So good evening everybody, and thank you for joining us for tonight's webinar that has been very kindly sponsored by Mackle Health, the manufacturer of oral aid. Tonight we have Nicola Ackerman presenting for us. So Nicola works as headed nurse at Plymouth Veterinary Group.

Nicola has written for many veterinary publications and textbooks and is the author of the editor of Aspinall's Complete Textbook of Veterinary nursing. Nicola has won the BVNA slash Blue Cross Award for Animal Welfare, the SQP Veterinary nurse of the Year, and the SQP Nutritional Adviser of the Year. Nicola is currently studying for a master's degree in advanced veterinary nursing with Glasgow University.

Tonight, Nicola is going to be discussing oral rehydration and microenteral nutrition therapy for GI disorders. But firstly, we have a few slides from Anthony at Mackle Health. So over to you, Anthony.

Thank you for attending the webinar this evening. My name is Anthony Mackle from Mackle Animal Health. And so we are the manufacturer of orallaid, rehydration and nutritional products.

So we're a family company located in Northern Ireland and first launched Ola back in 2008 as a simple palatable oral rehydration solution, as an alternative to standard electrolyte powder products. The idea of making Life easier for vets with a ready to serve product that patients will readily consume. Since then, we have worked with veterinary specialists and nutritionists over the years to further develop or lead into a unique formula that would provide both palatable oral rehydration support.

But combining this with microlateral nutrition. Which is really trickle feeding the gut to help nourish enterocytes and restore gut health and motility. Particularly for patients with GI disorders.

So this year, we're really excited to be launching our new look as OA GI support, and also have launched a new product RF support for patients with renal problems. This evening we are really delighted to sponsor this webinar. I would like to say a very big thank you to Nicola Ackerman, who will presented.

And also to the webinar vet for hosting. If you have any questions you would like to direct myself or anyone at Mackle following the presentation, please send these to us after the presentation, and you can also email directly to that at Mackle.com.

Thank you and on to Nicola. Hi, everybody. Really, really thank you for joining us this evening.

I know what it's like working all day. You get home, you want some dinner, and, you know, just want, wanna watch a bit of telly and, and you end up thinking, oh, we'll do a webinar instead. So thank you so much for, for attending.

It really, really does make my day actually. So we're gonna be talking about oral rehydration and micro nutrition, but I also really want to look at it, . You know, I'm, I'm a nurse in first opinion practise.

I mainly do clinics, as most of you know, and I really want to look at what the nurse's role in first opinion practise, looking at these cases and how we can actually improve the service that we're giving these animals and actually help improve clinical outcomes. So just sort of, you know, recap a little bit, looking at what actually causes gastrointestinal upset and, you know, if you go and look at any of the textbooks, you'll see a multiple of different reasons. Most of them, and most of the cases that we see, we actually never actually find out what that one definitive reason is why we have gastrointestinal upset.

You know, the, the dog or the cat will present with . You know, a little bit of diarrhoea, maybe vomiting. And it really is the case that we treat the clinical signs, you know, whether that is with you know, diet, rehydration support, a syringe loaded with, with pre and probiotics, .

Signs get better, the dog or cat goes back to normal, you know, just chalk it up to experience. It must have eaten something, must have caught a bug when it was out walking, you know, all these sort of things that we tend to say to people, but what the actual cause was, in many cases we never actually really find out. So, you know, there's a long list there, you know, looks up into some textbooks.

Those were all the different multiple things we found, you know, I've lumped metabolic disease at the bottom that really could be anything, couldn't it? But obviously the things that we tend to look for parasites, bacteria, when we do faecal samples, things like, viruses, really difficult to actually isolate. We, we really can't almost, and protozoa, we tend to look at things like iardia.

Obviously sensitivities and allergies to different types of food can cause problems, but most of the time, there's been a lot of research work done recently and There's actually things like dust mites and storage mites in the food that cause a lot of skin and sensitivity type upsets and actually the ingredients in the food themselves. I see there's inflammatory processes, you know, if we look at things like, IBS, more of an autoimmune issue, and I put foreign bodies in, in there as well because you will see vomiting and, and diarrhoea with a, with a foreign body. So lots and lots of different reasons why we're seeing gastrointestinal upset.

Just want to talk a little bit about the gut biome, because this is what we really need to focus on when we're looking at, at, anything to do with the gastrointestinal, system. Now, my nurses laugh at me a lot when I tell them this. In ourselves, we have 100 trillion bacteria cells in our own gastrointestinal system.

