-G or nasaljejunal tube eliminates the risk of
leakage through a jejunostomy site. These tubes can be removed or "backed out" once
pancreatitis or the intestinal disease has resolved and still allow for further enteral nutrition
without an additional procedure. These feeding tubes are best utilized in a veterinary hospital
where continued monitoring and care can be provided.

Tube removal

Gastrostomy, gastroduodenostomy and jejunostomy tubes should remain in place for at least 5
days before being removed to ensure adequate adhesion formation to prevent gastrointestinal
leakage

Complications of tube feeding

Complications of tube feeding can be divided into mechanical complications, gastrointestinal

complications and metabolic complications. Mechanical complications include improper tube
placement, GI perforation by the feeding tube, peritoneal leakage, subcutaneous leakage,
leakage through osteotomy site, regurgitation or vomiting the tube, esophageal irritation,
infection at tube exit site/focal cellulitis, tube occlusion, tube kinking, premature tube removal
by the patient and tube migration. Gastrointestinal complications include vomiting, cramping,
abdominal distension, diarrhoea, reflux esophagitis and aspiration pneumonia. Metabolic
complications include hyperglycaemia and hypophosphataemia. Tube complications can
generally resolved by slowing the feeding rate, replacing the tube, or placing a different type of
feeding tube.