Following on from my last post, sometimes animals simply will not eat on their own and are now at risk of deteriorating even further as a result of prolonged anorexia. This is where feeding tubes come in! I promise you they are not scary, they are superheroes of the nutrition world. Sometimes the only way we can overcome the roadblocks stopping our patients from eating, is bypassing the mouth altogether with a feeding tube. For veterinary professionals who don’t see feeding tubes every day, and clients who own pets who require a tube feeds, it can be daunting. However, no need to fear the feeding tube! I’m going to run you through five simple steps on how to administer a tube feed safely and effectively. But first, let’s talk a bit about the types of tubes we use and what they can be used for.
Types of feeding tubes:
The most commonly used tubes are nasogastric and nasoesophageal tubes that are very small diameter tubes fed via the nose into the oesophagus or the stomach, and sutured in place externally; they do not require general anaesthesia to place and are ideal for short term use. However only liquid diets can be used through nasogastric and nasoesophageal tubes; you can use commercial products such as Royal Canin Liquid diet (there’s a variety for different situations) or CliniCare Canine/Feline Liquid diet, and some human liquid diets also but this is not recommended long term. Oesophagostomy tubes (O-tubes) are for short and medium term use, and are surgically placed in the oesophagus; they are larger in diameter so can handle blended diets and have a lesser chance of blockage, however its contraindicated in patients with vomiting, delayed gastric emptying or a diminished gag reflex due to the risk of dislodgment. Gastronomy tubes are for medium and long term support and need to be left in place for a least a week for a stoma to form but once placed can be left for many months or years with good management. The final type of tube is a J-tube or jejunostomy tube placed in the jejunum; these tubes are very rarely used but may be considered in patients where the stomach must be bypassed. Because these tubes are placed in the intestine and are small, food must be administered in liquid form via a CRI. It is important to be aware of what type of tube your patient has before attempting a feed as they all are slightly different.
How to use a feeding tube
1. Calculate nutritional requirements
- RER can be used in clinic when the patient is recumbent and not active, DER can be calculated at discharge and used for feeding at home to adjust the amount of the daily feed. Typically you will use either a factor for geriatric or critical patients, otherwise something appropriate for the pet’s lifestage.
- Check the food that will be fed as to what the kcal/ml will be – food that is especially designed for tube feeding will often tell you how much water to add to prepare the correct amount and consistency of food. For most liquid diets it is 1kcal/ml for your convenience, therefore you will only need to calculate the RER and feed this in ml. There’s lots of different methods of calculating the amount to feed, and if you are unsure, seek the help of your vet or have a look at these case scenarios here.
Resting Energy Requirement: (BW)^0.75 x 70
Daily Energy Requirement: RER x DER Factor
Canine and feline DER factors (Source: Small Animal Clinical Nutrition )
2. Pre-feed checks
- Check how the most recent feed was tolerated
- Check which diet is being fed, amount required and frequency
- Is the patient stable to receive feed? Also consider recent blood and/or electrolyte results, or any vomiting
- Sit patient in sternal as this is a more natural feeding position and gravity helps reduce blockages
3. Prepare the food
- You may have a liquid diet, or a blended diet; liquid diet may be in powder form needing to add water
- Draw up the diet into syringes – 20ml syringes are usually best for tube feeds
- Place syringes in a bowl of warm water to warm to body temperature
- Draw up a flush solution (sterile water) to flush the tube before, and another for after. These should also be warmed, and kept sterile in their packet after drawing up the necessary volume
4. Prepare the tube
- Don gloves before handling the tube to ensure it remains clean
- Assess the tube integrity, security and connectors for damage or interference from the pet
- Check the stoma site and dressings (these should be replaced daily) for any signs of infection, or cellulitis
- Clean the stoma with sterile saline or dilute iodine
5. Begin feeding
- First, check if patient has regained appetite and wants to eat by mouth (if safe to do so, and your vet approves)
- If using a G-tube, draw back first to aspirate stomach contents (if there is food from the last feed, delay feeding for a few hours). For other tubes, slowly flush the tube with 5ml sterile water – if it has migrated, the patient may cough, in this case, seek your vet’s direction before continuing the feed.
- If everything is all good, you can now administer the diet reasonably slowly, about 1ml per minute
- As you deliver the food, watch your patient for signs of nausea (drooling, gulping, retching) and stop feeding if this occurs. If any other unexpected complications occur, stop immediately, recap the tube and call for your vet.
- Flush the tube again once the feed is finished with about 10ml (if feeding a liquid diet), or 20ml (if feeding a blended diet) to clear any blockages
Great job! Now clean the stoma again, change the dressings and record the feed on your monitoring sheet – if in hospital this can be recorded on the patient’s chart. If sending the patient home, you may like to provide your client with the WSAVA Nutrition Toolkit Feeding Monitoring Chart to record how much their pet has tolerated at each feed and keep track.
So you’ve mastered how to use a feeding tube, now to teach your client! Not all tubes will be removed at discharge, sometimes in the case of O or G tubes, they may stay in place for some time and the owner can administer the diet at home if they feel confident in doing so. It is most important to talk to clients about caring for the feeding tube; cleaning the stoma daily, how to prevent or correct any blockages that may occur and how to replace their pet’s dressings; you can purchase tailor made feeding tube ‘collars’ that can be used with O tubes and machine washed in between uses, alternatively a tubular bandage can secure the tube to prevent interference and cover the site. Ensure that the client knows the correct amount of food to feed and how to mix the diet, and follow up with them regularly; this is also to ensure the pet is maintaining their body condition and weight, and they are not experiencing any complications or migration of the tube.
Have you ever cared for a pet with a feeding tube? Let us know in the comments about your experience with tube feeding!
References
Boor, C. How to tube feed. The Veterinary Nurse. Available online at: https://www.theveterinarynurse.com/practical/article/how-to-tube-feed
Kathrani A. Nutritional support in the intensive care unit. In Practice 2016;38:18-24.
Mark Morris Institute (2019) Small Animal Clinic Nutrition 5th Ed., Chapter 1: An Iterative Process. Available online at: http://www.markmorrisinstitute.org/sacn5_download.html
WSAVA Nutrition Toolkit. (2011) Available online at: https://wsava.org/wp-content/uploads/2020/05/WSAVA-Global-Nutrition-Toolkit-English.pdf