That is 10 times more human cells in your own body. I think that is just a phenomenal fact. And a friend of mine once told me, I always recount this to everybody, if aliens came down and scanned us, they would really think that we were just like a, a holding cell, you know, a holding body almost for all of these trillions of bacterial cells, because that's predominantly what we're made of.

The problem is when it comes down to looking at the finer points of all these things, only 5000 species of bacteria have actually been identified. Only 8% of that 5000 have been found to cause disease. .

And you know, obviously, most of these have been identified cos obviously for obvious reasons we need to know what they are and, you know, how to treat them. But microbiologists estimate there's 10 million other species of unidentified bacteria in, on the, on planet Earth. So there's a massive amount of bacteria out there that we just don't know.

We haven't been identified. And the problem is when you send a faecal sample to the lab. Only between 1 and 5% of bacteria can be actually grown in that laboratory.

So, you know, It's really, really tricky to find a causal bacteria if we can't even grow most of them. This new technologies being produced all the time. It's got an i chip which is helping.

And, and that's just looking at the bacteria. It isn't just bacteria that we have in our gut biome. There's also protozoa and there's viruses.

And the thing to remember is it might be that one bacteria digests something in, in the nutrients that it's being fed, and the products that it produces feeds the next bacteria. So some of the bacteria, the protozo viruses might actually have a symbiotic relationship in, in the biome. So we just don't know, you know, what is going on in our gastrointestinal system.

We know that obviously some nutrients are are good. We know, too much excess of other nutrients. So if we eat lots and lots of simple sugars, you know, it really fermentates and it can cause, what we call gut dysbiosis.

So this is, you know, uneven, it's bad. And we have the wrong population of bacteria growing too fast, too quickly. So when it comes to the gut biome, we know what good things, you know, what some things do work, but we're really, really only just starting to understand how important the gut biome works.

There are thoughts that actually feeds back and actually has a lot of Influence on other factors in our, in our body. There's been links to neurological issues as well. So it's a really interesting thing to, to have a look at and just, you know, keep on top of the, the information that that's coming out.

So, one of the things I want you guys to do tomorrow, when you're at work, and hopefully if you, if you are at work, have a look through your appointment list. Have a look through the diary list, and just see how many of those animals are being presented for diarrhoea. So, you know, vomiting and diarrhoea, have a look how many are acute cases, how many are chronic cases, and go have a chat with your receptionist as well.

I personally believe receptionists are probably the most important people in your practise. They know everything that's going on. Go and have a little chat with them and just ask them nicely.

Can you make a note of how many people phone in the practise each day? They don't want an appointment, but they do want just a little bit of advice regarding, you know, their dog's got, got diarrhoea, but they don't feel that it needs to come into the vets yet. Just see how many you get.

I did it a couple of days ago at my own practise, it is quite big and it is, it is quite a big busy practise. There was 5 on the list for to see the vets, we normally have 2 vets consulting most days, . So yeah, 5 on the list to actually come in to see someone.

And I think they reckoned that they'd had about 8 people just phone up just for advice. Our receptionist is obviously really good at converting those, those into actual appointments, but there's a few questions I've written on the slide there are things that I want you to just think of. If.

So if a member of your family or a child or even yourself, unfortunately had a a dietary indiscretion and had diarrhoea, would you go to the GP's practise? Most of you, you know, in acute diarrhoea sort of say, will say no, you, you wouldn't, it would, it would just pass and off we go. And I think that's the case that that happens with most of our dogs and cats that we see.

And I really think it happens a lot more commoner in cats, but people aren't aware of it because they're not seeing the end result with cats because they're toileting outside. So these people that are phoning the practise and just asking for advice. Are or do your receptionist, do the people that are answering the phone, have they actually been given a, a standard, this is what we need to be telling our clients.

This is what we need to be recommending. Do you know what everybody in your practise is telling our clients? I think that's really important.

Just to sort of throw an idea out there, how many of these people that phone up for advice are being offered a nurse appointment. Now, I think that's a really, really good thing to sort of, you know, chuck out there almost. A lot of these clients are looking for advice, and we're giving away an awful lot of free advice on the phone.

This is a really, really good opportunity to get these clients into the practise and actually so the nurses can make good nutritional . Recommendations to to these clients about what we need to be doing in these cases. So have a little think about, you know, having a protocol for your receptionists because it, it, it actually would really make a lot of sense.

So if these animals do come into a nurse clinic and we are seeing them, you know, what should we be doing? Well, as nurses, we're not allowed to make a clinical as diagnosis, but we can, you know, make an assessment, we can make a judgement. So a full clinical history is required, you know, that that's, you know, basic sort of thing.

