Page 474 - Small Animal Clinical Nutrition 5th Edition

488 Small Animal Clinical Nutrition

Observed physiologic alterations in study cats were associated recognized for more than 40 years and are now primarily asso-
VetBooks.ir with obesity-induced oxidative damage. Calories can easily ciated with substandard catheter care. Most catheter-related
septicemias are due to microbial invasion at the catheter wound
and safely be administered peripherally to dogs and cats using
a TNA of 400 to 650 mOsm/l or an isomolar 20% lipid solu-
either during or after insertion, but other risk factors include
tion piggybacked with standard fluid therapy at volumes suf- poor patient and personnel hygiene, operator inexperience,
ficient to meet RER. i method and site of catheter insertion, duration of catheteriza-
tion and number of catheter manipulations (Bozzetti, 1985;
Other Routes of PN Infusion Yilmaz et al, 2007).
Intravascular complications associated with repeated catheter Catheters for PN administration must be placed using
placements, insufficient blood flow or coagulation abnormal- meticulous aseptic technique. Bandage contamination increas-
ities can limit vascular accessibility. Alternatives for PN sup- es the risk of infection; peripheral vein catheters are more like-
port include the intraosseous and intraperitoneal (IP) routes, ly to be exposed to and soiled by feces, urine and vomitus com-
as reported in several laboratory species, people (adults and pared to CVCs (Hansen,2006).For either peripherally- or cen-
children) and dogs. In two separate studies, rats were infused trally-placed catheters, bandage and administration sets should
with PN solutions through IP catheters for seven or more be changed at least every other day, and preferably daily. When
days. No adverse effects from the placement or use of IP the bandage is changed,the venipuncture site should be cleaned
catheters were found. Weight maintenance was dependent with an iodine solution and examined for redness, edema or
on the caloric profile of the admixture; a PN solution approx- swelling. A topical antibiotic ointment (e.g., povidone iodine)
imating 600 to 700 mOsm/l was preferred (Rubin et al, that contains antifungal properties should be applied to the
1988; LeLeiko et al, 1983). PN solutions (850 mOsm/l) have catheter-skin junction. If redness, edema or swelling is noticed,
been infused by IP routes for more than 20 days in 19 nor- the catheter should be removed and cultured and the site
mal dogs and in 12 normal dogs that had undergone intes- should be kept clean and hot packed, if necessary, to reduce
tinal resection (Moran et al, 1989; Garcia-Gamito et al, swelling. Appropriate antibiotics should be given if culture and
1991). IP infusion of a 10% lipid solution into three-month- antimicrobial sensitivity testing show the catheter or PN solu-
old beagles demonstrated that fat was quantitatively tion is contaminated.
absorbed from the peritoneal cavity over a four-hour period Cut-down incisions may be necessary for catheter placement
(Klein et al, 1983). Despite this apparent success, the IP at any location and can increase the risk of infection. Infected
route for PN support isn’t widely used in veterinary medi- or wounded skin at the catheter placement site increases the
cine. Intraosseous infusion of drugs and fluids is used as an risk of infection (Hansen, 2006). If there is no other option for
emergency, last resort access site for human and veterinary a catheter insertion site other than in close proximity to
patients. Reports of short-term PN infusion (e.g., bolus) are wounded or infected skin, aseptic placement is absolutely nec-
limited, but encouraging. Tibial intraosseous infusion is the essary. Extreme care should be exercised when assembling and
preferred site for critically ill children (Koenig, 2000), where- disassembling the admixture flow system and frequent bandage
as the sternum is reported to be the most effective site for changes are highly recommended. Tunneling or the “indirect
infusion of lipids in adults (Koenig, 2000). Likewise, a solu- catheterization” method forms a subcutaneous tunnel between
tion containing electrolytes, amino acids, dextrose and vita- the point of entry through the skin and the point of entry into
mins has been successfully infused intraosseously in dogs the vein. Catheter tunneling helps prevent infection.This tech-
(Otto et al, 1989). Several precautions exist for intraosseous nique is more commonly performed when placing a CVC for
infusions including appropriate catheter placement, avoiding long-term use. Tunnels serve as a barrier to bacterial migration
compromised skin areas and growth plates and extravasation (Hansen, 2006; Franga, 2002).
of fluid around bone cortices or vessel foramina (Moss et al, In human intensive care units, catheter-related infections are
2005). Although fat embolization is a reasonable considera- the third most common cause of nosocomial infections (CDC,
tion, it has yet to be reported in the literature. 1997). Although these data are not reported for veterinary
patients, the findings most likely would be similar. Catheter
Risks and Complications infections are either related to cellulitis from contamination at
Catheter placement and management come with potential the catheter exit site (type I) or microorganism contamination
risks. The most clinically significant problem in administering within the catheter lumen (type II). Both are due to a failure in
PN solutions involves the catheter, including loss of access, aseptic technique (Kaminski, 1997). Adding extra lumina to the
thrombophlebitis and infection generally in that order of occur- same catheter appears to potentiate the risk for type II infections
rence. Parenteral feeding can introduce additional risks not (Kaminski,1997; Early,1990; Kemp,1994).Data are controver-
associated with non-caloric fluid delivery. An overview of the sial regarding the practice of maintaining a dedicated catheter
risks and complications associated with central and peripheral line for PN administration. In the event a line cannot be dedi-
vein PN delivery follows. cated to PN administration, stopping PN delivery, flushing the
line adequately before and after delivery of medications, then
Infection restarting the PN delivery, will help minimize complications
Infectious complications with intravenous infusions have been associated with potential solution incompatibilities.