Introduction
The highest mortality of captive nondomestic ungulate species occurs during the perinatal period. Hand-rearing is often necessary in newborn nondomestic ungulates for many reasons, including maternal neglect, failure of passive transfer (FPT), neonatal maladjustment syndrome, or the diagnosis of a primary disease condition, such as pneumonia, diarrhea, or septicemia. Once it is decided that a neonate should be hand-reared, the administration of appropriate and adequate nutrition becomes one of the most important roles of the human surrogate mother. The two routes for meeting the caloric needs of the neonatal ungulate are enteral and parenteral.1,2,11
Total enteral nutrition (TEN) is the preferred route due to the ease of delivery and that it is the physiologically normal route, providing a direct source of nutrients for the gastrointestinal mucosa.1 Enteral nutrition can be delivered by bottle feeding, esophageal tube, gastric tube, nasoesophageal tube, nasogastric tube, and syringe feeding. When using any oral route in neonatal ungulates, it is important to stimulate the esophageal groove so liquid is shunted through the reticulum (bypassing the rumen) and delivered to the abomasum (the only truly functioning stomach chamber in the newborn ruminant). Unfortunately, in many such patients TEN is not an option. Patients that are premature, malnourished, semicomatose, comatose, or in which severe gastrointestinal disease exists, are poor candidates for TEN and may benefit from parenteral nutrition (PN). Total parenteral nutrition (TPN) is defined as the intravenous administration of essential nutrients (carbohydrates, protein, fat, vitamins, electrolytes, minerals, and fluids) to maintain body weight and normal metabolic function. As this is a daunting objective, partial parenteral nutrition (PPN) may be utilized. Partial parenteral nutrition is defined as the intravenous administration of essential nutrients in combination with the delivery of some nutrients by the enteral route. In this paper, we describe a case report in which a neonatal reticulated giraffe (Giraffa camelopardalis reticulata), diagnosed with FPT, was successfully hand-reared using TPN and PPN.
Case Report
A 2-day-old, approximately 60 kg, male reticulated giraffe was pulled from its dam for hand-rearing after failure of passive transfer (FPT) was diagnosed based on negative results on the sodium sulfite and glutaraldehyde tests.7 Significant clinical pathology abnormalities were hypoglycemia (36 mg/dl) and hypoglobulinemia (1.8 mg/dl).5 The neonate was bright and alert with normal clinical findings, except for an empty stomach. The calf was vaccinated with tetanus antitoxin (Fort Dodge Lab., Inc., Fort Dodge, IA, USA; 1500 IU SQ), Clostridium 7-way (Bayer Corp., Shawnee Mission, KS, USA; 2.0 ml IM), Salmonella dublin typhimurium bacterin (Grand Lab., Inc., Larchwood, IA, USA; 2.0 ml SQ), and bovine rota-coronavirus-Escherichia coli (Pfizer Animal Health, Exton, PA, USA; 2.0 ml IM), and received vitamin E alpha-tocopherol (Schering-Plough Animal Health Corp., Union, NJ, USA; 1800 IU IM), and penicillin B benzathine and G procaine (The Butler Company, Columbus, OH, USA; 3,600,000 IU SQ), during the initial physical examination. Whole cow’s milk with lactase (Lactaid®, McNeil Consumer Healthcare, Fort Washington, PA, USA; 9 drops/1.8 L milk), was administered by tube feeding on the first day of hospitalization.
The calf refused bottle feedings during the first night and into the second day. It became weak and hypothermic (97.5°F). Significant blood results on day two of hospitalization included leukopenia (1.15×103/µl) and a rise in glucose (94 mg/dl).5 A jugular catheter was placed in the giraffe to initiate IV maintenance fluids with initial fluids consisting of 2.5% dextrose in 0.45% sodium chloride (5.5 L IV), potassium penicillin (Marsum Pharmaceuticals Inc., Cherry Hill, NJ, USA; 60,000,000 IU QID IV), and amikacin (Fort Dodge Lab., Inc.; 170 mg BID IV), pending blood culture results. On day two of hospitalization, the giraffe received a total of 2 L of a cow’s milk/electrolyte mix by syringe using a ball-tipped metal catheter, and 1 L of plasma (IV), collected from an adult giraffe in the collection. Escherichia coli and Pseudomonas putida were grown from the blood on the fourth day of hospitalization. Both organisms were sensitive to penicillin and amikacin.