You know, have, has there been a dietary indiscretion? Does it scavenge? Is it eating things?

Has it been rummaging around the bins, and all of these sort of different things. We need to be doing the 5 vital assessments. So the 5 vital assessments is temperature, pulse, respiration, that's the 1st 3.

The 4th 1 is the pain assessment, you know, does the tummy feel sore? That's what I'd be looking at. And then 5th vital assessment is, is nutrition.

So it can be as basic as weighing the animal, doing a body conditions school, muscle conditions school, and just asking them what food is it on, what is it eating. And obviously we need to relate that to the situation that we're currently seeing. So if we've got an animal that's been presented with diarrhoea, you know, we need to ask them, have you changed the diet recently?

Have they scavenged, you know, have, you know, they've been on normal kibble all week and then it's Sunday and someone's given them 3 pork sausages and some mashed potatoes for their tea. You know, these things do happen. Obviously, we need to know, you know, what's available in your practise.

What's your practises protocol. And I think that's really important. Does your practise say, OK, if you see a dog with diarrhoea, it needs to go home with an electrolyte solution, or it needs to go home with a tube or something, or we would actually recommend it went home on a GI diet for a couple of days, .

If it is dehydrated, it's a practise protocol to actually recommend that it comes in it goes on to IV fluids. It's an important aspect that we, we have these guidelines, we have these protocols written down to actually help the nurses if they are gonna start undertaking these clinics and advising clients accordingly on, on what information they need to be giving out. I would really, really highly recommend visiting the WSAVA website.

There's a nutrition tool kit on there. Part of that is a nutritional history sheet, and that can be used as part of your 5 vital assessments. It, like I said, it's got body condition sco, muscle condition score on there, you know, it asks a lot about, the, you know, what diet they're on, what they're eating, those sort of things.

So you don't have to go out, you don't have to, you know, reinvent the wheel. It's already there for you. Just go to their website.

Also on their website, there's a lot of detail on how, how to actually perform a body condition score. And how to actually perform a muscle condition score. So I'm gonna talk a little bit more about that, but if you want some more information that that's that's the place to go.

So all these animals we need to weigh is a picture of me and Bramble, . I would really, really recommend weighing these animals, but really take into consideration, the type of scales you're using, use the right, you know, scales for the right size animal. If you're seeing a cat, you need to be using cat scales.

If these animals are dehydrated, we need to sort of take that into consideration as well. You know if it's a Westie and the last time you weighed it it is 10 kg and you've assessed it and it's now 9 kg and you know that weight was quite recent. Then, you know, we could be looking at a 10% deficit if it's that dehydrated.

That, that's a kilo, that's your kilo, you know, there. So, weighing these animals and making sure that we weigh them every time they come into the practise can really help you work out how dehydrated these animals are. So just for completion really, there's a a diagram of the body condition scoring system it's something that we really should be using every time we, we see animals.

And muscle conditions growing as well. This is really, really important, especially, if you do end up seeing any renal clinics as well. We're actually finding that a lot of renal cats that we're seeing, have huge amounts of muscle loss, and they can become quite sarcopenic.

And we need to make sure that they are eating enough to make sure they're actually getting enough protein in so we don't have muscle loss. So, Really, really good website. Have a look at the WSAVA website and, and have, have a little look at this.

So, going back a step, looking at our hydration levels, this is gonna be part of your clinical assessment of, of these animals. You know, do we have tenting of the skin, synchronise? Obviously things like hemo concentration of blood consistent, you know, you're gonna know that if you take blood, but a lot of these cases, we're not gonna take a blood sample.

Ability or inability to sweat. If you're, I, I have an equine background, and that used to be a big one for, for us. Obvious in dogs and cats, it's, it's not so much.

Quantity of the urine that's being produced, blood pressure, if you aren't able to measure blood pressure in practise, refill time and dryness of mucous membranes is a really, really important one. And these are the things that if someone is on the phone wanting advice, And, you know, you've offered them a nurse appointment and they don't want to come in. And I talk to them, you know, what do the mucous membranes feel like?

Do they feel tacky? What's the removal time like? Now, I teach this, to clients I see in puppy and kitten clinics.

And the reason I teach in puppy and kitten clinics is I want them to know for later on in life that if we ever get into this situation, they know what they're looking for. Also really important in renal clinics as well, so we're maintaining hydration. So If the animal does have tacky mucous membranes, it's dehydrated.

