CLINICAL

Nutrition in critical care

Veterinary professionals in emergency and critical care see the sickest and most unstable patients, and it is
understandable that nutrition is not at the forefront of their minds. This article demonstrates why nutrition is
important in the most critical patients, and why studies show it is no longer advisable to delay assisted nutrition.
Absence of nutrition in the critical patient leads to muscle catabolism, protein deficiencies and increased risk
of sepsis. There are options for enteral or parenteral nutrition, and various feeding tubes that can be used
depending on the status of the patient. Both underfeeding and overfeeding can be detrimental to the critical
patient; requirements should be calculated for each patient on an individual basis, considering the dietary
requirements and risks associated with each presentation and disease process. There are also changes that can
be made in the hospital to encourage patients to eat voluntarily; it is important not to forget holistic care in the
critical patient.

Steph Phillips GradDipVN, RVN, ISFM CertFN, Queen Mother Hospital for Animals, Royal Veterinary College, Hawkshead
Lane, AL9 7TA. [email protected]

Key words: nutrition | malnutrition | assisted feeding | monitoring | enteral nutrition

T
he World Small Animal Veterinary Associa- Malnutrition
tion (WSAVA) nutritional guidelines recom- Simple starvation is described as the absence of nutrition
mend including nutritional assessment into in the otherwise healthy animal, and involves the uti-
the five vital signs of patient assessment, along- lisation of glycogen stores to meet energy requirements
side temperature, pulse, respiration and pain (Freeman et (Chan and Freeman, 2006; Chan, 2013). Stressed starva-
al, 2011). Nutritional assessment involves a multi-faceted tion is the term used to describe a metabolic response to
approach, including duration of anorexia/hyporexia, abil- trauma, inflammation or disease triggering changes in
ity to eat voluntarily, body and muscle condition scoring cytokine and hormone concentrations leading to catabo-
and risk factors. See Figure 1 for a downloadable checklist lism of lean muscle and preservation of fat stores in the
available from the WSAVA. Nutrition is often in the back absence of adequate nutrition (Chan and Freeman, 2006;
of veterinary professionals’ minds with many patients, not Chan, 2013). Catabolism of muscle is more pronounced
only critical patients. While they carry out stabilisation in cats, as glycogen stores are rapidly depleted in the strict
and investigations into the patient’s current condition and carnivore, and as gluconeogenesis is a constant process in
presentation, they will rigorously investigate inappetence cats, amino acids (specifically alanine and glutamine) are
and treat the underlying cause, but implementing a nu- mobilised early from muscle stores to fuel enterocytes and
tritional plan and methods of assisted feeding generally macrophages in the immune system (Saker, 2006; Chan,
comes much later. 2013). Starvation will also result in gastrointestinal (GI)
mucosal atrophy and subsequent increase in permeability
What is nutrition and why is it important (Sigalet et al, 2004).
Nutrition is described as the processes of food utilisa- Illness in many forms induces biochemical, metabolic
tion by a plant or animal (Merriam-Webster, 2020). The and pathological abnormalities which influence nutrient use
terms macro and micronutrients refer to the volume of (Saker, 2006). The term critically ill could refer to instabili-
each that is required. Macronutrients include protein, ties of the cardiovascular, respiratory or neurological systems,
carbohydrates and fats, and they are predominantly re- or any patient experiencing hypermetabolic derangements.
sponsible for energy provision. Protein is responsible for Chan (2013) states that critically ill patients or those recover-
metabolic regulation, tissue growth, function and repair; ing from surgery are often reluctant or unable to ingest ad-
carbohydrates are mostly converted to glucose and used equate nutrition, and with an increased nutritional demand as
for energy; fatty acids omega-3 and omega-6 are essen- a result of metabolic changes they are at an increased risk of
© 2020 MA Healthcare Ltd

tial and significant in immunosuppression and inflam- malnutrition. Protein-calorie malnutrition (PCM) is associ-
mation (McCune and Girling, 2007). Micronutrients are ated with reduced production of immunoglobulins, secretory
the vitamins and minerals required to maintain healthy antibodies and complement components, as well as atrophy of
function and immunity; minerals are often collectively the thymus and lymphoid tissue, atrophy of the skin and GI
known as ash. mucosa, neutropenia, reduced neutrophil function and sub-

