VETtech U Proceedings 2024

PROCEEDINGS GUIDE

Saddle up

for a wild ride,

VETgirl Pack!

2024

Welcome to our inaugural VETtech U conference brought to you by VETgirl, Royal Canin, and Merck!

We are thrilled to connect with this exclusive group of veterinary technicians who are the heartbeat of the veterinary world. Knowing your dedication, we are set to pamper you VETgirl-style during these upcoming days! Our team is eagerly awaiting to host you in the charming city of Houston. Start by settling into your hotel room, then venture out to explore the venue! Discover the rich history of the C. Baldwin and make sure not to miss the hidden speakeasy! Upon checking in, head to the registration area in the B. Jordan pre-function foyer on level 2. Here, collect your badge (your access pass for the weekend) and the fantastic VETtech U conference swag! Our amazing sponsors have put together quite an array of goodies for you to take home. Visit their booths (only five to explore!), get scanned for a chance to win more prizes and raffles! While you're here, relax and soak up the insights from our exceptional speakers and VTS gurus, covering topics from wellness to practice management! To kick off your experience, make sure to attend the Friday evening reception in the Lobby Bar at the C. Baldwin Hotel for drinks and light bites! Enjoy complimentary meals and connect with a remarkable community of veterinary technicians and resources throughout the weekend. During your free time, explore the vibrant Houston Galleria. Known for its shopping, dining, and entertainment options, the Houston Galleria district offers a diverse range of retail stores, gourmet restaurants, and chic boutiques for you to discover.

Thank you for joining us at VETtech U. We promise we will try to meet your every need while here! Immerse yourself in the knowledge and enjoy the experience! It is an honor to share this weekend with you.

Warm regards,

Amy Johnson BS, LVT, RLATG, CVJ - Senior CE Manager Tiffany Gendron CVT, VTS (ECC) - CE Specialist Amanda Shelby RVT, VTS (AA) - Senior CE Specialist The Entire VETgirl Team (Family)

TABLE OF CONTENTS

SCHEDULE

Get ready for a whirlwind of CE in H-Town! 14 hours packed with learning.

SPEAKERS

Get ready to be wowed with 11 industry giants about to rock the stage!

Sponsored by

Panel SESSION 5 | LUNCH/MO' WELLNESS, MO' HEALTH: TECHNICIAN LEAD NUTRITION SESSIONS Sponsored by Chantelle Hanna, CVT, VTS (Dermatology) Alexia Vilchis, LVT SESSION 6 | "SWEET" AND LOW: TECH TIPS FOR CLIENT EDUCATION ON DIABETES | OTITIS: INSIDE & OUT Sponsored by Kara M. Burns , MS, MEd, LVT, VTS (Nutrition) SESSION 7 | TINY TAILS, BIG ADVENTURES: TECHNICIAN PEDIATRIC, COUNSELING Sponsored by Brianne Morrow , LVT, VTS (Nutrition) Walter L. Brown , RVTg VTS (Emergency & Critical Care) SESSION 8 | SURVIVING PARVO: VETERINARY NURSING STRATEGIES FOR PUPPIES IN CRISIS Sponsored by Brianne Morrow , LVT, VTS (Nutrition)

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

FROM ADMISSION TO RECOVERY: NAVIGATING THE HOSPITALIZED PATIENT WALTER L. BROWN, RVTg VTS (ECC)

Sponsored by

SATURDAY AM • SEPTEMBER 21 8:15 – 9:15 AM

Effective patient management is crucial for successfully treating and recovering hospitalized animals in veterinary medicine. This paper explores the various aspects of patient management in veterinary hospitals, emphasizing essential protocols and practices for optimal outcomes. It underscores the significance of integrated patient management strategies encompassing medical treatment and the patients' environmental and psychological needs. PATIENT ASSESSMENT & TRIAGE The initial assessment and triage of veterinary patients are crucial in determining the urgency and type of care required. Rapid assessment techniques are used to identify life-threatening conditions and initiate appropriate interventions. The primary survey focuses on the ABCs: Airway, Breathing, and Circulation, while the secondary survey involves a detailed physical examination to identify any additional injuries or abnormalities. Triage categorizes patients based on the severity of their condition and the immediacy of required care. 1. Immediate: Patients needing urgent care to prevent death or severe deterioration. 2. Urgent: Patients requiring prompt attention but are not in immediate danger. 3. Delayed: Patients with stable conditions that allow for a brief delay in treatment. 4. Non-urgent: Patients with minor issues that do not require immediate intervention. Proper triage ensures that resources are allocated efficiently, prioritizing those in critical need while still attending to all patients appropriately.

