Feeding the emaciated patient

•Was there access to water & food? •What food was accessible to the patient? •How much food was accessible to the patient? •How will the pet be managed upon returning home?

assess the diet and feeding management

•Depends on initial BCS and duration of hyporexia •Maybe < 4/9 •Maybe > 4/9 (e.g. cat with hepatic lipidosis)

assess the patient: BCS

•Depends on initial MCS, duration of hyporexia and concurrent disease

assess the patient: MCS

•RBCs - anemia may occur with chronic malnutrition, but isn't specific to malnutrition •Leukocytes - leukopenia may occur with chronic malnutrition, but isn't specific to malnutrition Dehydration? •Correct before applying nutritional support

assess the patient: clinical evaluation: CBC

1. Encephalopathy (hepatic) 2. Trauma (including burns) •Oral •Head •Neck •Abdomen 3. Is the gastrointestinal tract (GIT, gut) functional? •Vomiting •Diarrhea •Ileus •Coma •Lower esophageal sphincter (LES)

assess the patient: clinical evaluation: abnormalities that influence nutrition recommendations

•Electrolyte abnormalities? - correct before applying nutritional support •*Glucose* •*Potassium* •*Phosphorus* •Magnesium •Calcium •Albumin - low with low protein diet, liver dysfunction •BUN - low with low protein diet, liver dysfunction; elevated with high protein diet, kidney dysfunction •Creatinine - low with reduced muscle mass; elevated with kidney dysfunction

assess the patient: clinical evaluation: chemistry

•If hyporexic, for how long? •If anorexic, for how long? •Does the caregiver know when the pet last ate? •Mealtime behavior Initial interest, but sniffs and walks away No initial interest

assess the patient: history and observations

•BCS < 4/9 •Recent unintended wt loss >10%BW •Anorexia or Hyporexia >3 days •Laboratory abnormalities: Hypoalbuminemia, anemia, lymphopenia, electrolyte abnormalities

assess the patient: indications for nutritional support

-RER for current body weight -Day 1 25-50% RERc -If no hyperglycemia, hypokalemia, hypophosphatemia or evidence of GI dysfunction (nausea, vomiting, diarrhea), then •Increase to 50-100% RERc on day 2-4 •Speed of transition to 100% RERc should be slower for: prolonged anorexia, BCS 1/9-3/9 Potential for complications (GI dysfunction suspected)

assess the patient: initial goal: RERc

•Enhance •Neutral (NRC) •Restrict •Depends on what the underlying disease is limit fat in patients with pancreatitis, EPI, lymphangectasia

assess the patient: key nutritional factors: fat

•Restrict (generally) •Highly digestible •Fermentable fiber for GI health

assess the patient: key nutritional factors: fiber

•Enhance •Neutral (NRC) •Restrict •Depends on what the underlying disease is •Glutamine

assess the patient: key nutritional factors: protein

-The patient didn't lose weight overnight, so no rush to achieve ideal BCS -Physiologic adaptation to starvation: •Reduced thyroid hormone production •Reduced digestive enzyme production •Reduced basal metabolic rate •Primarily catabolizing adipose

be proactive, but dont overfeed

Inability -Dysfunction: Mandibular fracture -Coma Unwillingness -Pain -Pain meds: opioids -Nausea -Stress/fear -Hepatic lipidosis pain negatively influences appetite, and some opioids can as well

causes of hyporexia and anorexia

•Malnutrition •Weight loss •Reduced BCS •Reduced MCS •Ketone production •GI dysfunction: Stasis, Reduced digestive enzyme secretion, Enterocytes (glutamine), Colonocytes (butyrate) •Insulin resistance: Secondary to reduced non-fiber carbohydrate intake & inflammatory mediators •Hepatic lipidosis

consequences of hyporexia and anorexia

•Hyporexia or anorexia •Unable •Unwilling •Unable to preserve lean tissue

critical patient def

the sick patient that doesn't want to eat or can't eat. The ill patient is less able to adapt to starvation due to ensuing stress and inflammation; protein catabolism generally occurs at a faster rate during starvation -The critically ill patient is stressed; in the critically ill patient ... •the neuroendocrine response stimulates release of catecholamines, glucocorticoids, glucagon, ADH -> stimulates metabolic rate •pro-inflammatory mediatiors (e.g. TNF) promote insulin resistance and hyperglycemia

critically ill def

indications: if the gut works, feed it! -Pros: physiologic, long term, can meet all essential nutrients -Cons: need a gag reflex -Routes: NE, NG, E, G, J tube

enteral feeding

•Maintain current BW until stable •Stop further weight loss •Neutral energy balance

initial goal

indications: +/- active vomiting, ileus, pipe stream diarrhea -Pros: do not need a gag reflex -Cons: Higher risk of metabolic complications, cost, short term (~1 week), does not meet all essential nutrients -Routes: Central catheter, peripheral catheter

parenteral feeding

•Starved patients without underlying disease typically have a very good appetite: So, generally do NOT need an energy dense food for starved patients without underlying disease •Critical patients may need an energy dense food •Life-stage appropriate

recommendations: general considerations

Voluntary •Environment •Food palatability •Palatants •Appetite stimulants Assisted feeding •Enteral •Parenteral

recommendations: method

•Shift to carbohydrate metabolism •Insulin secretion •Intracellular shift of P & K •Death within 3-5 days Hyperglycemia, hypokalemia, hypophosphatemia, which can lead to cardiac failure Risk is highest in the first week Risk is greater with high starch feeds & parenteral nutrition Feeding too aggressively can also lead to malassimilation --> diarrhea

refeeding syndrome

•Neglect, appetite is good •Attempt to preserve lean tissue referring to the otherwise healthy patient that has inadequate access to adequate feed quantity or quality; the neglected animal. The otherwise healthy starved patient (no underlying disease) is better apt to dealing with starvation. The body adapts metabolically to starvation by altering hormone production, reducing basal metabolic rate, and using body fat as the primary energy source

starved def

-Capromorelin (Entyce) •Dogs •Ghrelin agonist -Cyproheptadine •Cats* •Serotonin antagonist -Remeron (Mirtazapine) •Dogs & Cats •Serotonin antagonist also consider anti nausea therapy (maropitant; cerenia), ondansetron

voluntary appetite stimulants

•Minimize noise •Provide a "safe space": Box to hide in, Cover front of the cage •Proximity of food/water to little box •Physical barriers: E-collars, Face shape & bowl diameter, Bowl height

voluntary: environment