Nutritional Support In Pancreatitis: A Retrospective Study

Nutritional management of acute pancreatitis in dogs and cats

OBJECTIVE

To review current and emerging nutritional approaches in the management of acute pancreatitis (AP) in people, dogs, and cats, and to provide a framework for further investigation in this field.

DATA SOURCES

Veterinary retrospective studies and reviews, human prospective clinical trials and reviews, and experimental animal studies focusing on nutritional management during AP.

SUMMARY

Nutritional management is an important part of the treatment plan for patients with AP. In human medicine, the general approach for providing nutrition in patients with AP has changed in recent years and favors enteral over parenteral nutrition with an emphasis on early enteral nutrition (EN). Although there are limited data available, there is increasing evidence in the veterinary literature that supports the beneficial role of EN in AP and contradicts previous assumptions about poor tolerance to enteral feeding in this patient population. Parenteral nutrition may be appropriate alone or in combination with EN as a temporary measure in malnourished patients that do not tolerate adequate EN; however, enteral feeding should be attempted first in most cases. Immunonutrition is being investigated for its positive role in modulating pancreatic inflammation and improving gut barrier function in cases of human AP.

CONCLUSIONS

The nutritional management of veterinary patients with AP remains challenging. Based on clinical evidence in people, experimental animal studies, and preliminary studies in dogs and cats, the choice of EN over parenteral nutritional support during AP in dogs and cats appears to be beneficial and well tolerated. Optimization of nutritional therapies in dogs and cats including the use of immunonutrition during AP warrants further investigation.

Prospective evaluation of a peripherally administered three-in-one parenteral nutrition product in dogs

OBJECTIVES

Peripheral parenteral nutrition is an option for short-term nutritional support in dogs which cannot be supported with enteral nutrition. The objective of this study was to examine the use of a three-in-one, 840 mOsmol/l peripheral parenteral nutrition product containing amino acids, lipids and glucose in separate compartments in dogs.

METHODS

Nine dogs were administered the three-in-one product, and two dogs were administered the amino acid part of the product, via a peripheral vein. Dogs were monitored for mechanical and metabolic complications.

RESULTS

Mechanical complications (apparent thrombus or thrombophlebitis) caused failure of infusion at a median of 36 hours. None of the dogs appeared to develop catheter-related sepsis. Using a 10-hour infusion period appeared to decrease the incidence of line failure. Mild and clinically non-significant hyperglycaemia was the only metabolic complication. In four of the dogs, serum folate, cobalamin and homocysteine concentrations were determined before and after peripheral parenteral nutrition administration. Oral and parenteral administration of methionine has been previously associated with lowered serum folate concentrations. Low serum folates and the subsequent hyperhomocysteinaemia have been associated with venous endothelial damage and venous thrombus in other species. Serum cobalamin also affects homocysteine metabolism. Median serum folate, cobalamin and homocysteine concentrations were not affected by the short-term administration of this three-in-one product.

CLINICAL SIGNIFICANCE

Using the product for 24 hours/day may require catheter replacement due to line failure. Other than line failure, which may be improved by 10- to 12-hour infusion times, this product was found to be safe and practical for short-term peripheral parenteral nutrition in dogs.

Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs

OBJECTIVE

To evaluate feasibility of performing laparoscopic-assisted placement of a jejunostomy feeding tube (J-tube) and compare complications associated with placement, short-term feedings, and medium-term healing with surgically placed tubes in dogs.

DESIGN

Prospective study.

ANIMALS

15 healthy mixed-breed dogs.

PROCEDURES

Dogs were randomly allocated to undergo open surgical or laparoscopic-assisted J-tube placement. Required nutrients were administered by a combination of enteric and oral feeding while monitoring for complications. Radiographic contrast studies documented tube direction and location, altered motility, or evidence of stricture.

RESULTS

Jejunostomy tubes were successfully placed in the correct location and direction in all dogs. In the laparoscopic group, the ileum was initially selected in 2 dogs, 2 dogs developed moderate hemorrhage at a portal site, and 2 J-tubes kinked during placement but were successfully readjusted postoperatively. All dogs tolerated postoperative feedings. All dogs developed minor ostomy site inflammation, and 1 dog developed bile-induced dermatitis at the ostomy site. Despite mild, transient neutrophilia, no significant difference was noted in WBC counts between groups. No dog had altered gastric motility or evidence of stricture, although the jejunopexy site remained identifiable in several dogs at 30 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Requirements for successful J-tube placement were met by use of a laparoscopic-assisted technique, and postoperative complications were mild and comparable to those seen with surgical placement. Laparoscopic-assisted J-tube placement compares favorably to surgical placement in healthy dogs and should be considered as an option for dogs requiring enterostomy feeding but not requiring a celiotomy for other reasons.

Evaluation of complications and prognostic factors associated with administration of total parenteral nutrition in cats: 75 cases (1994–2001)

OBJECTIVE

To determine frequency and types of complications, prognostic factors, and primary diseases affecting clinical outcome associated with administration of total parenteral nutrition (TPN) in cats.

DESIGN

Retrospective study.

ANIMALS

75 cats that received TPN for > or = 12 hours.

PROCEDURE

Medical records were reviewed, and information was obtained on signalment, history, problems at initial evaluation, physical examination findings, weight and changes in weight while receiving TPN, duration in the hospital before initiation of TPN, the type of TPN catheter used, duration of TPN administration, and final diagnosis. Laboratory results obtained immediately prior to TPN and at 24 and 96 hours following initiation of TPN administration were compared.

