Presenter Suraj Subedi Roll no. 29 B. V. Sc. & A. H., 9th sem1

Care of the surgical patient does not end when the procedure is finished. Postoperative care of surgical patients often determines the ultimate outcome; with critical patients it may determine whether they survive.2

Patients Outcome in relation to 3 different aspects of surgeryPostoperative Manageme nt

Patients OutcomePreoperative Manageme nt

Surgical procedure3

Postsurgical ManagementyNormalization of Homeostasis yControl of Pain yPrevention of Secondary Infection yEarly Recognition of Complications yNutritional Management4

Nutritional ManagementPatient Requirement

Feeding Route

Proper Nutrition of Post surgical patients5

Calorie Requirementsy Basal Energy Requirement (BER)y Animal less than 2 kg body wt.

y Animal more than 2 kg body wt.

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y Maintenance Energy Requirements

(MER)

Associated Clinical Problems Cage Rest Postsurgical Stress Trauma or Cancer Sepsis Major Burns

Factor

1.00 1.25 1.25 1.35 1.35 1.5 1.50 1.70 1.70 2.007

Protein Requirements

Species

Maintenance

Hepatic or Renal failure

Canine

5.0 7.5 g/100 kcal

< 3.0 g/100 kcal

Feline

6.0 9.0 g/100 kcal

< 4.0 g/100 kcal

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How the nutrients are provided???Nutrients

Enteral Nutrition

Parenteral

Normal Voluntary

Hyperalimentation9

Parenteral Nutritiony Provision of the readily utilized nutrients in their simplest form

that a body can utilize.y Route is the slow continuous infusion through catheter i/v. y Indicated when intestine cannot adequately absorb nutrients

(severe malabsorption, impaired motility, massive small bowel resection etc.)y 8.5% amino acids with electrolytes (protein source), 10 to 20%

lipids (fat) and 50% dextrose ( carbohydrate) are generally used. B-complex are added at 1-2 ml per ltr.10

Common Parenteral Infusionsy Hermin T (Alembic) y Aminodrip (Wockhardt) y Aminosteril-N Hepa 8% (Fresenius Kabi) y Intralipid (Fresenius Kabi) y Dextrose 50%

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Complications of Parenteral Nutritiony Catheter kinking and displacement y Phlebitis y Thrombosis y Sepsis y Hyperglycemia y Hyperlipidemia y Azotemia y Electrolyte imbalance12

Enteral Route of nutritiony Ideal enteral diet should be well tolerated, readily digested

and absorbed, contain essential nutrients, be readily available, inexpensive, have a long shelf life and easy to use.y diets should be isotonic (approx. 300 mOsm/L) y Caloric density of approx. 1.0 kcal/ml y Include fiber at 1.0 to 1.5 g/100 kcal and y provide approx 16% of total calories as protein and approx

30% of calories as fat.13

Types of Enteral DietsA. Monomericy y y y

Indicated in patients with Gastrointestinal disorders crystalline amino acids for protein glucose and oligosaccharides as carbohydrate safflower oil as essential fatty acids source indicated for patients with intact digestive and absorptive function contain large molecular weight proteins, carbohydrates and fats.

B. Polymericy y

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Some commercial dietsy Polymeric Dietsy Jevity Osmolite HN y Impact y Vital HN y ProMod

y Monomeric Dietsy Vinonex HN15

A homemade dietFor dog and caty 1 jar baby food y 1 cooked egg y 15 ml corn oil y 15 ml corn syrup y 100 ml water

Nutrient : 1 kcal/ml

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Enteral Hyperalimentaiony Designate supplying of the nutrients by methods likey Nasoesophageal y Pharyngostomy y Esophagostomy y Gastrotomy y Enterostomy

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Nasoesophageal intubationy Small bore soft polyvinyl and silastic feeding tubes y Well tolerated y Can be left for several days y Can drink and swallow around the tubes avoiding

repeated intubation.y Liquid diet administered y Cats and Dogs < 15 kg wt. : 5 French X 91 cm

Dogs > 15 kg wt. : 8 French X 91 cm18

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Pharyngostomyy Contraindicated for patients with esophageal disorders

(

i.e.

esophagitis,

esophageal

stricture,

recent

esophageal surgery, esophageal foreign body removal, neoplasm).y Larger diameter gen. 20

24 French.

y Placed upto the midesophagus

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Esophagostomyy Large bore tubes 20

24 French

y Eliminates coughing, laryngospasm, and/or aspiration

occasionally associated with laryngostomy tubes.y Disadvantage:

need for general anesthesia for tube

placement

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Gastrotomyy Ease of patience, patients tolerance y Large bore size y Oral feeding can commence normally y Disadvantage:y Need for specialized instrument y General anesthesia y Waiting for 12

24 hrs before initiating feeding23

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Enterostomyy Celiotomy is required for placement of these tubes y A 5French , 36 inch infant needle used y Highly digestible food materials are supplied

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Rate and Volume of Feedingy Depends upon the state of patient and capacity of intestine y Normal canine and feline capacity: 80 ml fluid/ kg b. wt. y Anorectic Patients: 30 40 cc fluid/kg b. wt. and gradual

increase over 2-3 days.y A minimum of 3 feedings daily28

Guidelines for feeding via an Enterostomy tubey Calculate total requirement y Give of calculated volume during first 24 hrs y Give of calculated vol. during second 24 hrs y Give of calculated volume during third 24 hrs y Give entire calculated volume during fourth 24 hours y Note: a minimum of 4-5 feedings /day needed.29

Complications of enteral hyperalimentationy Mechanicaly inadvertent tube placement in trachea or peritoneal cavity y gut perforation y regurgitaion in tube y Irritation y infection at exit site y Occlusion y tube removal30

y Gastrointestinaly Vomiting y Cramping y abdominal distension y diarrhoea

y Metabolic complicationsy Hyperglycaemia (major) y Hypophosphatemia y hyperkalemia31

Referencesy Bojrab, M. J. 1998. Current Techniques in Small Animal Surgery, 4 th

edition, Williams & Wilkins, USAy Denise, A. E. Parenteral Nutrition. In

http://www.vin.com/proceedings/Proceedings.plx? CID=WSAVA2004&Category=1252&O=Generic Accessed on 24th may, 2011y Denise , A. E. Home Made Diets In

http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA200 4&Category=1252&O=Generic Accessed on 24th may, 2011y Fossum.,T. W. 1997. Small Animal Surgery. 1st Mosby, USA y Pierson, A. L. Feeding tubes for Cats In www.catinfo.org accessed

on 25th may, 201132

Thank You33

Questions are highly welcomed

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