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CLINICAL

critical care medicine, however implementation of nutrition

is often overlooked once stability is achieved. In any kind of
malperfusion associated with unstable presentation, splanch-
nic perfusion will be compromised, and feeding the patient in
this unstable condition could increase the risk of intestinal is-
Nutritional Assessment Checklist chaemia (Sigalet et al, 2004). Nutrition should be implement-
To be completed by the pet owner. Please answer the following questions about your pet:
ed as soon as possible after restoring haemodynamic stability,
Pet’s name: _________________________________ Species/breed: _____________________________ Age: ___________________________
electrolyte and acid–base disturbances, and hydration status
Owner’s name: _______________________________ Date form completed: ___________________
(Delaney, 2006; Chan, 2013).
1 How active is your pet? Very active Moderately active Not very active
2 How would you describe your pet’s weight? Overweight Ideal weight Underweight In some diseases, it has been the historical approach to
3 Where does your pet spend most of the time Indoor Outdoor Indoor & Outdoor
Please list below the brands and product names (if applicable) and amounts of ALL foods, treats, snacks, dental hygiene products,
starve the patient on purpose, this view was also seen in
rawhides and any other foods that your pet is currently eating, including foods used to administer medications:
human medicine in the care of the elderly (Chan, 2013).
Food
Examples:
Form *Amount Number Fed since
In human medicine, however, the effects of malnutrition
• Purina Cat Chow
• 90% lean hamburger
dry
pan-fried
½ cup
3 oz (85 grams)
2x/day
1x/week
Jan 2010
May 2011
were found to have an impact on morbidity and mortality,
• Milk Bone medium
• Greenies Salmon Dental
dry
treat
2
2
3/day
daily
Aug 2012
Jan 2013
and implementation of nutrition was prioritised (Chan,
2013). Veterinary medicine has been delayed in follow-
ing this approach, and it is not unheard of to see the par-
*If you feed by volume, what size measuring device do you use? _______________ voviral puppy starved early in its care, as well as patients
*If you feed tinned/canned food, what size tins/cans? _________________________
4 Do you give any dietary supplements to your pet (for example: vitamins, glucosamine, fatty acids, or any
with haemorrhagic gastroenteritis or pancreatitis, in fa-
other supplements)? No Yes
If yes, please list brands and amounts:_________________________________________________________________
vour of emptying the stomach to allow rest time. Mohr
To be completed by the health care team:
et al (2003) reported several studies highlighting the oc-
Has the diet history form been reviewed? No If not, please review the diet history form Yes If yes, please continue: currence of bacteraemia in canine parvovirus, considered
Current body weight: __________________ Ideal body weight: _______________________________
Current body condition score* _____/9 or ____/5 *Refer to the body condition scoring chart
likely as a result of the breakdown of gut barrier function
Muscle Condition Score: normal mild wasting moderate wasting severe wasting
leading to bacterial translocation. The small bowel con-
Screening evaluation checklist
Pets that are healthy and without risk factors need no additional extended evaluation tains gut associated lymphoid tissue (GALT) with lym-
Nutritional screening risk factors (extended evaluation is OPTIONAL) Check if present
Extremely low or high activity level
Multiple pets in a household
phocytes and macrophages on the intestinal wall (Saker,
Gestation
Lactation 2006). This, alongside immunoglobulins secreted into the
Growth period
Age of >7 years
Nutritional screening risk factors (extended evaluation is MANDATORY)
GI lumen minimises pathological translocation. Trans-
History of altered gastrointestinal function (e.g., vomiting, diarrhea, nausea, flatulence, constipation)
Previous or ongoing medical conditions / disease
Currently receiving medications and/or dietary supplements
location is promoted by bacterial overgrowth, impaired
Unconventional diet (e.g., raw, homemade, vegetarian, unfamiliar)
Snacks, treats, table food > 10% of total calories defences, protein-calorie malnutrition, trauma, critical
Inadequate or inappropriate housing
Physical examination
Body condition score less than 4 or greater than 5 (on 9-pt scale)
illness and mucosal atrophy, as well as a change in lumi-
Muscle condition score: Mild, moderate, or severe muscle wasting
Unexplained weight change nal nutritional supply (Saker, 2006). In a review of several
Dental abnormalities or disease
Poor skin or hair coat
New medical conditions / disease
studies in human medicine Sigalet et al (2004) found that
the implications of starvation included mucosal atrophy
NO CHECKED ITEM(S) ON THIS PAGE? The Nutrional Assessment is complete
wsava.org
and increased intestinal permeability. A study by Hadfield
CHECKED ITEM(S) ON THIS PAGE? Continue on the next page
et al (1995) found that implementation of enteral nutri-
Figure 1. Nutritional Assessment checklist, WSAVA (2013) https://wsava.org/wp- tion can reverse the impairment to GI tract mucosal lin-
content/uploads/2020/01/Nutritional-Assessment-Checklist.pdf. ing associated with critical illness in humans. Historically
treating pancreatitis with starvation has been a common
sequent reduction in the capacity to neutralise phagocytosed approach considered necessary in order to rest the pan-
bacteria (Saker, 2006). Compromised immunity is detectable creas and avoid autodigestion; however, this theory is not
in cats by day 4 of anorexia, and metabolic changes in dogs proven, and studies have in fact suggested little to no neg-
by day 3, therefore it is argued that nutritional support should ative feedback from the pancreas in the presence of nutri-
be implemented by day 3 (Chan, 2013). Often the period of tion in the intestinal tract (Harris et al, 2017). A study by
anorexia at home is disregarded, and nutrition is implemented Harris et al (2017) found reduced GI intolerances (defined
on day 3 of hospitalisation, but this can be day 6 of anorexia in the study as vomiting and regurgitation) when enteral
for the patient and close attention should be paid to the pa- feeding was implemented within 48 hours of admission,
tient’s history. Hyporexia (reduction in appetite) should also compared with delayed nutrition. This study also found
be considered, as inadequate nutritional intake may result in early assisted feeding reduced the time to voluntary feed-
the same complications, such as infection, sepsis, organ failure ing, and any GI intolerances seen were predominantly in
and poor wound healing (Saker, 2006). the non-assisted feed period.
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Some patients are at an increased risk of delayed nutri-