We need to get hydration back in this animal. You all know yourself, if you put a bowl of water down, I've got Jack Russell, she'll just look at it, turn her nose up and walk away. You need to be using something that's really palatable to get these animals to take that fluid on board, because if they're not going to, then, you know, we're going down the route of intravenous fluid therapy, and that's really, really expensive.

So weigh these animals, if we're getting hydration back on board, we weigh them, you know, our inpatients should be weighed twice a day minimum, so we know what that their weight is going up and that hydration is going back in. So I know everybody hates doing this, but I'm really, really, really pleased. We really need to be doing this.

If we do go down the route of intravenous fluid therapy, we need to be adding in our, percentages of dehydration deficits to our, fluid amounts and making sure that that deficit is readdressed within the 1st 6 to 12 hours. And that will be on top of the maintenance amounts for that period of time also. So I know everyone has seen this, this table before.

It's in every single nursing textbook that's out there. It's in all, all the veterinary textbooks as well. It will really, you know, look at the clinical signs, clinically examine the animal, make sure you, same as with all your clinical exams, you're talking your way through the exam and telling the client what you're seeing because that helps them to sort of formulate why you've made the recommendation that you have.

Synchronised can be quite easy in some species. It can be really difficult in others, . You know, if you think, let's go pug or Frenchy, how do you tell that they've got sunken eyes if they're dehydrated?

It's really, really difficult. But obviously, you know, if you're seeing a Siamese, it's really, really noticeable. So there, you know, a lot of these clinical signs, you know, will have, breed variations, we just need to be aware of that and obviously make sure that we explain that to clients as well.

So the one thing is, do we need to refer to a veterinary surgeon? And in our practise, . We, we do have a little protocol regarding what we're doing.

And obviously this whole refer to veterinary surgeon is actually part of the, the student nurse MPL, it's part of the day one competencies also. So we have a, a, a sort of scoring system. If I just go back one slide, if the animal is between sort of, Between 5 or 0 to sort of, you know, anything below 8, then the vets are quite happy that we can recommend a rehydration support, you know, and all of the other other things that go alongside that.

Anything. Above, then we would need to go get the vet, so the vet can make a judgement and then we're looking at potentially intravenous fluid therapy. Obviously, if I'm, you know, seeing that the animal is in a lot of pain, if we've got protracted vomiting, and if there's a lot of blood in the stool, or if the animal is pyrexic, then, at our practise, any, any one of those, if that ticks the box, then it needs to be referred to the veterinary surgeon.

We do charge for our nurse clinics. What we then do is if they are then referred to the veterinary surgeon, they're not then charged a nurse clinic and a vet consultation. They're just charged the, the, the vet consultation that, that, that price.

So, owners are really keen to take that on board because they know, OK, we'll just, you know, we'll, we'll see the nurse, . It will cost this amount, in many practises, same as in our practise as well, if they're part, if they have a pet health club, then the nurse clinics are actually complementary. We never use the word free.

They're complimentary, so clients can actually come in and see the nurse, get the advice, and, and go from there. And then we know they've had a clinical assessment and we know that they're going away with the right, recommendations for that patient. So what recommendations am I gonna make?

Well, it, it, it does depend. We do recommend a GI diet for some of these animals. I'm finding that more and more difficult, with some clients, they are, you know, they're quite, Strongly opinionated on, on what food they want to feed nowadays.

Some of them are quite happy to take my recommendation. But if we are making a recommendation on food, I want to use something that's really, really easily digestible. It has a low residue diet.

The reason we tend to use, these low residue diets is because we're still giving the nutrition, but there's less coming out the other end. And if you've got a dog with diarrhoea. You want less coming out the other end, and normally when I talk to clients, that is, that's the game changer, that's what we're coming for.

A lot of these diets tend to be supplemented with electrolytes, which is good because we're obviously losing these electrolytes as well through, you know, through the diarrhoea. And, they're often supplemented with, water-soluble vitamins. So the water-soluble vitamins, especially vitamin B, especially vitamin B12, they're the ones that actually help boost our appetite.

And we see this with cats with renal disease, especially that, They're losing all these beef vitamins, their appetite drops and it's, you know, they're not getting more in and it's a sort of vicious circle. So a lot of these foods have got them in there. Obviously from a hydration point of view, I want to be recommending a rehydration support, you know, electrolyte solutions, but we need one that's got really, really good palatability.

I know the guys at OLAid have actually done palatability studies and they've shown, you know, compared to water, it's, it's hugely beneficial. So going down that route is is ideal. Do you actually recommend to clients just to keep a bottle at home and then they don't have to, you know, panic and come up to the practise and and go from there.