decisions. Setting clear expectations about the pet’s condition, potential outcomes, and the next steps in the treatment plan is equally essential. Transparent and empathetic communication helps build trust and ensures that owners are well informed and prepared for their pets’ care. STABILIZATION & IMMEDIATE INTERVENTION Stabilization and immediate intervention are critical for veterinary patients needing medical attention. Fluid therapy is a cornerstone of stabilization, addressing dehydration and shock, and maintaining adequate circulation. There are two primary types of fluids used: crystalloids and colloids. Crystalloids, such as saline or lactated Ringer's solution, are typically used for volume expansion and hydration. Colloids, like hetastarch or plasma, are used for patients requiring more substantial volume support due to their ability to stay within the vascular space longer. Calculating the shock dose, typically 80-90 mL/kg for crystalloids in dogs and 40-60 mL/ kg for cats, is essential to ensure appropriate fluid resuscitation. Monitoring and adjusting fluid therapy based on the patient’s response is vital to prevent complications such as fluid overload. Pain management is crucial for immediate intervention. Standardized pain assessment scales like the Glasgow Composite Pain Scale (canine) (feline) or the Colorado State University Pain Scale allow for appropriate intervention. Pharmacologic options include NSAIDs, opioids, and local anesthetics. Tailoring pain management to individual needs improves comfort, aids recovery, and reduces stress-related complications. Oxygen therapy is often needed for respiratory distress or hypoxia. Delivery methods include nasal cannulas, oxygen cages, or mechanical ventilation. Continuous oxygenation monitoring ensures adequate support and guides therapy adjustments for better outcomes.

Effective communication with pet owners is crucial for the initial assessment and triage. Gathering a concise and accurate history from the owner is essential for informed diagnostic and treatment

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

FROM ADMISSION TO RECOVERY: NAVIGATING THE HOSPITALIZED PATIENT (CONT.)

Sponsored by

SATURDAY AM • SEPTEMBER 21

WALTER L. BROWN, RVTg VTS (ECC)

DIAGNOSTIC PROCEDURES Diagnostic procedures are crucial for accurately assessing and managing hospitalized veterinary patients. Laboratory tests provide essential information about a patient’s health status. A complete blood count (CBC) is routinely performed to evaluate red and white blood cell counts, hemoglobin levels, and platelet counts, helping to identify infections, anemia, and other blood-related conditions. Blood chemistry tests assess organ function by measuring electrolytes, enzymes, and metabolic byproducts, offering insights into liver and kidney health, among other parameters. Coagulation profiles, including tests like PT (prothrombin time) and aPTT (activated partial thromboplastin time), are crucial for identifying bleeding disorders or monitoring patients on anticoagulant therapy. Blood glucose measurements are essential for managing diabetic patients and those with suspected hypoglycemia or hyperglycemia, ensuring proper glucose control. Imaging techniques are essential in veterinary diagnostics, providing visual insight into the patient’s internal structures. Radiography (X-rays) is commonly used to examine bones and thoracic and abdominal organs, aiding in diagnosing fractures, tumors, and respiratory or gastrointestinal issues. Ultrasonography offers a non-invasive method to visualize soft tissues and organs, such as the heart, liver, kidneys, and bladder. It is particularly useful for guided biopsies or detecting fluid accumulations. Advanced imaging modalities like CT (Computed Tomography) and MRI (Magnetic Resonance Imaging) are used when detailed cross-sectional images of complex structures are required. However, their use may be limited to specialized facilities. Point-of-care testing, such as packed cell volume/total solids (PCV/TS) and blood gas analysis, provides rapid, bedside results crucial for the immediate evaluation of hydration status, anemia, and acid-base balance, enabling timely and appropriate therapeutic interventions.

MONITORING & SUPPORT Continuous monitoring of vital signs is crucial for managing hospitalized veterinary patients, enabling prompt detection and response to changes in condition. Regularly measuring heart rate, respiratory rate, and temperature provides essential insights into the patient's cardiovascular and respiratory status. Blood pressure monitoring and ECG assessments help identify hypotension, hypertension, and cardiac arrhythmias, guiding necessary interventions. Consistent monitoring ensures that treatment plans can be adjusted to optimize patient outcomes. Nutritional support is vital for recovery, with enteral nutrition preferred when the gastrointestinal tract is functional and parenteral nutrition used when it is not. Accurate calculation of caloric needs, considering the patient's weight, metabolic rate, and health status, ensures sufficient energy intake for healing. Regular reassessment and adjustment of nutritional plans support optimal recovery. Maintaining fluid and electrolyte balance is also critical. Regularly assessing hydration status and managing electrolyte imbalances help prevent severe complications and ensure the patient's stability and health. SPECIALIZED CARE & CONSIDERATIONS Specialized care for hospitalized veterinary patients includes meticulous management of infectious diseases, pain, stress, and coagulopathies. Strict isolation protocols and rigorous handling and hygiene practices are essential to prevent the spreading of infectious diseases. Adequate pain and stress management is achieved through environmental enrichment, such as providing comfortable bedding and stimulating toys, pharmacological interventions like analgesics and sedatives, and non-pharmacological methods such as gentle handling and calming techniques. Recognizing and managing coagulopathies involves identifying bleeding disorders early and using appropriate blood products, such as fresh frozen plasma or packed red blood cells, to