When to implement nutrition in tion, such as obese cats at risk of hepatic lipidosis, a condi-
critical care tion where cats mobilise peripheral fat stores in the absence
Cardiovascular, respiratory, urogenital and neurological sta- of food and hepatocytes overwhelm with triglycerides, or
bility will always require priority attention in emergency and young growing animals (Chan, 2013). Conversely, recum-

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 CLINICAL

bent patients, or those with obtunded mentation, are at risk duration of support, disease affecting the alimentary tract,
of aspiration where there is risk of regurgitation, such as if cost and whether or not anaesthesia or sedation is re-
fed orally or by upper GI feeding tubes. Patients with ileus quired. Feeding tubes allow the opportunity to administer
are at an increased risk for feeding complications, as are pa- feed by CRI. This may be preferred if the patient is not
tients on systemic opioids and anaesthetised patients, such as tolerating large volumes in the stomach, or if the patient
ventilated patients (Chan, 2013). Pain should be assessed as a has a jejunostomy tube, where bolus feeds are not toler-
painful patient is unlikely to eat voluntarily regardless of the ated (Chan, 2013). There are many tube options, such as
underlying condition; however, opioids can slow gut motility naso-oesophageal (NO), naso-gastric (NG), oesophagos-
and exacerbate anorexia (Delaney, 2006). Alternative analge- tomy, jejunostomy and percutaneous endoscopic gastros-
sic options should be considered, such as multi-modal anal- tomy (PEG) (Figure 2). The advantages and disadvantages
gesia, and constant rate infusion (CRI) combinations that can of each method should be considered.
facilitate decreased bolus opiate doses. Tube placement should be confirmed by aspiration of
gastric content, or imaging, preferably radiographic. An al-
How to implement nutrition ternative tube placement check uses capnography — place-
Enteral vs parenteral ment into the airway will cause a capnograph trace and
Parenteral nutrition (PN) is the administration of nutri- reading, placement into the alimentary tract should not
tion intravenously via a central catheter, or intraosseous give any capnographic reading and thus can be used as con-
catheter in neonates or very small patients. PN should firmation of correct placement.
only be chosen if there is an inability to feed enterally or Patients can be discharged with feeding tubes indwell-
if the patient is at an increased risk of aspiration, such as ing for management at home (Eirmann and Michel, 2015).
depressed mentation (Michel and Eirmann, 2015). It can This should also be considered in tube choices, as NO or
be used to supplement enteral nutrition if the patient is NG tubes are generally not suitable for long-term use be-
unable to meet 50% of its requirement via the digestive cause of patient interference and tube blockage. To avoid
tract, a method that has proven successful in improving the risk of confusion between enteral feeding ports and
outcome in small animals (Freeman et al, 2011; Chan, central line ports, there are commercially available con-
2013; Michel and Eirmann, 2015). There are now PN bags nectors and tubing reversing the male-female connection
commercially available containing amino acids, dextrose, (Nutrisafe, Vygon), therefore feeding lines cannot be ac-
electrolytes and lipids (Kabiven, Fresenius Kabi). There cidentally connected to a venous port. Alternatively and
are many complications associated with PN including additionally, feeding lines and ports should be clearly la-
