Nutrition- Final- 2

wilsbach's version from 2016-04-17 21:14

jezebell, the food allergy cat

Question Answer
If you think there is a food allergy, what is the first thing to do?start with elimination food trial. MAKE SURE NO OTHER FOOD-- ONLY ELIM DIET. (must be indoor only so isnt eating mice and stuff outside)
How long might you have to try elim food diet? What can you do in the meanwhile?8-12 or more weeks-- make sure you do rechecks! Owners might not see gradual changes but you might. Have them write down any adverse events.
some things you might not think about to avoid when on elim diettreats, outdoor cat eating mice, oral tablets having flavors is bad. Make sure external parasites under control!
So after 12 weeks the skin has improved on the elim diet-- but what now?we elim a lot of things- how do we know it's the food? Now can do a food challenge- challenge them with old food, signs will show up in 2 weeks if that was what it was. If signs don't come back, it wasnt the food. If they do-- you can't prove it was a particular protein. It could be anything in the diet. (also technically you can't prove it's an official dietary allergy unless you isolate protein and AbAg complex to prove allergy
remember when an animal is allergic to a diet, what can it be allergic to?NOT JUST PROTEIN-- can be anything in there- beet pulp, anticaking compound in mineral mix, etc
After the food challange, you do a provocation test. Explain thisadd 1 ingredient present in original food per 2 weeks- just go down ingredient list. So if chicken was first, put some chicken in the diet (note tho: if just chicken, its not the same as like in the commercial food, because that chicken was cooked with carbs too) Give it for 2 weeks- if no CSs, go to the next ingredient. Maybe ppl might be reluctant to cause relapse, you can assure them a few days on the elim food will get rid of the relapse signs.
What elim diets can you consider?There is no hypoallergenic diet bc company not held to standards. So, can try commercial allergy diets: Hills z/d (chicken) or Royal Canin hypoallergenic (soy), or anallgen (feathers), or HA (soy)
explain how hydrolyzed protein is less likely to cause allergies. what are things to consider tho.So have mast cell with granules. And on surface have IgE molecules attached by Fc portion. So have big globular protein and if attaches to 2 IgEs it will degranulate and --> allergies. (basophils too). so hydrolyzed protein is smaller cant bind to 2 IgEs. but there are haptens, but there are IgM and IgA etc....dont have to be type one. to not cross link has to be less than 10,000 daltons in size (human immunology) nobody's looked at animals.
Why are animal diets not truly hypoallergenic?must ask: So what are the size of proteins in these diets? (to not cross link has to be less than 10,000 daltons in size (human immunology) ) hills says ~3500 daltons. Hypoallergenic is 12-10000. Royal canin 7000-3000, HA is 14,000. So soy is tough to work with. When you start breaking up soy it becomes bitter and they wont eat it. And these daltons are average. In humans there are standards- need to be able to give it to known allergic pts and have 90% or more not respond to it. In human med-- the proteins are 200 daltons (and the animal ones are WAY bigger) basically an amino acid or a dipeptide.
what is a blood allergy test testing?Blood allergens tested-what is this test testing? its just a screening test. measure high IgE levels are in blood. if above certain level, can say is an allergy, look for causes. if below, not. but doesnt determine what they are alergic to. Cant tell client to do this- he thinks its malpractice. So blood test cant tell you what diet to use. dont recc blood test, and varying result with skin tests.
Remember if a derm patient comes in for food allergy, you also need to consider...dry skin, parasites
So what might you recc as a food for the elim diet again?novel protein or hydrolyzed protein.

Cally, acute care nutrition and hepatic lipidosis.