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

manage hemorrhage and stabilize the patient. These comprehensive approaches ensure optimal care and recovery for hospitalized veterinary patients. DOCUMENTATION & RECORD-KEEPING Thorough documentation and meticulous record-keeping are critical for effective veterinary care. Accurate and detailed records should include patient history, clinical findings, diagnostic test results, treatment plans, and daily progress notes. This ensures continuity of care, facilitates communication among the veterinary team, and provides a clear timeline of the patient's condition and response to treatment. Maintaining up-to-date records is also essential for legal and regulatory compliance, aiding in audits and reviews, and supporting better decision-making and patient safety. DISCHARGE PLANNING & OWNER EDUCATION It is crucial to have effective discharge planning and owner education to ensure a smooth transition from hospital to home care for veterinary patients. Discharge criteria include the patient's clinical stability and the owner's readiness to manage ongoing care. Detailed discharge instructions should cover home care guidelines,

medication administration, and scheduling follow-up appointments. Providing owners with educational materials and emergency contact information gives them the knowledge and resources to care for their pets effectively. Supporting owners through clear communication and accessible resources enhances their confidence and ensures the continuity of care, ultimately promoting the patient’s recovery and well-being. Navigating the care of hospitalized veterinary patients requires a multifaceted approach that encompasses rapid assessment, stabilization, thorough diagnostic procedures, and continuous monitoring. Effective management involves addressing immediate medical needs and providing comprehensive care that includes nutritional support, pain and stress management, and specialized considerations for infectious diseases and coagulopathies. Thorough documentation and clear discharge planning with owner education are crucial for ensuring continuity of care and optimizing patient outcomes. By integrating these practices, veterinary professionals can significantly enhance their hospitalized patients' recovery and overall health, ensuring they receive the highest standard of care throughout their stay and beyond.

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SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

TRICKS OF THE TRADE AMANDA M. SHELBY, RVTg, VTS (ANESTHESIA & ANALGESIA) SENIOR CE SPECIALIST, VETGIRL

Sponsored by

SATURDAY AM • SEPTEMBER 21 9:15 – 10:15 AM

Have you ever witnessed someone doing something a little differently or truly thought, “How have I not thought of that before?” This presentation provides a career collection of helpful suggestions for common clinical situations many of which have presented veterinary staff challenges leaving us to think, “Surely there is an easier way.” The ‘smartest’ person is often the one not scared to help someone, to share their knowledge, to ask questions, or to ask for help when they are unsure. This collection of clinical practice tricks from many colleagues is shared with the hope that you find this presentation full of helpful suggestions to avoid struggling in the trenches! Vascular access can be challenging. When working in veterinary teaching hospitals with students, part of the job as a veterinary technician is guiding the next generation of veterinary professionals while balancing the patients’ interests. Often people use a two ‘stick’ rule but sometimes learning takes more tries to become proficient. Sometimes patients are so sick that vascular access is near impossible, and pursuit wastes precious time when one could be providing life-saving therapies. Consider intraosseous catheter placement! It is not challenging, just intimidating and the great news is that you can practice on deceased patients (with permission of course) to hone the skill for when you need to make it count to save a patient’s life. Delivering intraosseous life-saving medications and fluids can be done within a short period following diagnosis and a veterinarian’s prescription, making it easier to obtain vascular access for continued care. Catheterization in conscious patients is often necessary but can be stressful. Consider applying eutectic mixture of local anesthetic (EMLA) cream to the skin following removal of organic debris and fur. The author finds covering the prepared area with an examination glove (plastic) dressing helps expedite the onset of effect to 20-30 minutes. EMLA creams have been shown to increase the success of