During the third and fourth days of hospitalization, the calf refused to nurse from a bottle or swallow when fed using a syringe. For this reason, an 18-Fr catheter was secured as a nasoesophageal (NE) tube to provide essential nutrients to the calf. Whole cow’s milk (1.5 L), with lactase (8 drops/1.5 L) added, was delivered at 5-hour intervals, and the calf accepted these feedings for the first two days. Clinical signs associated with the NE tube were noted on the third day of use and included regurgitation of curdled milk. These signs were most likely due to ileus, secondary abomasal overload, and rumen filling. On the fifth day with the NE tube, the gastrointestinal tract was suctioned, and gas and sour milk were removed via the nasoesophageal tube. At this time, day eight of hospitalization, it was decided to begin TPN, formulated similar to that used in equine patients.8
Based on the giraffe’s weight (68 kg), a total of 680 ml 50% dextrose (Phoenix Scientific, Inc., St. Joseph, MO, USA), 800 ml 8.5% amino acid solution (Baxter Healthcare Corp., Deerfield, IL, USA), 340 ml 10% lipid solution (Baxter Healthcare Corp.), 300 ml 0.9% saline (Abbott Lab., North Chicago, IL, USA), 40 mEq KCl (The Butler Co.), and 1270 ml sterile water were mixed in a sterile filtered compounding bag (Baxter Healthcare Corp.) using sterile techniques under a hood. The maintenance rate of delivery was determined to be 2.5 ml/kg/h. The rate was started at 25% of maintenance and then gradually increased during the first 12 hours. Parenteral nutrition was delivered through a 14-G jugular catheter (Abbocath-T radiopaque FEP IV catheter, Abbott Ireland, Sligo, Republic of Ireland), placed in the jugular opposite the 18-G IV fluid catheter. Parenteral nutrition was administered for 12 days of hospitalization. A water-soluble/fat-soluble vitamin mix (Baxter Healthcare Corp.; per label) was added to the bags starting at three days of delivery. During the 12 days of PN, a total of two bags of solution and two 14-G catheters were used for this patient. The PN was discontinued when the second catheter became blocked, and the giraffe was taking food from bottles and had become more difficult to handle.
The giraffe was offered bottles and syringe feedings throughout PN, consisting of a mixture of goat’s milk, cow’s milk, and water administered at an estimated 10% body weight. Additionally, water was administered via the NE tube, and unlike milk via NE tube, did not cause irritation or side effects. During TPN, the calf would not take any food orally on many days. Therefore, both TPN and PPN were needed to provide essential nutrients to this calf.
Throughout the 56 days of hospitalization, the giraffe received a variety of parenteral (IV and IM) and oral drugs for maintenance of normal physiologic processes, the prevention and treatment of bacterial and fungal infections, and to minimize gastrointestinal complications associated with the NE tube, forced enteral feedings, and PN alimentation. In addition to the parenteral nutrition and those provided previously, drugs administered during hospitalization included Plasmalyte A (Baxter Healthcare Corp.; 20 L IV) with 20 mEq KCl/L (The Butler Co.), 50% dextrose (Phoenix Scientific, Inc.), penicillin B benzathine and G procaine (The Butler Co.; 3,600,000 IU SQ for one dose), potassium penicillin (Marsum Pharmaceuticals Inc.; 3,600,000 IU QID IV for 12 days), amikacin (Fort Dodge Inc.; 170 mg BID IV for 12 days), sulfadiazine/trimethoprim (Schering-Plough Animal Health Corp.;1000 mg BID IM for 7 days), sulfamethoxazole/trimethoprim (Mutual Pharmaceutical Co., Inc., Philadelphia, PA, USA; 2000 mg BID PO for 10 days), ceftiofur (The Upjohn Co., Kalamazoo, MI, USA; 750 mg BID IV for 3 days and SQ for 8 days), ranitidine (Glaxo Pharmaceuticals, Research Triangle Park, NC, USA; 140 mg TID IV for 15 days), cimetidine (Abbott Lab.; 340 mg TID IV for 10 days), vitamin B complex (Veterinary Lab., Inc., Lenexa, KS, USA; 10 ml/L fluid IV), nystatin (Pharmafair, Inc., Hauupauge, NY, USA; 1,500,000 U BID PO for 20 days), sucralfate (Hoeschst Marion Roussel, Inc., Kansas City, MO, USA; 6,000 g TID PO for 10 days), peptonized iron (Horse Health Products, a division of Farnom Co., Inc., Phoenix, AZ, USA; 4 ml SID PO for 10 days then 2 ml PO for 39 days), alpha tocopheryl acid succinate (Mazuri, Richmond, IN, USA; 900 U SID PO for 52 days), human baby multivitamin mix (Major Pharmaceuticals, Livonia, MI, USA; 3 ml QID PO for 52 days) and metoclopramide (A.H. Robbins Co., Richmond, VA, USA; 20 mg QID PO for 10 days).
