Veterinary Medicine - February 2008 - (Page MV14) MANAGING VOMITING options do we have to provide nutrition in those patients? Twedt: When I get an acute vomiting patient that hasn’t eaten for three days, I get concerned about its nutritional status. Leib: Are you talking about a young animal or an adult animal? Twedt: Either. Our philosophies are changing on this topic. We are trying harder to provide nutrition to acute vomiting cases, such as animals with pancreatitis or parvovirus. Sometimes e ective antiemetic and uid therapy helps these animals eat sooner, which is important. Our critical care clinicians think that now that we have started using maropitant, our parvovirus patients spend about a day less in the hospital because they begin eating sooner. Leib: Dr. Simpson, you commented on initiating feeding sooner. Are you feeding although vomiting continues? Simpson: I have been trying to promote it, but some people are reluctant. I think that if you have an e ective antiemetic and pain control, then attempting to feed even in the face of vomiting is worth a try. That is what the Mohr study6 shows; puppies with parvovirus receiving enteral nutritional support gained weight, had decreased barrier damage, and tended to leave the hospital a day earlier. So it seems to be doing no harm and may, in fact, be bene cial. I also started feeding our pancreatitis dogs soups and broths early on and try to feed them through their vomiting. I don’t have any evidence that it’s going to make the pancreatitis worse. Twedt: I agree with that philosophy. Still, if the animal is improv14 ing and doing well and then vomits, my residents and other clinicians want to continue the NPO period for another 24 hours. I think that if the pets are interested in eating, and we have ruled out obstruction, providing some nutrition is not contraindicated. Leib: Is the emphasis on enteral nutrition to promote barrier function vs. starting parenteral nutrition and maintaining the NPO status? Jergens: It is all about enteral nutrition. The population of patients that we have on total parenteral nutrition or even partial parenteral nutrition is markedly reduced from what it was three to ve years ago. There is a greater appreciation for supplementing through nasoesophageal or esophagostomy tubes. Even with some surgery cases, the surgeon is working with the internist to put in jejunostomy feeding tubes. There is an increased awareness of the bene ts of enteral nutrition in a whole spectrum of cases. Simpson: Another study of parenteral nutrition in dogs and cats6 found that dogs receiving supplemental enteral nutrition in combination with parenteral nutrition survived more often than those receiving parenteral nutrition exclusively. 7 Williams: So, as long as they are keeping down a substantial proportion of what you feed them, you should continue to do that. Simpson: And I think we tend to overestimate how much food an animal is vomiting. If the animal is vomiting bile, it has likely kept down the food you fed it. There is a disconnect sometimes. We think it has vomited everything. That’s where the Mohr study6 was really interesting. They were feeding puppies with parvovirus—our poster children for severe vomiting and diarrhea—through an esophagostomy tube. Those puppies gained weight and experienced no adverse e ects. Twedt: I think the big contraindication would be if there was any fear of aspiration pneumonia. You may not want to feed a semicomatose animal with a nasogastric tube if the animal is going to vomit and aspirate. Leib: My comment on the parvovirus study was that they didn’t describe the di erence in nursing manpower for puppies receiving continuous nasoesophageal feeding. Looking at the di culties in keeping intravenous lines clean and untangled, adding an Elizabethan collar and nasoesophageal tube requires a great deal of nursing support. Even in veterinary teaching hospitals, manpower in an intensive care unit is often challenged with traditional therapy for parvovirus. Williams: Bringing this back to antiemetics, should we give a potent antiemetic when we are tube feeding an anorectic patient and there is vomiting? An antiemetic might not only ameliorate vomiting, but it may help reduce nausea and diminish the anorexia. Twedt: We had an anorectic dog in chronic renal failure with serial serum creatinine levels of 5 mg/dl. Even with uid therapy, the dog would not eat and was very nauseated with salvation but did not vomit. We decided to use maropitant, and the dog started eating. So there may be some bene ts just for nausea, particularly with the chronic cases. (Sponsor’s note: Cerenia has not been approved for use to treat/control nausea in dogs.)
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