jugular cannulation in conscious, non-sedated cats. Preventing pain and reducing stress on the patient during restraint and cannulation is good patient care—the foundation of a veterinary technician’s oath. Intubation can be challenging or intimidating for many, especially in extremely small or exotic species. In small kittens or puppies requiring intubation place a flashlight on the ventral aspect of the larynx from the outside! This will help illuminate the airway as you attempt intubation. Don’t forget these tissues are delicate. If intubation is not successful, consider forced mask ventilation with a tight-fitted mask. This is an essential skill for neonatal resuscitation following delivery from cesarean section and is especially helpful for those challenging species—rabbits and small kittens! Being a distinguished anesthetist is a combination of being knowledgeable about how disease processes impact anesthesia, understanding drug pharmacokinetics and pharmacodynamics, and finally, a thorough understanding of patient monitoring. Attention to detail, ability to recognize minor changes in trends or waveforms, and understanding when to rapidly alert the veterinarian and respond with appropriate treatment are traits that hail the title of expert. Furthermore, understanding advantages and limitations of monitoring devices is fundamental to becoming an expert patient monitor and dedicated anesthetist. Pulse Oximetry…do you commonly get values below 97%? Are you guilty of saying “that’s just the pulse ox…”— learn to maximize “reliable” readings. Explore the potential use of the reflectance probe, a flat pulse oximeter probe that is placed along a bony structure to provide you with reliable oxygen saturation values. Understand the limitations of the pulse oximetry technology and how to maximize reliable readings. Furthermore, learn why the plethysmograph waveform exists and what valuable information the pulse oximeter could indicate regarding fluid assessment.

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

caution is advised when using unapproved or homemade warning devices like rice socks. Thermal burns can occur and may be life- threatening in the context that wound management is a financial and emotional burden that exceeds many pet owner’s threshold. In addition to monitoring body temperature, use of a Doppler can be a valuable tool to assess not only blood pressure but also provide an audible heart rate in patients, especially neonates following a caesarian section. The Doppler can be placed directly over the heart in the neonate to assess viability. During CPR efforts, the Doppler could be placed on the eye of the patient to assess if the compressions are generating sufficient output to reach the eye in hopes that if the eye is perfused then the brain will be as well. Between compressions the Doppler is placed on the eye and used to assess for the return of spontaneous circulation.

Utilizing the ECG is more than recording heart rate. ECG use involves interpretation of the waveform through three fundamental questions: 1.) What is the heart rate (slow/normal/fast), 2.) Is there a P wave for every QRS complex and a QRS complex for every P wave, and 3.) Is the waveform predictable? Mastering these three questions will help you confidently identify arrhythmias. For example, if a patient is experiencing a ventricular escape rhythm, the heart rate is characteristically slow, there are QRS complexes without P waves, and the rhythm can be regular or irregular. Most importantly there is often a pause or delay following the preceding P-QRS complex before the wide-bizarre QRS ventricular escape beat occurs. In the case of ventricular premature contractions (VPC), the heart rate is generally fast, the QRS complexes do not have P waves, and the rhythm is regular or irregular. The QRS complexes are generally wide because they are ventricular in origin but happen before expected compared to delayed ventricular escape beats. Accelerated idioventricular rhythm can also be challenging to identify but when asking the questions, the heart rate is generally less than 160 bpm. Capnography provides more than a respiratory rate, including end tidal CO2, inspired CO2, and waveform analysis that can provide you a means to evaluate ventilation, circulation, a mechanical equipment-related issue, leak, or obstruction. Waveform interpretation is essential to gain the most from a capnograph. When using any monitoring equipment that provides values and waveforms, the anesthetist should strive to become proficient at recognizing normal and abnormal values and waveforms. The capnograph is also recommended during CPR efforts to aid in the evaluation of compression adequacy as well as return of spontaneous circulation. The advantage is that this assessment can be performed without interrupting compressions. Commonly underappreciated, thermoregulation is essential to optimizing patient outcomes. Veterinary technicians are outstanding at developing creative methods for minimizing heat loss and rewarming patients. However, when actively warming patients,

HOW DO YOU PROVIDE CONSTANT-RATE INFUSIONS WITHOUT A SYRINGE PUMP? SIMPLE, USE THIS FORMULA:

Drug dose (mg/kg/h)

X Vol. of fluid bag (mL) = mg of drug to add to fluid bag

Fluid rate (mL/kg/h)

After calculating how much of the drug to add to the fluid bag, simply calculate the hourly (or drip) fluid rate specific for the patient using the fluid rate from the equation. When administered at this fluid rate, the patient will receive their fluids containing the CRI of the drug placed within the fluid bag. Fluid boluses are generally avoided using this fluid bag because it contains drugs that may not be ideal when administered as a bolus. In our profession there are likely endless tricks that each of us have that improves our patients’ comfort, delivery of their care, and ease of our job. Sharing what you have learned or discovered can advance the profession and the people that make up the profession. Gone are the days when anyone is singular. The veterinary profession has advanced to a place where teams are more powerful in providing the highest level of care, including involving and considering the pet’s owner as the caregiver, financer, and decision-maker. Share your tricks of the trade to advance the profession and make the next generation of veterinary technicians able to provide better care.

