Page 484 - Clinical Small Animal Internal Medicine

452 Section 5 Critical Care Medicine

considered at the time of surgery, if applicable; their use in atrophy and prevention of gut‐derived inflammatory
VetBooks.ir contaminated wounds (bite wounds) should be avoided, complications. There are many ways of providing EN,
including voluntary ingestion, force feeding or syringe
however. Epidural administration or placement of an epi-
dural catheter can provide excellent pain management
tube feeding or surgically placed feeding tube (esophago-
for animals with pelvic limb or pelvic ring trauma. If sacral feeding, nasogastric, nasoesophageal or nasojejunal
fracture or sacroiliac luxation is present or the landmarks stomy tube, percutaneous gastrostomy tube, surgically
used for epidural administration are disrupted then placed gastrostomy tube, jejunostomy tube or gastrojeju-
epidural administration should not be performed. Local nostomy tube). The best way to provide EN will likely
anesthetic drugs can also be used systemically, with IV vary on an individual case basis and consideration should
infusion of lidocaine being useful as both an analgesic be given to several factors when deciding the best
adjunct and a promotility agent for management of ileus. method for each patient.
Both blunt trauma and burn injury are capable of Nasoesophageal or nasogastric feeding tubes are useful
inducing a very pronounced inflammatory state. The use for animals that are not stable enough for an anesthetic
of nonsteroidal anti-inflammatory drugs (NSAIDs) can event or for those that need a temporary bridge to
be very beneficial in these patients. However, animals voluntary eating or placement of a longer term feeding
that are severely traumatized or are in shock should not tube option. Nasogastric tubes can be useful for gastric
be administered NSAIDs until all tissue perfusion has decompression in animals with severe ileus and delayed
normalized and is not anticipated to change abruptly. gastric emptying. One major limitation to the use of
Patients with severe soft tissue injury or crush injury are nasoenteral feeding tubes is the limited number of diets
at risk for development of myoglobinuria and renal that can be administered through the small diameter of
failure. Any animal that has pigmenturia or evidence of the tube. Although generally well tolerated in the hospital
renal insufficiency should not receive NSAIDs. The deci- setting, these tubes are not particularly useful to send
sion to use NSAID medications should be deliberate and home with patients. Nasoenteral feeding tubes can be
if case selection is appropriate then NSAIDs may prove used in most veterinary patients but some small dogs
to be a very useful analgesic adjunct. Due to the risk of and cats may not be able to accommodate the tubes
systemic side‐effects, including further impairment of comfortably within the nasal cavity.
the already compromised immune system in these Animals that require a definitive surgical treatment
patients, animals that have suffered severe trauma or may benefit from placement of a longer term feeding
burn injury should not receive corticosteroid medica- tube option at the time of surgery. Esophagostomy tubes
tions unless specifically indicated. or PEG tubes can be placed quickly in patients under
Many animals that suffer severe soft tissue injury general anesthesia. Esophagostomy tubes can be used for
require repeated sedation events on concurrent days or provision of nutritional support immediately following
even multiple sedation events within the same 24‐hour placement but are often limited in the types of food that
period. Patients that are going to require repeated seda- they can accommodate. Tube clogging is a common
tion should be identified early in the course of hospi- problem and may necessitate altering the food formula
talization and measures should be taken to coordinate to a more watery consistency. Percutaneously placed
their care. Following repeated sedation with the same gastrostomy tubes cannot be used for nutritional sup-
anesthetic medications it is common to see recovery port for the first 24 hours to prevent leakage of gastric
times become more prolonged and patients require contents until a fibrous adhesion forms at the stoma.
larger doses of drugs to achieve the same level of seda- Surgically placed gastrostomy or gastrojejunostomy
tion due to the development of tolerance. It is good tubes can be utilized immediately.
practice to alter the sedation protocol every few days to The optimal timing of implementing nutritional sup-
prevent development of tolerance or toxicity with port is not known but evidence suggests that earlier is
repeated dosing such as reported with propofol admin- better. The clinician should strive to provide nutritional
istration in cats. Additionally, animals that are sedated support within the first 24–48 hours following severe
serially are at risk for nutritional deficiency due to trauma or burns. Patients that are hemodynamically
repeated fasting. Efforts should be made to sedate the compromised should not have nutritional support begun
animal at the same time every day to allow for the most until they are fully resuscitated and stable.
opportunities to provide nutrition. When starting nutritional support, it is important to
have a plan in place for meeting nutritional require-
Nutrition ments. There is no evidence that provision of calories in
The benefits of enteral nutrition (EN) for critically ill excess of basal energy requirement (BER) is beneficial; in
patients are well documented and include stimulating fact, it may be detrimental. Many formulas are available
production of local antibody, prevention of villous for calculating caloric requirements but the basal energy