Inappetant but anxious hospitalised patients

RE: Inappetant but anxious hospitalised patients

Andreia Dias — Wed, 29 Jan 2020 16:58:59 GMT

We also follow the same approach. Bit more relevant as we only do cats. They sometimes go home for the night and return the following day for a re-assessment. And we do use appetite stimulants (mirtazapine, cyproheptadine, diazepam) if we feel like we want them to eat but they won't with us/at home and for some reason we want to avoid a feeding tube.

Must say, I was not one for using diazepam, but it has not failed me in the few cases where I've used it.... (and it's particularly useful for stressy cats xD)

RE: Inappetant but anxious hospitalised patients

Bob Russell — Wed, 29 Jan 2020 14:59:55 GMT

Mirtazapine can be useful for some chronic renal cases. It is a relatively inexpensive and pretty safe to use. Just remind owners that it can be sedating.

RE: Inappetant but anxious hospitalised patients

Rebekah Robinson — Tue, 28 Jan 2020 23:09:40 GMT

Thanks for all your thoughts. Ordinarily I might have given her longer at home before admitting but felt I could offer this dog better medical management in hospital given the home circumstances. As you say outpatient management goes a long way in nurses these patient’s emotional state. Out of interest do you find mirtazapine helpful in dogs at all as I certainly don’t and haven’t found any specialist recommend it at any CPD. Different story for cats where it works a treat!

RE: Inappetant but anxious hospitalised patients

Rebekah Robinson — Tue, 28 Jan 2020 23:03:41 GMT

Agree incredibly sad, it was only this weekend I heard this was the case for this owner. Her Parkinson’s mean she us housebound and she doesn’t have any help with this dog. Sadly the Cinnamon Trust have advised they can’t be any help due to this being a big dog, which I was surprised to hear. I’ve already stared making enquiries to put this owner contact with some local dog walkers, her last one stopped offering this service and she’s not been able to connect with another...

RE: Inappetant but anxious hospitalised patients

Nicola Cole — Tue, 28 Jan 2020 23:00:58 GMT

Does anybody use trazodone or similar in anxious hospitalised dogs?

RE: Inappetant but anxious hospitalised patients

Beats — Tue, 28 Jan 2020 19:24:24 GMT

great discussion point!

I assess the patient and try to conclude if I think it is likely that it will remain anorexic at home - if so, then I keep it in. Generaly, I'll get the owners to come in and spend some time with the dog offering it food - if it won't eat for the owners in a room in the clinic, and I reckon it is unlikely to eat on dsicharge, I keep it in. If I'm not sure, then I give it some SC fluids and send it home for the night to see back in the morning perhaps.

I manage patients in their home where possible, so will give SC fluids once or twice daily and daily cerenia injection (and sometimes buprenorphine or other) quite happily for 3 days without admitting an anxious patient. I think the benefits of "hospitalisation" need to be weighed against the negatives. We are guilty at times, in my opinion, of elevating pain to a pedestal rather than considering the overall affective state of the patient (pain being one of many negative feelings, and does not necessarily trump fear and nausea every time). If we consider a preference ethic approach, on a given patient do we think that they would choose hospitalisation over outpatient treatment? I think it depends on the patient and one can only make ones best judgement. Equally, I try to avoid discharging a patient "just to see if it eats" if I think this is unlikely and there is a convenience to having the patient there the next morning to reassess first thing.

I'm not in a hurry to put in an esophagostomy feeding tube, but if must, then that can work well for getting a patient home as well at times. Generally if it's been 3 days with no food and I don't expect likely to eat in next 24 hours will consider. Likely to try other means first though, and I often find can feed most anxious orally if I just spend a good bit of time with the patient [lift up lip gently by hair and shove in some soft food into gap between teeth, 2/3rds of patient I find will swallow well and tolerate this well when I do it]. Once they get some food in for 12 hours usually much improved and eating again without needing to place feeding tube. If resistant to oral feeding, and not likely to eat, then I would go to esophagostomy tube quicker.

In your patient, I'd try mirtazapine, cerenia and very tasty things and orally feeding first most likely. Failing that I'd send home for 12 hours (sometimes I'll discharge early morning and get back in late afternoon instead) and re-admit if not eating at home [and then not discharge again until I was satisfied likely to eat at home.

RE: Inappetant but anxious hospitalised patients

Chris Geddes — Tue, 28 Jan 2020 15:26:36 GMT

Is there a reason why the dog is indoor-only-but-for-toileting-in-back-yard? Sounds sad, especially for such a large dog. Good luck with the case. Is it due to the owner's medical problems? in which case I presume you've suggested Cinnamon Trust etc.

RE: Inappetant but anxious hospitalised patients

Rebekah Robinson — Tue, 28 Jan 2020 15:15:45 GMT

An answer right from the top, thanks for your reply Andy. So great to hear that us in the GP land aren’t missing some little trick in these cases.

RE: Inappetant but anxious hospitalised patients

Andrew Kent — Tue, 28 Jan 2020 15:11:11 GMT

Hi Rebekah,

Good discussion!

[quote userid="9315" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/28844/inappetant-but-anxious-hospitalised-patients"]I’vecalways Wondered what referral clinics do in this situation, surely they don’t put feeding tubes in every nervous patient that won’t eat. [/quote]

I do the same as you - scratch my head about discharging vs feeding tube. Often it ends up with a trial at home for 24 hours with a view to readmission if the appetite remains poor.

I also take a view on the underlying disease/what has been seen and the probability that would lead to true inappetence.

[quote userid="9315" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/28844/inappetant-but-anxious-hospitalised-patients"]Case of example - yesterday I admitted a 10yo FN indoor other than for toileting in an enclosed back garden ridgeback cross. Very inappetant for 3 days but is drinking, temperature 39.1C and some abdominal discomfort when performing an abdominal ultrasound. Extensive investigations so far consistent only with pancreatitis. We have started treatment but this dog is clearly very anxious in hospital, to the point of shaking when her cage is opened. I can’t envisage her eating with us at all. My dilemma is do I send her home and hope that her elderly housebound owner with parkinson’s can at least get pain relief and anti-emetics into her - she will be more relaxed at home. Or do I keep her in, and so need to consider putting either a NG tube or O-tube in....[/quote]

So in this case I guess I would be worried that the underlying disease (pancreatitis) often does lead to genuine inappetence so many dogs we see in this situation will have an O tube placed to help with management. I also worry we can't appropriately manage pain, nausea etc on an outpatient basis. But ultimately comes down to trial and error!

Andy