but not limited to: thrombophlebitis because of hyper- belled to avoid any mishaps. This is particularly pertinent
osmolarity (therefore use should be limited to a central where there are concurrent O tubes and central venous
line); hyperglycaemia; hypertriglyceridaemia; hyperam- catheters, as the insertion sites are wrapped in the same
monaemia (Chan, 2013). The catheter (or central venous neck dressing.
port) and line used should be handled aseptically, and
dedicated to the PN only, as there is an increased risk of Resting energy requirements
sepsis (Michel and Eirmann, 2015). In the author’s prac- Canine and feline adults
tice, PN is prepared with sterile gloves and the ports and Nutritional requirement is calculated as a resting energy
connections are sealed with tape to avoid accidental dis- requirement (RER), as the calories required per day to
connection and prevent use for sampling or medications. maintain homeostasis in a thermoneutral environment
PN adversely affects immunoglobulins in GALT, but also
affects mucosal affected lymphoid tissue such as found in
the respiratory system (Sigalet et al, 2004).
Enteral nutrition is important in maintaining the enter-
al immune barrier (Sigalet et al, 2004). Sigalet et al (2004)
reviewed many studies in human medicine on enteral
nutrition versus PN in surgical and trauma patients, and
found that overall patients receiving PN were more likely
to develop significant infections, and that enteral feeding
reduced not only the risk of infection, but also the length of
hospitalisation and mortality.
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Tube options
Assisted feeding should be implemented if the patient is
not voluntarily meeting 75% of its resting energy require-
ments (RER) (Freeman et al, 2011; Chan, 2013). There are Figure 2. A cachexic dog with a naso-oesophageal feeding
many components to tube selection, such as anticipated tube for the provision of enteral nutrition.

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CLINICAL

to tetanic patients with a markedly increased metabolic

demand. If the patient is not tolerating the quantities of
food required, then supplementation with PN should be
considered. Despite the guidelines of feeding the standard
RER, some disease processes are expected to exceed these
requirements, such as thermal burns or tetanus.
While aiming to achieve 100% RER intake, this can be
Feeding Instructions
achieved gradually over 3 days, starting at approximately
Feeding preferences at home 30% RER. This method may be preferable in patients with
Patient name:
prolonged anorexia, metabolic instabilities and GI disease,
(e.g. What type of diet? How much? Fed at what time of day?
Treats? Type of bowl? Brand and flavour preferences?)
Patient number:

Client name:
and is subject to daily reassessment (Eirmann and Michel,
Species: Breed:
2015). Nutrition specific monitoring charts are available
Sex: Age: from the WSAVA (Figure 3).
VN/technician: Vet: The RER can be calculated using:

Date: Weight today: BCS today: (9 point scale) Muscle wastage: (tick below) Bodyweight (BW) <2 kg or >30 kg
None Mild Moderate Marked RER = 70 x BW0.75 = k/cal per 24 hours
Voluntary (per os) assisted feeding (via tube)*
Route of feeding (*if delivering enteral nutrition, try to avoid meal sizes of more than 10ml/kg)

Diet to be fed BW 2–30 kg

Type of diet dry wet liquid other (please state):
RER = (30 x BW [kg]) + 70 = k/cal per 24 hours
% of RER to be given per day 100% 75% 50% 25% (please state):
(Chan, 2013)
Number of feeds per day