The other things I sort of talk to them about, I'm gonna call a bit more of the hygiene aspects. So it really annoys me when I take my dog out for a walk and, you know, you can, there's still sort of puddles of diarrhoea left behind where people are still walking their potentially infectious dog around the park. So, you know, if we're seeing these dogs, you know, yes, they do need exercising, but if they're unwell, then we don't want to pass it on, you know, to the next pet.

So, you know, talk to them about how they need to disinfect, you know, their own gardens, disinfect after the dog as well. Do we need to talk to them about, you know, supplying some form of, of disinfectant for the house that will actually, you know, Infection control and get and get on top of these things. Obviously, cleaning the animal, do we have to, you know, discuss, cleaning off any soiling on the fur?

If it's a dog, with lots of feathers or a big fluffy Persian cat, you know, do we need to clip off a little bit of hair, you know, just help them keep clean, you know, do you supply them with a little bit of, of bandage that they can just put around the tail just to help, help with that. There's lots of little things that As nurses, we would automatically do for an animal if it was in our care, but we need to talk to our clients about this as well. And also a recommendation we're gonna make is when I want to see them back again, you know, do you want them just to phone or email in in sort of 2 to 3 days' time, you know, if check that they're OK.

Are you gonna phone them? Are you gonna email them? You know, what happens if they're not better in 2 to 3 days?

Would you recommend that they just booked in straight away to see the veterinary surgeon? There's lots of different elements there that we we need to really be thinking of. So electrolyte solutions, they really, really need to be palatable, .

I don't know if you've ever ever I've, I've got kids, and I went to the pharmacy and they gave me some Diolite, which was blackcurrant flavoured electrolyte solution. It was disgusting. It's like there's no way I'm gonna get my kid to drink that.

But if you think things like glucozade sport. But, you know, you would rapidly drink that up. It's almost the same thing.

So palatability makes a huge difference, and it makes a huge difference to our pets as well. You need to be giving them something that they're gonna like. There is an argument that actually giving it a little bit to them when they're not ill.

So they actually learn to appreciate that it's a nice thing. And then when they are poorly, you can still give it to them and then, and then they carry on. It needs to have the right correct balance in, it's not very good English there, sorry.

It needs to have the correct balance of electrolytes as well. It really needs to have some form of prebiotics. So prebiotics are the nutrients that feed the gastrointestinal biome, and help just re-establish that correct balance of the correct bacteria that, that are in there.

Have a look, I would really recommend, you know, having something that you can, you know, discuss all these elements with your clients. Now, I am hugely, hugely for using evidence-based medicine, in our nursing and especially in our nutritional recommendations as well. And when it comes to things like acute diarrhoea, there's an awful lot of things that we do because we've always done them.

They're not necessarily the right things to do. And if you go on to things like the R CVS Knowledge, Which basically looks at, lots of research, and they'll write something called a PEO, the knowledge summaries really where someone, in this case, someone called Jacqueline has looked at all the research that's there. She's asked the question, and in this instance, it's in canine acute diarrhoea with no identifiable cause, does daily oral probiotic improve clinical outcomes?

So, something we all do, we all give a little tube or something, . Does it actually, you know, do anything? She's looked at the research, this is, this is literally off the RCBS website.

I would really recommend having a look on there. There is, the strength of evidence is limited, and there is uncertainty around it, but there has been shown that it actually does . Improved clinical outcomes.

So in 5 placebo controlled trials suggest, you know, this probiotic supplement does provide better clinical outcomes to these dogs. So, you know, they've had a little look. The evidence is weak, but there there is a positive there.

Another site that you can go to is the Nottingham vet school one. In this case, it's called best bets for vets. Try saying that quickly 5 times.

And the question they said was, does the use of antibiotics in dogs of aseptic hemorrhagic gastroenteritis have any benefits? So these are dogs with hemorrhagic diarrhoea. So obviously there's blood in there.

And the bottom line from all the research that they looked at, and this was Rachel Dean and Rachel Parry, treatment of dogs with aseptic hemorrhagic gastroenterittis with moxicloud does not reduce the time to resolution of clinical signs. So, you know, how many of your vets would prescribe antibiotics for dogs with hemorrhagic gastroenterittis? Obviously there's, there's aspects we need to look at.

I'm sorry if you can hear my dog barking. There are aspects that we need to look at. Regarding, you know, are these animals pyorexic?

