Samantha has been very active in feline medicine since graduating from the RVC in 2002. She interned in private referral practice before starting a FAB residency at Bristol University. She obtained the RCVS certificate in small animal medicine in 2006 and in 2009 became a diplomat of the ECVIM. She is a recognised specialist at both RCVS and European level. She was awarded FRCVS in 2019 for outstanding contributions to the profession. She works as an internal medicine specialist at Lumbry Park Veterinary Specialists in Hampshire and is the Academy Lead and Specialist Consultant for the ISFM. ISFM is the veterinary division of International Cat Care, providing a worldwide resource for vets on feline medicine and surgery. On July 1st 2022 ISFM published consensus guidelines in the Journal of Feline Medicine and Surgery. This is a very comprehensive open access publication, which contains all the information in the webinar and more, including two owner guides and three videos.
2022 ISFM Consensus Guidelines on Management of the Inappetant Hospitalised cat
Samantha Taylor, Daniel Chan, Cecilia Villaverde and others
The content of Samantha Taylor’s veterinary webinar is outlined in the following headings:
- Background on cats and eating
- Consequences of poor nutrition
- Nutritional assessment
- Hospitalised patients
- Appetite stimulants and when to use them
- Feeding tubes and when to use them
And we are advised as a general point -‘Don’t hope they will eat tomorrow-act today!’
For cats, a period of inappetence can lead to deleterious consequences. Often there are multiple causes that require a combination of approaches. Anorexia should never be ignored.
The webinar continues with an algorithm outlining the consequences of inadequate nutrition in cats, with 12 consequences under discussion. This includes everything from poor compliance, accelerated euthanasia decisions, owner anxiety and dissatisfaction, through to multiple metabolic diseases such as hepatic lipidosis.
The importance of body condition is emphasised and nutritional assessment is considered the fifth vital sign after temperature, pulse, respiration and pain assessment. Assessing nutritional status is therefore a good habit that should be evaluated in every patient. Body condition guidelines exist, such as the WSAVA one, which is useful following a short dietary history. Also a good habit is assessment of muscle condition, which can be assigned a score from 0-3:
- 0 severe muscle wasting
- 1 moderate muscle wasting
- 2 Mild muscle wasting
- 3 Normal
Some cats may be overweight but have a poor muscle condition score. Muscle wastage is seen in arthritis, chronic kidney disease and gastrointestinal disease. ISFM guidelines cover nutritional assessment in some detail including the use of a handy graph. You are asked ‘Are you monitoring nutrition in your hospitalised patients?’
Every hospitalised cat should have:
- A nutritional history taken
- Body weight and body condition
- Calculation of energy requirements. Resting Energy Requirement (RER) based on actual weight, admitted weight and ideal weight, calculation of grams of food, a consideration of underlying disease and body condition score.
Hospital sheets are available to download from the consensus guidelines. A promising 95.2% of consultations record weight but only 22.5% record body condition score, demonstrating where room for improvement exists.
Eight non-specific factors associated with inappetance in hospital are listed followed in the next slide by nine suggested interventions in the management of inappetance. Anxiety is the cause of many cats not eating in hospital and there are varied simple changes to the hospital cage that can help with this. A useful resource is www.catfriendlyclinic.org.
Other factors to manage include nausea and pain. Suitable anti-nausea drugs are summarised and it is advisable to pain score all hospitalised cats. The feline grimace scale is simple and easy to use, and other pain scoring systems are available. It is important to avoid polypharmacy since drug interactions are often undiagnosed, and many drugs cause nausea.
There is a section on ‘When to intervene, with a general bullet point ‘Don’t wait until tomorrow!’ Appetite stimulants can be useful in the management of hyporexia, but their inappropriate use will result in treatment failure. In the presence of nausea and pain appetite stimulants will fail. Adding more pills will affect compliance also. Appetite stimulants have a use as part of the management of chronic illnesses, and various are listed with the use of mirtazapine emphasised.
The final part of this webinar deals with feeding tubes, having first asked the question ‘How often do you place feeding tubes (any type) in cats in your clinic?’ Three possible answers were given-never, occasionally, frequently. The follow up question was ‘If never-why not?’ Discussed in this section are:
- Naso-oesophageal tubes with instructions on how to place them, their indications and complications
- Naso-oesophageal tube or naso-gastric tube (routine in USA/Canada)
- Oesophagostomy tubes with instructions on how to place and complications. Of these between 12-18% develop a stoma infection. Other less common complications include infection and cellulitis, haemorrhage, nerve damage and rarely Horner’s syndrome.
- Further advice is given on dealing with stoma site infections and their prevention
- Feeding tube obstruction-causes and treatment
- When should you consider placing a feeding tube? Suggested indications include cats consuming less than 80% RER for 3 days or more, cats with jaw fractures that are unable to eat, and if undernutrition is anticipated (following surgical procedures or chemotherapy)
- If malnutrition is a risk
- Medication compliance.
The advantages of feeding tubes are listed and there are suggestions of what diet to feed and how much, followed by practical tips for friendly tube feeding, which also emphasised not to attempt syringe feeding.
Samantha’s summary -inappetant cats:
- Multifactorial causes
- Deleterious to recovery
- Nutritional assessment important
- Confidence to intervene rather than leave another day (you can always take the tube out!)
- Appetite stimulants can be useful-but manage other factors too
- Remember the role of stress for hospitalised patients
This is a comprehensive webinar with lots to think about that may have escaped your attention previously.