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Geni C. Ana R. Eyherabide 2. Ricardo A. Dias 2. Marcio A. Brunetto 2. Silvia R. Cortopassi 2. The aim of this study was to explore the role of early central parenteral nutrition support with and without lipid emulsion in enterectomized dogs undergoing small bowel partial resection.
Enterectomized dogs often cannot be fed properly via an oral or enteral route immediately post-surgery. After enterectomy, the animals received parenteral nutrition or crystalloid solution until they were able to voluntarily take in an oral diet. All dogs were recruited at the University of Sao Paulo veterinary teaching hospital. Eighteen dogs with intussusception, a foreign intestinal body, linear foreign intestinal body, or intussusception associated with a foreign intestinal body underwent enterectomy surgery and were randomly assigned to receive one of three treatments: crystalloid solution CS group , parenteral nutrition with a mix of glucose and amino acids GA group or parenteral nutrition with a mix of glucose, amino acids and lipids GAL group.
A serum chemistry panel and complete blood count were collected prior to surgery and at the end of the study. Body weight decreased by 4. Early parenteral nutrition was beneficial for patient recovery in post-surgical small bowel partial resection, indicating better quality, and no major complications or side effects were observed during the hospitalization period in the studied dogs.
Nutritional support of a critically ill patient is an essential part of supportive care Remillard Dogs undergoing the removal of large segments of the small bowel commonly have pre- and postoperative impairment of digestion and absorption. In specific cases, some dogs may develop short bowel syndrome Davenport et al.
The resting energy requirement RER is provided using the equation 70x body weight [kg] 0. Pibot et al. Nevertheless, the final ideal energy requirement is largely undefined Preiser et al. A critically ill patient might have different protein requirements due to muscle proteolysis, which can lead to muscle cachexia under the effects of cytokine production, hormonal release, immunosuppression and hemodynamic instability Wray et al.
Parenteral nutrition PN is a well-established method of administering calories and nutrients to dogs that cannot tolerate traditional enteral feeding routes Chan Metabolic complications hyperglycemia, lipemia and hyperbilirubinemia as well as mechanical and septic complications have been associated with parenteral nutrition Chan et al.
However, mechanical and septic complications were not associated with a higher mortality rate. The most common indication for parenteral nutrition is pancreatic disease Queau et al.
The parenteral nutrition route is often discussed for nutritional support in case of gastrointestinal tract intolerance; however, the timing for starting therapy is still debatable in dogs Liu et al.
Early nutritional support is provided until 24 hours after surgery, and recent studies have shown a shorter hospitalization time in animals that received early enteral or parenteral nutritional support compared to late support Liu et al. Lipid emulsions are often used as caloric supplements to critically ill dogs because they increase calorie intake with a lower risk of thrombophlebitis and may be a beneficial calorie supplementation to animals with higher peripheral insulin resistance Remillard However, the potential benefit of lipid emulsions in early parenteral nutrition remains unclear.
This study aimed to address the effects of early nutritional parenteral support, with or without lipids, in enterectomized dogs, according to the following parameters: albumin, body weight, recovery score, hospitalization time and laboratory values complete blood count - CBC and serum chemistry. The Bioethical Commission of this faculty approved this study, and client consent was obtained before the admittance of any dog into the study.
Over the course of 1. Only 18 of the 42 dogs met all of these criteria and were included in the study. A serum chemistry panel urea, creatinine, alkaline phosphatase - AP and alanine aminotransferase - ALT and CBC results were obtained prior to surgery and at the end of the study. Total and direct serum bilirubin was measured when serum was icteric.
All dogs were randomly assigned into one of the three groups: crystalloid solution CS , glucose and amino acid GA or glucose, amino acid and lipids GAL. The GA and GAL groups did not require glucose or insulin supplementation for blood glucose maintenance. The GA group received central parenteral nutritional CPN support with a mixed solution of glucose and amino acids.
Triglycerides and cholesterol were measured in the GAL group both after surgery and during the hospitalization period for a lipid infusion assessment. Table 1. Laboratory values, body weight, hospitalization days and number of deceased animals of the CS, GA and GAL groups before surgery and at the end of hospitalization median, first quarter and third quarter. During hospitalization, the heart rate and rhythm, respiratory rate, rectal temperature, arterial blood pressure and urinary output were monitored continuously and recorded 4 times daily.
Blood glucose was measured every 6 hours. The hospitalization time was defined as the number of days between the surgery and hospital discharge. The CPN solutions were formulated according to individualized prescriptions and established proportions in the study.
The CPN was initiated immediately after recovery from anesthesia Kleiber Dogs were discharged from the hospital after a hour period of baby food diet ingestion if voluntary intake was observed and no repeated vomiting or severe diarrhea were present.