Are those animals, unwell, clinically unwell? Are they lethargic? There's lots and lots of different things to look at there.

But one of the things is, is that there are other things we need to look at. Do we need to look at rehydration? Excuse me.

Come here. So do we need to look at diet? Do we need to look at probiotics?

There's lots and lots of other aspects that we need to look at. So if we look at, rather than looking at sort of diarrhoea sort of cases now, I would like to sort of move on to microenteral nutrition and actually look at ways and well introduce the idea of microenteral nutrition to you first, and then actually look at how we can supply these to the patient. So one of the things I, if we're looking at microconal nutrition is it can be supplied by syringe feeding and it's such a small amount that this is actually quite easy.

But another way that we can look at is through nasal tubes. I call them nasal tubes because there's huge debate about whether they should be nasogastric or nasoesophageal. We, we really don't know, .

There is a lot of debate about where the, the end of the tube should end, whether it should be in the stomach or whether it should be in the oesophagus, . The argument is, is that one might feel reflex. It might be that it also Interferes with with sphincters.

But like I said, the jury is still out where, where that tube should end. The thing and the joy with nasal tubes is that they can be placed by nurses. Obviously we shouldn't be using them in patients with nasal infections or with head traumas.

But in the majority of cases in dogs and cats, we can place them really, really easily. Most animals tolerate them really, really well. We use them a lot, just to get a little bit of nutrition into these animals.

They tend to do really, really well, and then they actually start eating because they've got something in their stomach. Obviously, if we are able to give a general anaesthetic to these animals, we would then, place an esophageal tube. So the thing with micro nutrition, and the reason it works so well is that the amount that we're giving is so, so small that it doesn't stimulate, the whole gastrointestinal process of, of digestion and all those peristaltic waves that, that goes alongside it.

The thing is, is that we need to give something that is very easily digestible and actually leaves the stomach really really quickly. And there's lots of things that factors that affect gastric emptying. I've listed them there.

The fat content of the diet is the main thing. So the higher the amount of fat in the food, the longer it takes to leave the stomach. So we want a diet that's really, really low in fat, and that really increases the digestibility.

Particle size also really does affect my next slide I've I've got a little graph to show you about that. I, I put a picture of triangular shaped kibbles there because I was once told by a client that triangular shaped kibbles take longer to digest than circular ones. There's obviously, she'd read it on the internet somewhere.

There's obviously no evidence that obviously the surface area or something is going to be affected purely because of . You know, get all those digestive processes getting to to it, which is why, liquid diets will leave the stomach a lot quicker. The overall gastric mobility of the diet of, sorry, of the animal does have an influence.

Obviously if the animal is unwell or we're having lots of regurgitation or, you know, those sort of things, then that will, will affect the size of the meal, again, will affect, if you're going to be feeding them a massive great big meal, that's going to take an awful lot longer to come out the stomach than if it's just a small amount. So this is the diagram I was alluding to the liquid meals. You can see there after about 30 minutes, the majority of, of that meal has left the stomach.

And obviously if you, you know, you're feeling slightly unwell, . Having lots and lots of food in your stomach is really, really, you know, gonna predispose to actually feeling nauseous and maybe potentiate any vomiting that, that's, you know, just brewing under the surface. So liquid meals make a huge, huge difference.

They leave the stomach an awful lot quicker. And this is the whole premise between micro internal nutrition. We obviously using a liquid that will leave the stomach quickly.

What tends to happen is if you have nothing in your stomach at all, you haven't eaten all day. You, you know, imagine you, you know, you've been in theatre all morning. It's now 2, maybe 2:30 in the afternoon.

You haven't eaten your lunch and your stomach is rumbling. It will probably rumble away. Those are called housekeeper contractions.

It, it excuse my little bit, there was something outside our house that's really irritating her, . The rumbling will continue for a little bit and then it'll stop. And then probably 10 minutes later it'll start again.

And what is happening is your stomach every now and then, it's still filling up with things like saliva and it's just pushing them out of the system. Micro internal nutrition, the, the premise behind it is that you're using such a small amount that we're not kicking off all of those massive digestive processes, but those housekeeper contractions are are still working. So the fat content of the diet is really, really important.

The higher the fat in the diet, the longer the gastric emptying time. So high calorie recovery diets are really, really, really high in fat. That's what makes them high calorie.

And that is why they're no, no use at all if we've got any sort of gastrointestin or sort of, you know, vomiting or diarrhoea. We want to be really careful not to use those. We really need to use a low fat, easily digestible diet.