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

LIFELINES: THE CRITICAL ROLE OF TUBE FEEDING KARA M. BURNS, MS, MEd, LVT, VTS (NUTRITION) PRESIDENT, PET NUTRITION ALLIANCE

Sponsored by

SATURDAY AM • SEPTEMBER 21 10:30 – 11:45 AM

WHAT PATIENTS SHOULD BE FED? In the past, nutritional support was not considered necessary until animals had inadequate intake for 10 days. This concept currently is outdated and unfounded. Evidence suggests a more appropriate goal in most cases is to initiate nutritional support within 3 days of hospitalization (at the latest). 3-5 Evaluating nutritional status may be challenging for healthcare team members. Historical weight loss may provide some evidence of inadequate intake and body condition scoring may be helpful to assess fat loss but is not as sensitive for muscle wasting. Laboratory abnormalities may not be present or may be nonspecific. Because of the limitations in assessing nutritional status, early risk factors must be identified that predispose patients to malnutrition. The risk factors to consider are: • History of inadequate nutritional intake lasting more than 5 days. • Serious underlying disease (e.g., severe trauma, sepsis, peritonitis, acute pancreatitis, major gastrointestinal surgery). • Large protein losses (e.g., protracted vomiting, diarrhea, protein-losing nephropathies, draining wounds, burns).

Nutritional support of critically ill patients has historically been considered a supportive measure of low priority. However, advances in both human and veterinary medicine have demonstrated that nutritional support is an important therapeutic modality and can aid in the management of diseases. In diseased states, the inflammatory response triggers alterations in cytokines and hormone concentrations and shifts metabolism toward a catabolic state. 1 With insufficient food intake, the predominant energy source is derived from accelerated proteolysis, which is an energy-consuming process. Thus, critically ill animals may preserve fat deposits in the face of lean muscle tissue loss. 1 The goal of nutritional support in these catabolic patients is to feed the catabolism with exogenous sources of protein and fat thus sparing endogenous protein that is critical to recovery. Malnutrition in veterinary patients is believed to increase morbidity and mortality. 2,3 In the GI tract, transit times increase, absorptive capabilities decrease, villous atrophy occurs, and there is an increased risk of bacterial translocation. In the kidneys, excretion of urinary calcium and phosphorus increases, ability to excrete acid decreases, gluconeogenesis increases, and glomerular filtration rate decreases. Malnutrition has been documented to decrease humoral immunity and barrier function (skin and mucosal surfaces), inflammatory response, leukocyte motility, and bactericidal activity. Patients are at risk for pulmonary complications as a result of decreased response to hypoxia, decreased lung elasticity, and secretion production, altered permeability and decreased tidal volume. Cardiovascular complications include increased incidence of arrhythmias and decreased weight of the heart muscle. Protein malnutrition may also alter the normal or expected metabolism of certain drugs, which may increase or decrease their therapeutic effect even when given at recommended dosages.

Patients with these risk factors are candidates for nutritional support.

As with any intervention in critically ill animals, nutritional support may pose some risk. The risk of complications increases with disease severity. To minimize risks, patients must be cardiovascularly stable before nutritional support begins. If the patient is found to be in shock, perfusion of the gastrointestinal tract is reduced in favor of maintaining adequate perfusion of heart, brain, and lungs.3,5 With reduced perfusion, processes such as gastrointestinal motility, digestion, and nutrient assimilation

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

Awareness. Detection. Diagnosis.

November is Pet Diabetes Month. It is estimated that 1 in 300 adult dogs and 1 in 230 cats in the U.S. have diabetes. 1,2

Educating pet owners about the symptoms, treatment, and management of pet diabetes, so they can seek appropriate treatment for their dog or cat, is the goal of Pet Diabetes Month. Early detection of pet diabetes is critical to proper management, and actively promoting diabetes awareness shows leadership from your clinic.

Use your social media channels, such as your clinic’s Facebook page, to create interest in your program and spread awareness with #PetDiabetesMonth !

Learn more at usa.petdiabetesmonth.com.