Temperature, pulse, respiration, fecal and urine output, chemistry profiles and CBCs were monitored daily for the first 32 days of hospitalization. This daily monitoring was extremely important to assess the calf’s health status. Antibiotic and antifungal drugs were based on the WBC count. Both leukopenia and leukocytosis with left shifts were identified at different periods. Additionally, changes in the chemistry profile were used to make adjustments in the contents of the parenteral nutrition and fluid delivery. Although mild abnormalities were noted during hospitalization (i.e., hyperkalemia, increased creatinine, increased triglycerides), no life-threatening problems developed as the veterinary staff continually modified treatments based on clinical pathology.
In addition to the difficulties associated with feeding this calf, and possibly directly related to these difficulties, many clinical abnormalities occurred during hospitalization. These included peripheral edema which progressed to sloughing of tissue from an ear, coronary band, and hoof, hypopyon and keratic precipitates, and bloat with regurgitation and constipation. Treatments for these conditions included attempts to increase the blood total protein and topically medicate wounds associated with sloughed tissue, parenteral and oral antibiotics and antifungals, and soapy enemas and stomach tubing to remove gas and soured milk, respectively.
The giraffe was released to its enclosure after 56 days of hospitalization after receiving a second bovine rota-coronavirus-E. coli vaccination (2 ml SQ). Although no body weight is recorded for this date, he was eating hay and grain, very alert and active and off all medications, except long-term supplementation with oral peptonized iron and alpha tocopheryl acid succinate. Three years later, the giraffe is thriving at White Oak Conservation Center.
Discussion
The success of hand-rearing this giraffe was due in large part to our ability to provide an initial plasma transfusion then to supply essential nutrients by the parenteral route for an extended period. Complications associated with attempts to feed this giraffe (patient’s refusal to eat and severe gastrointestinal upset associated with the NE tube) made providing proper enteral nutrition virtually impossible. For this patient, we used PPN as much as possible by offering small amounts of formula enterally. Partial parenteral nutrition leads to much fewer metabolic derangements than TPN in patients and ensures a healthier gastrointestinal tract due to nutrient supplementation for enterocytes via intermittent enteral feedings.
The PN solution we used was formulated based on recommendations for equine patients.8 Therefore, it was imperative to monitor serum chemistries frequently so that necessary modifications of the PN solution and supplements could be made based on the status of our giraffe patient. Daily body temperature recordings and CBCs were also important, due to the common complication of catheter sepsis in patients receiving PN.9 Vitamins may be added to some PN solutions using a multivitamin which provides all fat- and water-soluble vitamins, with the exception of vitamin K as it is incompatible with PN solutions.
The cost associated with parenteral nutrition is one factor that may preclude its use in many nondomestic species. Parenteral nutrition has been used successfully in a premature black rhinoceros (Diceros bicornis), reticulated giraffe, and a neonatal llama (Lama glama).3,4,6 Although, the true cost (daily estimated cost for TPN in a horse foal is $65), laboratory monitoring, and hidden costs (24-hour staff monitoring) of PN is high and probably impractical for many zoos, PN could be the difference between survival and death in some zoo patients.10 Additionally, in endangered species cost may not be an issue and PN may be invaluable for the survival of neonatal or diseased individuals within these populations.
Acknowledgments
The authors thank Karin Andre, Shelly Angell, Dr. Tracy Clippinger, Dr. Gus Gevanthor, Kelly Hernandez, John Lukas, Cyd Teare, and the hoofstock keepers at White Oak Conservation Center for technical assistance and Dr. Bonnie Raphael for information on the use of PN in giraffes.
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