If we're using an actual solid food, a lot of these, diets actually have pre-emulsified fats, and that means that they're digested an awful lot quicker. We just want to be careful though, that when the fat content is, is taken right down that the fibre content doesn't come up too high cos again that can affect gastric emptying times. So there's just a little diagram, little dia a little table even, 50% of your stomach contents, if you ate a normal meal would be gone within 2.5 to 3 hours.

Total emptying of the stomach is 4 to 5 hours, and that is where that recommendation about preoperative starving, we really should only be starving them or withholding food for 4 to 5 hours before doing GAs. You know, I get told, I'm gonna say once or twice a week, that food you gave my dog, it went straight through them. I'm sure you've all heard that that, that saying before.

No, it didn't. It takes that long to get through the gastrointestinal system. And even if the animal, is hyper motile in its GI system because it's unwell.

It's still not gonna be that fast. What happens is when you eat, it sparks off all those peristaltic waves again, so it encourages the animal to defecate, so it's not the food going straight through. So I'm sure you all remember back to your anatomy and physiology days.

If we're looking at the GI system, we have this villi in, in, in the, lining the intestines. We have this microvilli, the microvilli, are on the epitheical cell. They're long because they stop all the, the bacteria that's in that biome coming through into the bloodstream.

This is another diagram. At the top is the inside, the lumen, and in then you're gonna have all the food, the bile, you know, antibi antibodies like IGA you're gonna have all of that gastrointestinal biome as well. And then you have those interocytes, and they're covered by a nice mucus layer to to protect them.

Now, those entire sites you can see in that picture, they're buttered up nice and close to each other, and they're almost joined by something called a tight junction. And that does exactly as the name suggests. It holds it really tight and it stops things that are in that lumen getting through, through the gaps between the cells into the mesenteric vein, into the mesenteric lymph node.

Now the thing to remember is those interocytes, they, they do quite a few jobs. Obviously, their main job is something called active transport. So all of those nutrients are in the lumen, need to get into that vein.

So all of those amino acids, all of those sugars, all of those building blocks go into those ocytes and then back out the other side. But what those enterocytes do is they obviously take what they need as that stuff passes through. So that's where they get their energy from.

That's where they get their amino acids from. They don't get it from the bloodstream because they're putting things into that bloodstream. They're getting their nutrients from what is being fed.

So if we don't feed these animals, those parasites really, really struggle. They're not getting the nutrition that they need. And that's why we really can't starve these animals.

That's why we don't starve animals after GI surgery, if if there's any vomiting, you know, if there's any diarrhoea going on. So this is, a very similar sort of, picture to what I just showed you a couple of slides back. The one on the right, villa, nice and long, nice and, you know, tight, you know, next to each other.

And this is, this is an animal that, you know, the villae have degraded, and you can see how easily it would be for that bacteria to get from the lumen into the bloodstream and setting up a, a sepsis. So you, we need to really remember that that food is for the digestive system. The gastrointestinal tract derives its nutrients from the lumen, not from the bloodstream, and the only way to stop that atrophy is to supply nutrients, .

Into the lumen. And that's where micro internal nutrition comes in. It might be the case that the animal isn't well enough to eat a whole meal or it's not eating a whole meal or, you know, that then it might be contraindications.

We still need to be given some form of micro internal nutrition. So the micro nutrition amounts that we sort of recommend, normally about 0.5 to 0.2 mL per kg per hour.

And this is an amount that won't stimulate the digestive process. Those housekeeper contractions will stop the stomach from filling, you know, all those normal secretions from the gastrointestinal system, but also things like saliva, and it will move it through and it will move that nutrition through into the lumen. Glutamine, this is an amino acid.

It's an amino acid that's not an essential amino acid, but during times of illness is what's classed as an essential conditionally essential amino acid. And this is the amino acid that is used the most in rapidly dividing cells. And obviously, that's what we have in the gastrointestinal system is rapidly dividing cells.

So we need to be using a food and electrolyte support, whatever it is you're using that has this in it to, to help it get through. And it might be, it might be in a different format, like something like glu glutamate, but it helps, get that amino acid in and to feed those cells. So what can we use to micro internal nutrition?

Obviously it has to be palatable, you know, if we want them to lick off a syringe. Liquid diets are really, really important because we can pop them down a nasal tube, and not as as nurses, we can place those tubes, we can put the nutrition down that way. It must be low fat.

It needs to be low fat so that it leaves the stomach as quickly as possible. And that's where something like oralla comes in because of that low fat content that that is there, but it has the nutrition that we need. It has the simple sugars.