Special considerations
Young canines and felines
Hospitalised growing puppies and kittens should initially
be fed the percentage of RER they will tolerate, aiming for
Calculating Daily Energy Requirements and Food Intake 100%, subject to frequent reassessment. Regular assessment
should determine early if the patient has an increased calorie
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
Calculate RER Calculate % of RER Identifiy kcal per Calculate number Calculate number
demand and the patient should be fed to meet this (Eirmann
and Michel, 2015). Growing animals are at an increased risk
RER 2kg - 30kg = required per day gram/ml/cup of diet of grams/mls/cups of grams/mls/cups
BW(kg) x 30 (+70) % RER ÷ 100 (x total to be fed required per day required per feed
RER <2kg and >30kg RER) Daily kcal requirement Total quantity of food
= 70 x BW(kg) 0.75 (from step 2) ÷ kcal
per gram/ml/cup
(from step 4) ÷ number
of feeds per day
of hypoglycaemia if nutrition is delayed.
(from step 3)

Considerations in hospital
Daily % RER Kcal per g/ml per g/ml per
Nutritional assessment, according to the WSAVA and
kcals = per day
(kcals) =
g/ml = day = feed =
American Animal Hospital Association (AAHA) guide-
lines should include environmental factors, such as lo-
cation, environmental stimulation and surroundings, as
these are all factors that may impact the likelihood of a
Figure 3. Global nutrition committee feeding instructions, WSAVA (2013) https:// patient eating in the hospital environment, and at home
wsava.org/wp-content/uploads/2020/01/Feeding-Instructions-and-Monitoring-Chart-
(Baldwin et al, 2010; Freeman et al, 2011). Other con-
for-Hospitalized-Patients.pdf.
siderations should include feed timings and frequency,
(Eirmann and Michel, 2015). Any energetic exertion method of feeding and poor husbandry (Baldwin et al,
would increase the requirement, such as in a working 2010; Freeman et al, 2011). For example, a food bowl next
dog. Historically, illness factors were used to increase the to a soiled litter tray is unlikely to stimulate the appetite of
calorific calculation, with a range of 1.0-1.5 x RER to ac- a hyporexic cat (Delaney, 2006). Similarly, grooming the
count for increases in metabolic demand associated with patient if they enjoy it, or otherwise simply fussing them,
disease and wound healing. This method is less favoured may encourage eating, or the inclusion of feeding toys
now because of the risk of overfeeding, which is associ- may stimulate interest in food (Baldwin et al, 2010; Free-
ated with complications such as gastrointestinal intol- man et al, 2011). Raised feed bowls should be considered
erance, hepatic dysfunction, increased carbon dioxide for cats as well as large breed dogs. Attention should be
production and hyperglycaemia, among other metabolic paid to the environment: an anorexic cat is unlikely to be-
complications (Chan, 2013). Instead, the recommenda- gin eating in the presence of a noisy dog (Delaney, 2006).
© 2020 MA Healthcare Ltd

tion is to feed the calculated RER and monitor the patient A patient assessment questionnaire may be useful in de-
for signs of inadequate intake, increasing in increments of termining normal feeding routines, such as bowl type
25% per 24 hours as required (Chan, 2013). This method and environments, favourite food types and flavours. An
may well exceed 100% of the calculated RER; in the au- anorexic dog may prefer to eat in the clinic kitchen area
thor’s experience, it is common to feed 200% and more than its own kennel, as it more closely mimics a home en-

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 CLINICAL

vironment. The patient may be more inclined to eat if it is

fed by someone it does not associate with stress, therefore
the person that examines, restrains and carries out pro-
cedures most often on the patient may incite an aversion
to that meal and may not be the best person to feed that
patient (Delaney, 2006).
Chan (2013) suggests that strategies such as warming
foods and flavour enhancers are typically ineffective, and
that syringe or force feeding should not be used. Syringe
feeding is a high risk for aspiration and can induce food
aversion (Freeman et al, 2011), as well as being difficult
to accurately record due to spillage with poor patient
cooperation. Other commonly used tempting strategies
include using wet foods, high fat and high protein diets
(Delaney, 2006).