Important Safety Information: VETSULIN ® and VETPEN ® are for use in animals only. Dogs and cats known to have an allergy to pork or pork products should not be treated with VETSULIN ® . VETSULIN ® is contraindicated during periods of hypoglycemia. Animals with severe ketoacidosis, anorexia, lethargy, and/or vomiting should be stabilized with short- acting insulin and appropriate supportive therapy before use. As with all insulin products, careful patient monitoring for hypoglycemia and hyperglycemia is essential. Overdosage can result in profound hypoglycemia and death. Progestogen and glucocorticoid use should be avoided. The safety and effectiveness of VETSULIN ® in puppies, kittens, breeding, pregnant, and lactating dogs and cats has not been evaluated. Keep out of reach of children. Avoid contact with eyes. In case of contact, immediately flush eyes with copious amounts of water for at least 15 minutes. Accidental injection may cause clinical hypoglycemia. In case of accidental injection, seek medical attention immediately. Exposure to the product may induce a local or systemic allergic reaction in sensitized individuals. For complete safety information, refer to the product label.

References: 1. Canine diabetes mellitus; can old dogs teach us new tricks? Catchpole B, Ristic JM, Fleeman LM, Davison LJ. Diabetologia 48:1948-1956, 2005. 2. Feline diabetes mellitus in the UK: The prevalence within an insured cat population and a questionnaire-based putative risk factor analysis. McCann TM, Simpson KE, Shaw DJ, et al. J Feline Med Surg 9:289-299, 2007.

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

LIFELINES: THE CRITICAL ROLE OF TUBE FEEDING (CONT.)

Sponsored by

SATURDAY AM • SEPTEMBER 21

KARA M. BURNS, MS, MEd, LVT, VTS (NUTRITION) PRESIDENT, PET NUTRITION ALLIANCE

are altered, increasing the chance of complications. In addition, feeding should be delayed until preexisting fluid and electrolyte abnormalities are corrected to avoid exacerbating gastrointestinal hypoxia secondary to increasing cellular metabolism, and to prevent hypophosphatemia and hypokalemia related to refeeding syndrome. HOW SHOULD THE PATIENT BE FED? The gastrointestinal tract needs to be fed. The gut receives an overwhelming percentage of its nutrition from the chyme passing through it. In the small intestine, enterocytes utilize lumenal glutamine preferentially as their source of metabolic fuel. 6 The colonocytes prefer butyrate, a short chain fatty acid formed by fermentation of lumenal carbohydrates. In the absence of these fuel sources, the gut epithelium slows growth and replication resulting in atrophy, necrosis, and increased risk of bacterial translocation across the now abnormal gut barrier. 3-5 A key to prevention of this potentially serious problem is providing nutrition support to the gut. The rule of nutritional support is “if the gut works use it”. Force feeding sick, hospitalized animals is not ideal and is the best way to create food aversions. Force feeding is an inefficient feeding method resulting in more nutrients on the patient and the healthcare team member rather than in the patient. Typically feeding will not provide a significant percent of needed calories and will lead to a false sense of accomplishment and continued inadequate intake. Similarly, appetite stimulants are seldom successful in causing meaningful increases in food intake. Pharmacologic stimulation of appetite is often short-lived and only delays true nutritional support. Appetite stimulants should not be used to manage hospitalized animals when more effective measures of nutritional support, such as placement of feeding tubes, are more appropriate. Appetite stimulants may be considered in recovering animals once they are home in their own environment, because the primary reason for loss of appetite should ideally be reversed by discharge. As with many drugs, appetite stimulants also have negative side effects, such as behavioral changes associated with cyproheptadine and sedation associated with diazepam, and therefore should be used with caution.