It has those amino acids to help feed the gastrointestinal system. So these nasal tubes, like I said, can be very easily placed. Just a few drops of local anaesthetic.

I tend to use the immin's proxymehacaine, just pop it down. These things are also really, really useful if you're seeing puppies, with parvovirus. there has been, a couple of studies looking at, Drawing off some of the fluid in the stomach as well, if you put the nasal tube right into the into the stomach and then obviously replacing that with fluids with electrolytes, because obviously if you just draw it off, you're gonna remove a lot of electrolytes that the animal needs, needs to be replaced, but it can help reduce the amount of vomiting that that's being seen.

So, there is a feeding guideline for micro internal nutrition, It's all there. AllA actually have quite a good website, that actually does go through all of these different stages and how much to give. So I'm not gonna go into that in a huge amount of detail because that information is out there for you.

And, and one of the last slides I wanted to show you because obviously I love nutrition, and I get phone calls all the time from nurses about feeding tubes, and they get told that they can't place a feeding tube in an animal because it's too small. This little tortoise was 150 grammes, and we've put an oesophageal feeding tube in it. It's tiny.

This thing, this guy is tiny. You can see by the print on the newspaper it sat on, it's tiny. Everything can have a feeding tube put in it, whether it is a nasal feeding tube, an esophageal feeding tube, .

Huge believer that we should be placing, you know, more of these, and obviously there's loads of diets that are available now for certain situations that we can use to put down a tube. So I would really, really advocate, you know, as nurses, that's our job, we are advocates for our patients that we really should. You know, be speaking up for our animals and saying to the, to the vets, you know, that really needs a feeding tube put in and then we can start micro internal nutrition, and then we can start actually tube feeding these guys.

So just in conclusion really, I want you guys to really have a think about your protocols and practise, you know, what advice are you giving these animals for diarrhoea cases? What are your receptionists saying on the phone? What are they telling you?

What are they telling our clients, you know, what are we recommending? What is the evidence base? Well, there's a huge amount of evidence now looking at nutrition, looking at, you know, these diarrhoea cases as well, you know, looking at micro and nutrition.

So have a look on the RCVS Knowledge website, have a look at best bets for vets. There's really good evidence there that we shouldn't be giving antibiotics to these animals. We should be giving rehydration supports, prone prebiotics, and, you know, helping support and treat the clinical signs that are there.

So thank you again to our sponsor for tonight. All the details are there. There is a phone number, there's an email address there as well, to bring your, you know, to your attention.

If you have any queries or questions about the products, then, you know, just ping them an email. I'm happy to take questions tonight. I think Caroline is there still.

Oh yes, I'm here. Thank you very much, Nicola. Yeah, and, and little beep by the sounds of things.

So I don't know if anyone has any questions. Yeah, if anyone has any questions, if you go to the bottom of the screen, there's a question and answer box. So if you type your question into there, and then I can put that across to Nicola.

At the moment there's nothing come through, so we'll give you guys, we'll give you guys just a couple of a minute or so just to see if you want to, if there's anything else that if any comments or any questions to come through. Well, Jose has said an excellent presentation. Thank you very much.

No, so we can. Oh, thank you. Well, Nicola, I really enjoyed that.

I always, I, I always love to listen to nutrition lectures and have it all redrummed back into my mind so that I can go back into practise and say, well, actually, can we, could we maybe be trying stuff like this as well, and, with myself being in oncology and we're doing all the chemotherapy, a lot of our patients do end up with diarrhoea. Quite frequently after some of the treatments and, we do actually supply, metro metronidazole following diarrhoea, but I'm wondering if this is something that we should look into actually doing. There is I'm pretty sure on one of those, I can't remember which one, either the RCVS no.

Or on the best bets that, there is a knowledge summary looking at metronidazole for diarrhoea. OK. I will have, yeah, to have a, have a look at that.

I'll be having a little look at that. So yeah, I can see what else we could actually do to, to improve, everything for our patients. Well, there's, there's nothing come through at the moment, Nicola, so I think you might be able to, just get back to, get back, back to a cup of tea and, everyone else can get back to, a nice chilled out evening, hopefully.

So again, I'd like to thank Nicola for a wonderful presentation, again. And I'd like to, thank Mael Animal Health, for sponsoring this wonderful webinar. I'd like to thank everyone else for attending, and then Phil, from the webinar vets in the background, doing all the technical stuff for us.

So I'd like to wish everyone a happy evening. Yeah, have a lovely evening. See you soon.

Thank you.