Nutritional support of the critical patient | BSAVA Library

Nutritional support of the critical patient

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This chapter provides an overview of the potential benefits of nutritional support for the critical patient, demonstrates how to assess whether a patient should be considered a candidate for nutritional support, illustrates methods of providing nutrition to patients unable or unwilling to nourish themselves and suggests methods for monitoring these patients to avoid or address complications.

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22.9 Placement of a nasogastric tube in a 5-month-old dog. A 5 Fr naso-oesophageal tube has been measured to the 9th rib space and marked with a piece of white tape, and a topical anaesthetic has been placed in the left nostril. To facilitate passage into the ventromedial nasal meatus, the nares are directed upwards.
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22.10 German Shepherd Dog with a naso-oesophageal tube. Once in place, the tube is secured to the external nares with ‘superglue’, or preferably a small suture passed retrograde through a 24 G needle. Two more sutures secure the tube to the dorsum of the nose and the top of the head, out of the dog’s direct line of vision. An Elizabethan collar prevents the dog from interfering with the tube.
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22.11 Oesophagostomy tube placement. (a) Forceps have been placed in the cervical oesophagus and their points are being used as a guide for the position of the skin incision. (b) The forceps are forced outwards through the incision to the external surface. The feeding tube is grasped with the forceps and drawn into the pharynx through the oesophagostomy incision. (c) The tube is redirected down the oesophagus. (d) The oesophagostomy tube in its final position. It should be capped off and sutured in place and the neck bandaged.
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22.12 Gastrostomy tube placement. (a) Under general anaesthesia, the cat is placed in right lateral recumbency and an area (~10 cm × 10 cm) just behind the ribcage is clipped and surgically prepared. A mouth gag is used to protect the teeth from damaging the endoscope. The stomach is insufflated with air to move all other abdominal contents, specifically the intestines and spleen, away from the body wall. (b) The site within the stomach where the tube will be anchored is chosen with the aid of an assistant, who wears sterile gloves and indents the surface of the prepared skin just caudal to the rib cage and directed cranially. (c) This indentation can be seen by the endoscopist, who then directs the assistant to an area well away from the pyloric outflow tract into the fundus of the stomach where the tube is to be situated. (d) A small (~2 mm) incision is made in the skin just over the site and a 19 G catheter (dogs and cats) is sharply introduced. (e) The catheter stylet is removed and a piece of suture material is passed into the stomach. Biopsy forceps are used to retrieve the end of the suture material, which is pulled into the endoscope as it is removed from the patient. The assistant must allow the suture material to thread easily into the stomach, and the catheter can then be removed. (f) The suture material now passes into the stomach via the body wall, extends up the oesophagus and out of the mouth. Human enteral feeding tubes such as this one (Fresenius), have a narrow tip to pass through the body wall. When using a mushroom-tipped pezzar catheter, a small pipette tip is placed on to the end of the suture material (tip threaded first), and the suture material is then fixed to the tube with multiple knots. (g) The assistant slowly retracts the suture material, exiting the body wall until the tip of the pipette can be palpated. The stomach is held in place while the tube is pulled through the gastric mucosa and exits the body wall. A haemostat clamp can be used to grab hold of the pipette tip and exert an even upward pressure. Simply pulling the suture material may result in breakage. (h) Once the tube has been pulled into place, it is important to go back and look in the stomach to verify that the tip is not stuck at the lower oesophageal sphincter and the tube is in an appropriate position, away from the pyloric outflow tract. (i) Flexible plastic fittings hold the feeding tube in place. Tight placement may result in pressure necrosis and increase the incidence of infection. The tube site is then wrapped in sterile material. (j) A percutaneously placed gastric tube in a 3-year-old Labrador with megaoesophagus.
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22.13 A relatively inexpensive feeding tube can be made from a mushroom-tipped catheter with minor alterations. The wide end of the catheter is cut to form two stents, which are placed on either side of the body wall (internal stent shown) to anchor the tube in place and to prevent its inadvertent removal.
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