Monitoring and complications

Patients should be assessed daily to see if they are receiv- Figure 4. Complications of refeeding syndrome may require multiple intravenous
supplementation..
ing the prescribed RER voluntarily, and if they are being
supported sufficiently by tube, or if they require interven-
tion (Eirmann and Michel, 2015). A study by Brunetto KEY POINTS
et al (2010) found a direct association between patients zzEarly enteral nutrition is recommended as soon as the patient is stable.
fed <33% RER and a poor hospital discharge rate. All zzParenteral nutrition is an option for patients that cannot tolerate enteral
hospitalised patients should be weighed daily, particu- nutrition, or need extra support.
larly patients receiving nutritional support (Chan, 2013). zzFeeding tubes are advocated for patients that are not voluntarily eating a
Weight changes should be assessed alongside other clini- sufficient amount.
cal parameters, such as fluid balance; body condition zzNutrition plays an important role in wound healing, immunity and health.
scoring (BCS) may help distinguish changes between
the two (Chan, 2013). BCS is commonly seen and used
in practice, using a visual comparison of waist, neck and and severely malnourished patients. Regular monitoring of
shoulder width and abdominal tuck, as well as palpation bodyweight, urine output and electrolytes should be carried
of fat cover over the ribs, spine and pelvic bones (Free- out in all patients with recently implemented nutritional sup-
man et al, 2011). Muscle condition scoring (MCS) sys- port, specifically patients identified as at increased risk, and
tems are less well known. These involve palpation of bony particularly cats (Figure 4).
areas which should have adequate muscular cover, such Other complications associated with assisted enteral nu-
as the temporal bones, vertebrae and pelvis, and is scored trition include GI intolerances, such as vomiting, diarrhoea
as mild, moderate or marked muscle wasting (Freeman and abdominal pain (Chan, 2013).
et al, 2011). WSAVA recommendations are to use MCS
in chronic and acute disease, as muscle loss is greater in Conclusion
patients with stressed starvation (Freeman et al, 2011). A A nutritional plan should be made for every patient. Nutri-
study by Michel et al (2011) validated the use of a palpable tional assessment on admission should highlight areas of
four point muscle mass scoring system in cats. It found concern, and the requirement for restricted calorie intake,
differentiating between normal and severe muscle wasting restricted diet factors and interventions that may be required,
accurate when compared with dual-energy x-ray absorp- with a rigid timeframe. The latest guidelines advocate early
tiometry, but that determining mild to moderate wasting enteral nutrition where feasible, with parenteral nutritional
was less reproducible. Regular monitoring should also support as required.
include blood tests such as glucose, total solids, triglyc- Patient assessment questionnaires can be helpful in
erides, blood urea nitrogen and electrolytes to assess the determining patient preferences, such as favourite fla-
effects of nutritional intervention, both positive and nega- vours, food bowl types and normal environment, how-
tive (Eirmann and Michel, 2015). ever this is not a requirement. Developing a calorie cheat
Refeeding syndrome is a complication whereby a mal- sheet with the caloric value of each commonly used diet
© 2020 MA Healthcare Ltd

nourished patient undergoes metabolic derangements on and tempt food helps to quantify exactly how much of
implementation of feeding, resulting in depletion of phos- the patient’s RER they are achieving voluntarily, other-
phorus, magnesium and potassium, which can lead to cardiac wise hyporexia can be easily missed. Hospitalised human
arrhythmias and respiratory failure (Chan, 2015). This com- patients fed enterally rather than parenterally were
plication is generally associated with prolonged starvation found to often be significantly underfed, a risk that the

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CLINICAL

veterinary nurse should be aware of (Sigalet et al, 2004). cvsm.2006.08.001

Eirmann L, Michel K. Enteral Nutrition. In: Silverstein D, Hopper K, eds.
Nutrition-specific monitoring charts are available from Small Animal Critical Care Medicine. 2nd Edn. 2015. Elsevier, Canada: pp
the WSAVA and can play a pivotal role in early identifi- 681-686
Hadfield RJ, Sinclair DG, Houldsworth PE, Evans TW. Effects of enteral
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intervention. VN ill. Am J Respir Crit Care Med. 1995; 152(5):1545-1548. doi:10.1164/
ajrccm.152.5.7582291
Harris JP, Parnell NK, Griffith EH, Saker KE. Retrospective evaluation of the
Conflict of interest: none. impact of early enteral nutrition on clinical outcomes in dogs with pancrea-
titis: 34 cases (2010-2013). J Vet Emerg Crit Care (San Antonio). 2017;
27(4):425-433. doi:10.1111/vec.12612
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