An indwelling feeding tube is the method of choice if enteral assisted feeding is necessary for more than two days. 4,5 After an indwelling tube had been placed, feeding is easier and less stressful. Nasoesophageal, esophagostomy, gastrostomy, and jejunostomy feeding tubes are the most commonly used. In animals undergoing laparotomy, placing gastrotomy or jejunostomy feeding tubes should be considered. The decision to use one tube over another is based on the anticipated duration of nutritional support (e.g., days vs. months), the need to circumvent certain segments of the gastrointestinal tract (e.g., oropharynx, esophagitis, pancreatitis), clinician experience, and the patient’s ability to withstand anesthesia (very critical animals may only tolerate placement of nasoesophageal feeding tubes). 7,8 NE tubes are generally used for 3 – 7 days. Polyurethane tubes and silicon tubes may be placed in the caudal esophagus or stomach. An 8 Fr tube will pass through the nasal cavity of most dogs. A 5 Fr tube is more comfortable in cats. Anesthesia or tranquilization is not necessary (use topical ophthalmic anesthetics to numb the nasal cavity). These tubes can be used in patients considered anesthetic risks. • Pharyngostomy and esophagostomy tubes vary from 8 to 16 Fr and may be place in patients with disease or trauma to the nasal or oral cavity. These tubes can be used for long-term in hospital or home feedings. Gastrostomy (mushroom-tipped, 16- 22 Fr) can be placed either intraoperatively or percutaneously. • Any tube that has been placed in the esophagus or stomach generally allows for bolus type meal feeding except in patients that vomit after each feeding. These patients will benefit from a slow continuous drip administered by a pump or gravity. • Jejunostomy tubes (J-tubes, 5-8 Fr) are placed within the small intestine either surgically or endoscopically and are appropriate for cases where the stomach and proximal duodenum must be bypassed. Ideally food is administered at a slow, continuous drip delivered by a pump. FEEDING TUBE OPTIONS: •

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

VETTECH U

VETTECH U 2024 / HOUSTON, TX

WHAT SHOULD THE PATIENT BE FED? Nutritionists debate the exact formula for determining daily energy requirements in critically ill patients. A good starting point is to calculate the resting energy requirements for the patient’s current weight. If a patient’s ideal weight is used, underweight animals may be at greater risk for complications from overfeeding. Resting energy requirements can be calculated using the following equation: RER = 70 x (current body weight in kg)0.75. Another equation that may be used is RER = (kg x kg x kg, √ , √ ) x 70. It is imperative that the nutritional status of the patient be monitored vigilantly as caloric intake may need to be adjusted to prevent weight loss or unintended weight gain. Food selection depends on tube size and location within the GI tract, the availability and cost of products and the experience of the clinician. Commercial foods available for enteral use in veterinary patients can be divided into two major types: 1) liquid or modular products and 2) blended pet foods. Nasal and jejunostomy tubes usually have a small diameter (<8 Fr.), which requires use of liquid foods. Orogastric, pharyngostomy, esophagostomy, and gastrostomy tubes have large diameters (>8 Fr.) and are suitable for blended pet foods.3,5 Human liquid foods cost more than veterinary liquid products. Most human liquid foods are adequate for adult dogs but are too low in protein for cats, puppies, and adult dogs with increased protein losses (e.g., protein-losing enteropathies, drains). 3,9 Human liquid enteral products may not contain adequate concentrations of protein, taurine, arginine, and arachidonic acid for long-term feeding of cats, but are satisfactory for fewer than seven days. It is recommended that veterinary liquid products be used when managing veterinary patients. (See the comparison chart at the end for additional information.) Liquid foods are of two basic types: 1) elemental or monomeric and 2) polymeric. Foods said to be "elemental" are not truly elemental; rather they are ‘semi-elemental’ and contain nutrients in small hydrolyzed absorbable forms and are best described as monomeric. The proteins are usually present as free amino acids, small dipeptides or tripeptides or larger hydrolyzed protein fractions. The fat source is often an oil of mixed (medium- and long-chain) fatty acids and the carbohydrate sources are mono-, di- and trisaccharides. Semi-elemental nutrition provides easier digestion and rapid absorption of nutrients, designed to support the critical systems of the body.

The gastrointestinal tract is lined with cells called enterocytes, which aid in digestion, absorption, and transportation of nutrients into the body. Vital nutrients absorbed by enterocytes include amino acids and peptides, carbohydrate (complex and simple saccharides), lipids, water, vitamins, and ions (or minerals). Enteral nutrition is preferred whenever possible because enterocytes undergo atrophy without luminal nutrient stimulation. By focusing on the nutritional needs of the enterocyte, semi-elemental diets provide the maximum amount of nutrition that can be absorbed with the least energy expenditure. In critically ill patients, the body’s main goal is to support key organs like the heart, brain, liver, and lungs. Blood flow to the gastrointestinal tract is reduced thus slowing gastrointestinal motility. As enterocytes form a tight seal to protect the body from harmful bacteria or toxins, digestion and absorption of nutrients are similarly altered. Unfortunately, these physiologic changes make it difficult for nutrients to be absorbed when the body needs nutrition the most. Thus, weakened, and debilitated patients benefit from a predigested or a semi-elemental diet. Semi-elemental diets contain ingredients that are purified and hydrolyzed and are usually combined with a small amount of complex highly digestible ingredients. Semi-elemental diets that are nourishing the enterocytes of the GI tract help to maintain an osmotic balance which minimizes the risk of diarrhea by preventing the loss of water and other vital nutrients from the gastrointestinal tract.10 There is a company that produces species specific semi- elemental diets, which have been shown to be beneficial to the GI tract and to the management of the critical and/or recovering patient. (EmerAidvet.com) There are several liquid foods on the human medical market that are positioned as monomeric or hydrolyzed diets and are suitable when initially refeeding dogs and cats. These monomeric products are homogenized liquids that can be fed through any feeding tube including a J-tube. Monomeric foods are indicated in disease conditions such as inflammatory bowel disease, lymphangiectasia, refeeding parvoviral enteritis and pancreatitis cases and any other condition in which a patient's digestive capabilities are questionable. Polymeric products contain mixtures of more complex nutrients. Protein is supplied in the form of large peptides (e.g., casein or whey). Carbohydrates are usually supplied as corn starch or syrup,