A software package SPSS 9. The scores for quality of recovery were evaluated within a group using the Friedman test. The blood test results, age, body weight, hospitalization time, additional support and number of deceased dogs are summarized in Table 1.
Increased bilirubin values were observed in 2 dogs preoperatively 1 from the CS group and 1 from the GA group and in 4 dogs at the end of hospitalization 2 dogs from the CS group and 2 dogs from the GAL group. Four individuals required hemocomponent transfusion 3 in CS and 2 in the GAL group due to blood loss during the surgical procedure and increased clotting time at least twice the reference values.
The recovery scores are summarized in Table 2. Table 2. Number of dogs with scores of quality of recovery 1, 2 and 3 from the CS, GA and GAL groups at the first, second and third days of hospitalization. No significant differences in the number of days for oral diet intake or hospitalization time were observed among the groups.
Gradual oral diet introduction was accomplished after 3. The number of days that the animals received PN hospitalization time was 4. The glucose infusion did not lead to complications such as hyperglycemia, and no local infections due to catheter placement were observed in any group during hospitalization. No refeeding syndrome symptoms were detected.
No animals were euthanized. The prevention of weight loss is an important therapeutic goal in hospitalized animals Brunetto et al. The provision of amino acids and glucose improved nitrogen balance, which may be related to the weight maintenance observed in our study. Another important finding was the improved recovery scores in the GA and GAL groups; this demonstrated that there was a subjective improvement in behavioral responsiveness to clinical staff when GA or GAL were given compared to the CS group, in which the dogs exhibited more apathetic behavior.
Furthermore, the overall quality of recovery was better for animals that received parenteral nutrition support. No validated hospitalization scores were found in the literature review that could be used to evaluate the quality of recovery for dogs. We therefore designed a score for this study because the authors believe that improved animal responsiveness is an important sign of general recovery and an essential element of hospitalization assessment.
Early parenteral nutrition provided within the first 24 hours after surgery is related to a short hospitalization time Liu et al.
Although there have been previous publications about early parenteral nutritional complications in humans Casaer et al. Overall, the GA and GAL groups had better outcomes in terms of nutritional status, including a recovery in albumin values, in contrast to the CS group. Trow et al. However, albumin cannot be the only predictive factor for hospital recovery because others factors, such as the type and location of surgery, are essential for prognosis Kudsk et al.
The percentage of RER was appropriate to maintain body weight in the GA and GAL groups, and the amount provided appeared to be adequate for short-term support. However, in some cases, such as peripheral insulin resistance Liu et al. In agreement with our results, a recent study using parenteral nutrition without lipid emulsion showed a positive result in providing sufficient calories to critically ill dogs Gajanayake et al.
As expected, serum triglycerides and cholesterol were increased in the GAL group Table 1 , but gross serum lipemia was not recognized in any dog.
The other two groups were not tested for these parameters because they were not receiving exogenous lipids. Four dogs died during hospitalization with severe leukopenia. It seems possible that their death was associated to severe pre-operatory systemic infection, and not correlated to the administered parenteral nutrition. There are several limitations in this study to be considered, including the small number of dogs, which may have prevented the detection of any significant effects caused by other variables.
This was a clinical study involving critically ill patients, and the inclusion of animals was limited due to strict selection criteria and available time to enroll subjects. In addition, dogs that died within the first 24 hours after surgery were excluded, thus decreasing the final number of dogs.
Calorie intake was not precisely quantified for the enteral diet. At the moment of discharge, it was not possible to assess if the calorie intake was adequate for every dog and whether the hospitalization period would be affected by this factor as shown in Brunetto et al.
Additionally, an APPLE score Acute Patient Physiologic and Laboratory Evaluation would provide a relevant assessment of prognosis for each dog, and a better patient standardization that considered illness severity was not performed because insufficient laboratorial evaluations were available Hayes et al.
Furthermore, triglycerides and cholesterol were not evaluated in all groups. However, hypertriglyceridemia might be present in malnourished dogs, which would be an important element to analyze in all groups, regardless of lipid infusion.
The results of this study suggest that early parenteral nutrition may play an important role in recovery time in dogs that underwent partial resection of their small intestine and it is non-harmful. CPN provided weight maintenance and improved recovery scores and no relevant metabolic or mechanical complications were detected in the enterectomized dogs. Additionally, the inclusion of lipids in the short-term CPN did not benefit this population of dogs.
Brodbelt D. Anesthetic risk and informed consent, p. In: Grimm K. Eds , Veterinary Anesthesia and Analgesia. Wiley-Blackwell, Iowa. Brunetto M.
Resección del intestino delgado