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The importance of nutrition in trauma cases

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01 December 2016, at 12:00a.m.

Õnne-Marju Russak reports on a five-year-old Pomeranian admitted after being attacked by another dog, and stresses the need to prevent malnutrition in ill patients that are reluctant to eat.

HETTY IS A FIVE-YEAR-OLD Pomeranian presented to Pride Veterinary Centre emergency services in Derby after being attacked by another dog.

On arrival, Hetty’s mentation was abnormal and she was ambulatory but lame on her right back leg. She had sustained bilateral mandibular fractures behind the canines and showed multiple bruises and wounds all over her body. She was in shock.

Hetty was admitted to the hospital for immediate stabilisation and further investigation. An intermittent menace response meant an ophthalmic examination was performed first but didn’t ascertain any deficits. Hetty was then anaesthetised for further evaluation.

A full x-ray study of the thorax, head and spine were performed. Neither haemothorax or pneumothorax was detected and all bony structures except for the mandible were intact.

In the following 12 hours an exploratory laparotomy (with no remarkable findings) and mandibulectomy were carried out, at which point an oesophagostomy tube was placed for nutritional support.

Hetty weighed 4.2kg when admitted to the hospital and 4.1kg when she was discharged five days later. In trauma patients it is very important to maintain daily calorie intake at sufficient level.

Results of malnutrition

Studies with humans and animals have shown that malnutrition in clinically ill patients results in impaired immune function, wound repair and response to therapy, a slower recovery time and an increased chance of infection.

If trauma cases such as Hetty are not willing to eat voluntarily, a feeding tube is a good alternative.

The nutrient groups which provide the vast majority of energy include carbohydrates, fats and proteins. Studies have even shown that the body’s nutrition requirements increase in cases of surgery, infection, trauma, burns and fever.

Glycogen, which is found in the liver and muscle tissues, is an easily-accessed store of excess carbohydrate. Triglycerides in the fat tissue serve as fat storage. However, as there are no storage forms of protein, this is one reason why their continual intake is extremely important. 

Endogenous proteins are important in many processes within the body: for example, carrying other metabolites, serving as structural components, as enzymes, etc.

With regards to nutrition in emergency settings, it is important to keep in mind immediate glucose levels as well. In the state of starvation the body will start to synthesise glucose from glycogen. Glycogen reserves will be depleted in 24-48 hours after which the next substrate for glucose production is lactate, glycerol and certain amino acids.

Balanced diet

In order to provide calories to critically ill patients, a balanced diet of carbohydrates, fat and protein is needed. Diets high in fat are generally promoted because highly digestible, fatty acids are a high-yield source of energy (rather than glucose) for patients in a catabolic state. This also helps the organism to use dietary protein for anabolic processes instead.

Generally accepted recommendations after a period of starvation are to start with a third to a quarter of the daily caloric intake in the first day, divided into four to six small meals. If there are no adverse (mainly gastrointestinal) effects, intakes should be gradually increased to reach the normal calorie intake by the third or fourth day.

Close monitoring of the patient’s body weight and body condition should be used to help to adjust the calorie intake for each individual patient.

The enteral route is always preferred over the parenteral route, due to greater chances of complications via venous feeding. Tube placement usually needs sedation or, depending on the tube chosen, general anaesthesia.

As these patients are usually critically ill, it is very important to assess their stability for general anaesthesia. Based on the condition, there are different tubes to choose from: nasoesophageal tube, oesophagostomy tube and gastrostomy and jejunostomy tube.

When Hetty was anaesthetised for further evaluation, an oesophagostomy tube was placed for enteral feeding and Royal Canin Convalescence Support (instant powder) was chosen.

The powder can be easily diluted with 150ml of warm water to create a liquid which could be comfortably administered via the feeding tube. This diet contains: 

  • milk proteins 
  • vegetable oil (soya) 
  • barley malt
  • minerals
  • dried egg yolk
  • vegetable fibre
  • fructo-oligo-saccharides (FOS)
  • marigold meal (source of lutein)
  • soya lecithine
  • antioxidants and vitamins.

The synergistic antioxidant complex reduces oxidative stress by helping neutralise free radicals. Highly digestible ingredients compensate for the decreased activity of intestinal enzymes, ensuring an optimal nutrient supply.

Resting energy requirements for Hetty were calculated based on the following formula: (30 x kg) + 70, which in Hetty was 200Kcal/day. On the first day the enteral feeding was started with a third of daily requirements (66Kcal) which was then divided to five meals.

This calculation is based on a caloric density of Convalescence Support of 1.1Kcal/ml. This resulted in 12ml of Convalesence per feed. As the diet is diluted in water, we also need to be mindful of our patient’s daily fluid requirements, set at 50ml/kg/24 hours. This fluid intake had to be considered while Hetty was on intravenous fluids.

In patients who haven’t eaten for several days, a reintroduction of food should also be made over several days to avoid causing diarrhoea and hyperglycaemia.

On the second day, Hetty was fed 24ml of Convalescense which represented two-thirds of daily calorie intake and on the third day the volume of food given was 36ml.

Simultaneously, she was on twice-daily maintenance fluids intravenously (4ml/kg), ensuring at all times fluid intakes were balanced.

One notable achievement is that Hetty weighed 4.2kg when she was admitted and 4.3kg on the third day of hospitalisation. Our  first priority was stabilisation and weight maintenance, of course, and after the third day she started to eat on her own. On discharge she weighed 4.1kg.

Hetty was discharged five days after admission. She didn’t lose any further weight and her appetite remained healthy. Hetty benefited from nutritional support and by this we managed to reduce her hospitalisation time.

References and further reading

Giuliano, E. (2015) Canine Ocular Emergencies. Veterinary Focus 25 (3): 10-17. 2. Heyland, D. (1988) Nutritional support in the critically ill patient. A critical review of the evidence. Critical Care Clinics 14 (3) 423-440.

King, L. and Boag A. (eds) (2007)

BSAVA Manual of Canine and Feline Emergency and Critical Care, 2nd edition: BSAVA, Gloucester. 4. Murphy, K. (2011) Feed Me: I’ve Just Had Surgery. Lecture at BSAVA congress, Birmingham. 


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