SEPTEMBER 20-22, 2024 | PROCEEDINGS | VETGIRLONTHERUN.COM

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VETTECH U 2024 / HOUSTON, TX

LIFELINES: THE CRITICAL ROLE OF TUBE FEEDING (CONT.)

Sponsored by

SATURDAY AM • SEPTEMBER 21

KARA M. BURNS, MS, MEd, LVT, VTS (NUTRITION) PRESIDENT, PET NUTRITION ALLIANCE

and fats are provided by medium chain triglycerides (MCT) or vegetable oil. These foods require normal digestive processes and are appropriate for most veterinary clinical situations, especially when a small tube (<8 Fr.) has been placed and specific nutrient profiles are needed (e.g., low sodium, high protein, soluble fiber). One of the leading liquid veterinary foods is a polymeric form that meets the current AAFCO nutrient allowances for adult dogs and cats. This product is a homogenized liquid containing 1 kcal/ ml and is usually accepted better than human liquid products containing MCT oil. This liquid food is the best option currently available in North America when small-diameter nasogastric and jejunostomy feeding tubes have been placed, or when continuous drip feedings are necessary. Historically, these polymeric foods have caused diarrhea in cats after 24 hours of feeding. However, the manufacturer recently reformulated the product to reduce the incidence of diarrhea. The number of osmotically active particles was decreased by replacing a small-chain maltodextrin source with a larger-chain maltodextrin, and the casein source no longer contains lactose, thereby eliminating a lactase degradation process. Several liquid milk replacer products are available; however, these products are not appropriate to feed to adult dogs and cats. They typically contain lactose, have high osmolarity, are lower in caloric density and do not meet AAFCO nutrient allowances for adult animals. Module products are concentrated powder or liquid forms of nutrients and are primarily supplemental. These products may be added to a liquid product to increase the concentration of a specific nutrient. There are protein, fat and carbohydrate modules (e.g., casein powder, vegetable oil, or corn syrup). For example, a protein modular product may be added to a human liquid product for an animal with high protein requirements. Soluble fiber can be added to these foods using psyllium husk fiber or pectin; however, these fibers may block the small side ports in 8-Fr. and smaller tubes.

Blended pet foods refer to commercial products nutritionally complete and balanced according to AAFCO allowances for dogs and cats. These products can easily be blended with a liquid to make a consistency that flows through a feeding tube. Some products have a blended texture, a high water content and very small particle size, whereas others are products that must be blenderized with water and may have to be strained to remove particulate matter. The best recommendation when using the blended pet food method is to use a product that has been tested in feeding trials and is proven to be balanced and complete for dogs or cats. 5 These products are more readily available, better tolerated, and less expensive than human liquid foods. These pet food products contain essential amino acids and essential micronutrients properly balanced to the caloric density of the food. Fewer medical complications (e.g., diarrhea) are likely to result. However, blended products are more likely to plug the feeding tube if the tube is not properly flushed after feeding. Patients may later consume the pet food orally, eliminating a diet change when the patient's appetite returns, and the tube has been removed. These products are appropriate for patients in catabolic states that are using fat and protein substrates from body stores. When using small-diameter (<8 Fr.) feeding tubes, it will be necessary to dilute the pet food with water, which dilutes the caloric density. Blenderized moist veterinary therapeutic foods may have a place in assisted feeding of patients with specific disease conditions. Veterinarians have fed human baby food packed in jars because some canine and feline patients would voluntarily eat these products. The meat and/or egg baby foods are high in protein (30 to 70% DM) and fat (20 to 60% DM), which compares favorably with blended pet food products. However, baby foods are more costly, contain only one or two food types (protein, protein/grain) and do not contain a balanced mixture of other essential nutrients (amino acids, vitamins and minerals). For example, these products contain

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