RESULTS

Reports of weight loss at initial evaluation, hyperglycemia at 24 hours, or diagnosis of chronic renal failure were significantly associated with increased mortality rate. Greater serum albumin concentrations prior to and at 96 hours following TPN administration were significantly associated with decreased mortality rate. Mechanical and septic complications were infrequent and not associated with increased mortality rate. Most cats had multiple diseases. The overall mortality rate was 52%; among 75 cats, 36 recovered, 23 were euthanatized, and 16 died as a result of their primary illness or complications associated with their illness.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated high mortality rate in cats maintained onTPN that had multiple concurrent diseases associated with a poor prognosis. Indicators of poor prognosis included a history of weight loss, hyperglycemia at 24 hours following TPN administration, hypoalbuminemia, and chronic renal failure.

Laparoscopic-assisted enterostomy tube placement and full-thickness biopsy of the jejunum with serosal patching in dogs

OBJECTIVE

To develop laparoscopic-assisted techniques for enterostomy feeding tube placement and full-thickness biopsy of the jejunum in dogs.

ANIMALS

15 healthy dogs. PROCEDURE Dogs were anesthetized, and positive pressure ventilation was provided. A trocar cannula for the laparoscope was inserted on the ventral midline caudal to the umbilicus. For enterostomy tube placement, a second trocar cannula was placed lateral to the right rectus abdominis muscle, and a Babcock forceps was used to grasp the duodenum and elevate it to the incision made for the cannula. The duodenum was sutured to the abdominal wall, and a feeding tube was inserted. For jejunal biopsy, a third trocar cannula was placed lateral to the left rectus abdominis muscle. A portion of jejunum was elevated to the incision for the second or third cannula, and a full-thickness biopsy specimen was obtained. A second specimen was obtained from another portion of jejunum, and retention sutures for the 2 biopsy sites were tied so that serosal surfaces of the biopsy sites were apposed to each other. Dogs were euthanatized 30 days after surgery.

RESULTS

The enterostomy tube was properly positioned and functional in all 8 dogs that underwent laparoscopic-assisted enterostomy tube placement, and sufficient samples for histologic examination were obtained from all 7 dogs that underwent laparoscopic-assisted jejunal biopsy. None of the dogs had any identifiable problems after surgery.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that in dogs, laparoscopic-assisted procedures for enterostomy tube placement and jejunal biopsy are an acceptable alternative to procedures performed during a laparotomy.

Nitrogen balance in clinically normal dogs receiving parenteral nutrition solutions

OBJECTIVE

To determine nitrogen balance in clinically normal dogs receiving parenteral nutrition solutions.

ANIMALS

8 clinically normal female Beagles.

PROCEDURE

Dogs were randomly assigned to receive 4 treatments in random order. Treatment A consisted of IV administration of nonlactated Ringer's solution. Treatments B, C, and D consisted of IV administration of isocaloric parenteral solutions containing 0, 1.36, and 2.04 g of amino acids/kg of body weight/d, respectively, for 7 consecutive days. Urine and feces were collected on days 5, 6, and 7 of each treatment period, and Kjeldahl analysis was used to determine nitrogen balance.

RESULTS

Mean nitrogen balance was negative with treatments A and B but was not significantly different from 0 with treatments C and D. Dogs had the lowest nitrogen balance values and lost the most weight while receiving treatment A. Dogs were able to conserve protein and had higher nitrogen balance values when receiving treatment B, compared with treatment A. Dogs lost the least amount of weight while receiving treatment D. Regression analysis indicated that an IV amino acid intake of 2.32 g/kg/d (95% confidence interval, 2.00 to 2.81 g/kg/d), as supplied by the commercial product used in this study, would result in zero nitrogen balance in clinically normal dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that IV amino acid requirement of clinically normal dogs is approximately 2.3 g/kg/d.

The various types of parenteral fluids and their indications

Assessment of hydration and perfusion is essential in patient evaluation. The acid-base and electrolyte disturbances that accompany many illnesses should also be considered. The duration of illness and body systems involved are also of major importance in patient evaluation. Fluid therapy is an important and potentially life-saving treatment of many and varied problems. The clinician must be able to assess the patient and determine whether the intravascular or extravascular compartments, or both, are deficient. Of primary concern is the status of the intravascular volume, then restoration of total body water and electrolytes. Fluid therapy is divided into three phases; the emergency phase, the rehydration phase, and the maintenance phase; not all patients require the three-phase therapy. The clinician must also be able to select (1) the appropriate solution to treat the volume deficit and correct the acid-base and electrolyte abnormalities and (2) the rate of administration to optimize outcome. Therefore, knowledge of electrolyte composition in plasma and of the various types of commercially available fluids is essential in order to select the appropriate therapy for the individual animal. In addition to the therapeutic aspects of fluid therapy, a knowledge of the side effects and complications of inappropriate fluid selection and rate of delivery is also important. With the individual requirements of each patient seen in a practice, the prescription approach to parenteral fluid therapy will optimize patient response to this extremely important aspect of overall patient management as well as make the practice of fluid therapy intellectually stimulating. This article has introduced the clinician to the parenteral fluids available and their indications in veterinary patients; it also contains a discussion of how to utilize preferred solutions for treatment of specific diseased states. Although there are definite "right" and "wrong" fluids to select for specific problems, there also remains individual preference in fluid choice, which is based on appropriate laboratory data and the practitioner's clinical judgment of the status of the individual patient vis-à-vis the spectrum of its disease. Recommendations for selection of different fluid types to treat similar conditions are usually based on these variables.