Question Answer
how does LRS act as a buffer?there is lactic acid in the LRS solution, which acts as a buffer for acid, so can help dec acidosis
fluid with K+ in it?LRS, normosol-R
If you suspect hepatic lipidosis, you need to figure out why it happened- 2 possible reasons?(1) stress--> stopped eating. (2) 2* to other dz which make them stop eating.
which enzyme being elevated is a possible sign of hepatic lipidosis?inc ALP
if you have an anorexic hepatic lipidosis cat, you need to be careful when you start feeding them again bc...refeeding syndrome!! Eat--> release insulin--> kicks K+ into cells--> hypokalemia. gonna need K and P in the food!
So a hepatic lipidosis cat has low K+ levels bc she isn't eating. Which fluid do you want to give?YOU WOULD THINK LRS....but no. Because the lactate is buffered in the liver and this liver is not healthy. So rather just add K to a different fluid.
so Hepatic lipidosis started because they aren't eating. but you cant just start feeding them right away. what 2 things do you need to do first?Step 1: IV FLUIDS-- maintain circulation or pt is gonna die. Type of fluids: crystalloids- plasma lyte. normosol. saline (not LRS bc liver isnt functioning to covert it) so add K+ to your non-LRS crystalloid. Step 2: Electrolytes! and acid base balance. ....THEN you can start giving calories, when the body is in the proper state to recieve them
How can you get K+ into these HL patients?Remember that they are already acidotic, so the body tries to stick H in the cells which kicks K+ out (so the cells are low in it). So then we add water (fluids given) and it dilutes the K+ more. And also not eating so not taking in K+. So you want to give fluids with KCl! and fix the acid-base balance. It will prolly still be low though because if you fix the acid-base balance the K moves back into the cell and you still gave fluids to dilute. Can consider oral K-gluconate suppliment, as well as feeding them to inc K.
syringe feeding is diff from force feeding somehow?idk
easiest thing to do is offer food first. How can you make it very palatable?moist, warm it up. Can try to put some on their lips bc if you give them a taste of it they might wanna eat it
coax feeding is best done by..owner.
If you are considering appetite stimulants... what are some choices? And how should you use them?cyproheptadine, reglan, valium... these are like jumping a car tho. You give to start their appetite back up, but you don't keep giving it- if you depend on drug, they wont be eating enough calories
which drugs are contraindicated in hepatic lipidosis?Diazepam derivatives-- they upregulated due to HL so they can seize. And then liver can't break it down-- so acute hepatic necrosis follwong IV dose of valium. so diazepam derivatives CI in HL cats.
diff types of tubes to get food in? which does he recc?Eso tubes. G tubes. jejunostomy tube. nasogastric tube. Orogastric not advised for adults but good for neonates. Most desireable are probably NE or NG because they are the least invasive and dont require anesthesia. But these you can't do long term-- so an E-tube is more long term, and less invasive than a G tube (e tube gets out= bummer. G tube gets out= chemical peritonitis). So he reccs as new grads, e-tube as long term tube.
Ng vs NE tubewhy NE instea of NG? bc sphincters in way-- reflux. mm tone of eso
ways to tell the tube is in the eso, not the trach?can do rads. pull content and see if acidic to make sure in stomach. can try to palpate. can squirt water in it-- if in trachea they will cough.
benefit of a NG tube?can suck up fluid so they vomit less if thats a problem
why might you see sick patients with elevated blood glucose? how might you want to change the diet accordingly?Stress....relative insulin resistance...futile cycling of krebs cycle. So might wanna lower carbs (since they aren't being used well anyway) and inc protein (body is prolly starting to break down lean mass so giving more protein helps with this)
what two KNF (key nutritional factors) will you want to inc with acute patients?Want to inc fat and protein bc body is breaking both of these down under the influence of cytokines/interleukins. And then carbs aren't being used efficiently bc dec insulin INC PROTEIN AND FAT, DEC CARBS.
how can you stim release of insulin in dogs? Cats?in dogs it's based off glucose. But in cats can release insulin based on Arginine (shorter acting tho)
how does path of carbs and protein differ from fat to get to liver?when fat is absorbed from the GI (enterocyte-->attaches to lipoprotein produced by enterocyte as chylomicron--> chylomicron enters lacteals to go into lymph--> thoracic duct--> heart--> circulation-->hepatic artery) gets to the liver. Whereas Carbs and protein are absorbed directly and go to portal vein.
acute care diet includes low carb, high fat, high protein diet. but How do you take cat with liver full of fat and give them high fat diet? how is fat absorbed? Explain how fat metabolism differs based on hormones presentWhen fat is absorbed from the GI (enterocyte-->attaches to lipoprotein produced by enterocyte as chylomicron--> cylomicro enters lacteals to go into lymph--> thoracic duct--> heart--> circulaton-->heaptic artery) gets to the liver, is down to the capillary level the walls of the capillary lumen there is 2 enzymes- HSL (hormone sensitive lipase) and LPL (lipoprotein lipase). When under the influence of insulin (like they just ate), the LPL is stimulated, and the LPL breaks the chylomicron down into FFAs, which insulin encourage to go into adipose tissue, and only the chylomicron "remnant" gets to the liver, so the liver doesnt actually see that much fat from the GI. So we can HAVE an acute care diet for a HL patient be high in fat as long as they have insulin (which happens because they are eating). HL happens because they AREN'T eating--> there is no insulin and there is more glucagon--> this stimulates HSL in the capillary bed, and there aren't chylomicrons because they aren't eating so FFAs exit the adipose tissue due to HSL and move to the liver--> liver fills up with fat and the fat shoves the functional part of the cells off to the side. SO you want fat in the diet.
so overall...what should the KNFs of a HL cat's/acute care diet look like?high fat, high protein, low carbs, high arginine and inc N-3 PUFAs (NOTE: DO NOT GIVE HIGH PROTEIN IF HEPATIC ENCEPHALOPATHY-- the nitrogen--> ammonia will make it worse)
what is a good factor for a IER (illness energy requirement))Do factor of 1. This is the starting place bc every pt can tolerate this. so start with factor of one unless severely burned or septicemia- then need a little more.
how do you help avoid refeeding syndrome?you should do small, frequent meals (4-6 a day) and DONT start off with the full calculated amount. What we start off with is 1/4th or 1/3 of food dose on day one....then 1/2-2/3 calories on day 2, and then 3/4 to calories all the way to 1.0 on D 3. or 1.0 on day four if went with fourths. (so break into 4-6 meals per day and first few days not giving them all the calories the first few days) helps prevent refeeding syndrome. (make sure you ask what body weight the clinician wants you to use- ideal or somewhere in between, depending on what they think is better)
gold rule with starting to feed a patient again?If the gut works, used it. more physiological-- not as many problms as with TPN with refeeding syndrome
owner calls you and says Cali just ate with her mouth. Should you take the Eso tube out?NOT YET-- if you take it out and she stops eating again, youre gonna be pissed. Always offer food before feeding through E tube. make sure cat eating several days for at least 75% calories before consider taking out (if tube comes out you have one hour to get it back in) just have them flush tube with water twice a day and then leave it and cat will eat.
how similar is an acute care diet to a cancer diet?With cancer-- remember same diet is high protein and high fat and low carbs and lots of N3PUFA
why do we like N-3PUFAs in the diet?antiinflammatory effects :) (remember interleukins and cytokines are driving body to break down fat and mm)