FELINE MEDICINE
* Editor note : maropitant ( Cerenia ) is very effective for nausea in cats . Dose at 1 mg / kg OID
Complications
Complications are commonly encountered during the first three days of refeeding and patients must be closely monitored during this time . Vomiting is common in HL cats that are being refed and can result from severe hepatic dysfunction and reduced stomach volume .
Metoclopramide ( 1-2 mg / kg / day as a CRI ) has antiemetic and prokinetic actions and should be used if vomiting develops *. Additional antiemetics may need to be added if nausea persists ( e . g ., dolasetron 0.6-1.0 mg / kg IV q24h ). If vomiting does not subside , consider looking for other contributing conditions and / or switching from bolus to CRI (‘ trickle ’) feedings .
With refractory nausea , temporarily switching to total parenteral nutrition may be necessary . Hypokalaemia and hypophosphataemia may exacerbate GI signs and can cause weakness . Additionally , phosphorus levels below 1.5 mg / dl can induce hemolysis . Phosphorus should be supplemented if levels fall below 2.0 mg / dl ( potassium phosphate at 0.01-0.03 mmol / kg / hr ). Phosphorus levels should be monitored every 6 to 12 hours during supplementation . Reduce KCL in the IV fluids by the amount of potassium provided in the phosphate infusion . Hypokalaemia carries a negative survival risk and decreased levels should therefore not be ignored .
Hepatic encephalopathy ( HE ) is managed with antibiotics and lactulose to limit ammonia production and NH 3 diffusion across the blood brain barrier . Stuporous patients require more aggressive measures . Protein restriction may be needed in severe cases of HE . Monitor HL patients for risk factors that can worsen or precipitate HE which include hypokalaemia , alkalosis , gastrointestinal bleeding , constipation , infection , hypoglycaemia , and azotaemia . Overtranquilization and stored blood products ( increased ammonia content ) can also exacerbate HE .
Hypotension may develop in some patients following anaesthesia and blood pressures should be measured in patients who appear more depressed or have a slow recovery . Hepatic encephalopathy is another differential that can cause similar symptoms . Persistent hypotension should trigger aggressive supportive measures ( IV crystalloids , +/ - colloids , +/ - pressors in fluid-replete patients ) and a search for other contributing causes ( e . g ., sepsis ).
Vital signs are closely monitored . A PCV / TP , blood glucose , and azostrip are checked every day . Evaluation of electrolytes may be required one or more times each day and should be tailored to the individual patient . A sudden dramatic decline in PCV should prompt investigations for hypophosphatemia and blood loss .
Long-term care
Once patients have reached their full caloric needs , are stable , and vomiting is controlled , care can be transitioned to the owner at home . Owners must be given detailed instructions on feeding tube care , how to detect tube site infections , and trouble-shooting when problems occur ( e . g ., tube clogging ). Cats often require tube feedings for 3-8 weeks . Fresh food is offered each day throughout this period to encourage the patient to resume oral feeding . Once cats start consuming food orally , tube feedings can be gradually reduced each week as long as their weight remains stable during this time . The tube can be removed once the cat is completely off all supplemental feedings for at least one week and consuming a sufficient amount of food to maintain its weight during that ‘ tube-feeding-free ’ time .
Outcome
Survival rates in HL cats have been reported to range from 60-88 %. Early aggressive treatment combined with diligent monitoring and supportive care offer the best chance at a successful outcome . Higher median potassium and hematocrit levels as well as young age were more favorably associated with survival in one study . Bilirubin levels often decline by 50 % in the first 7-10 days in responders . Liver enzymes decline more slowly . Those with a poor prognosis often succumb during the first week of treatment . A lower survival rate has been reported with concurrent pancreatitis . Residual hepatic dysfunction does not persist following complete recovery and recurrence is unlikely unless the precipitating cause was not corrected .
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