August 15, 2019
Nutrition is quite often overlooked in hospitalized patients, which depending on what the patient is being treated for, can worsen the situation.
When a patient doesn’t eat, it is often force fed, but this stress-inducing practice should be done away with, particularly in our Fear Free world. In addition to stress ensuing on both sides of the syringe, force feeding can lead to food aversion.
Providing enough calories is critical to reducing protein catabolism and its multiple consequences: muscular atrophy, immunodeficiency, anemia, delayed healing, etc.
When oral nutrition is not possible, feeding tubes should quickly come to mind. The ideal timing of feeding tube placement is controversial, but consider placing one after 12 to 72 hours of anorexia. In some cases, it is wise to be proactive and to place a feeding tube at the time of surgery.
Indications of feeding tubes include:
Enteral nutrition is always preferable to the parenteral route for patients who refuse to eat (in spite of appetite stimulants and efforts from your wonderful nurses), as well as those animals who cannot or shouldn’t eat by mouth (e.g. vomiting, jaw fractures, and esophageal surgery).
All feeding tubes have their own indications, benefits, and disadvantages. Let’s look at each.
Nasogastric tubes (NG-tubes) usually don’t require anesthesia. To place an NG-tube, you will need an appropriately sized red rubber catheter (5 Fr in cats and 5 to 10 Fr in dogs), 1-in. tape, a local anesthetic, a mild sedative, sutures or staples, and an E-collar.
Choose the largest red rubber catheter that will fit in the patient’s nasal passage and administer a few drops of local anesthetic. Measure the tube’s length and mark it so the end is located in the stomach once it’s in place. Some veterinarians prefer placing the tube in the distal esophagus to reduce reflux. Insert the lubricated catheter into the ventral meatus and aim medially and ventrally.
Some veterinarians administer a few millimeters of sterile water through the catheter to induce coughing to confirm proper placement. However, not all patients cough, even if the tube is in the airway.
A lateral thoracic radiograph is a safer way to ensure the catheter has been placed properly. Secure it with tape and sutures or staples to the skin ventral to the alar fold and on the forehead. Then place an E-collar to prevent pawing at the feeding tube.
Besides premature removal, complications include clogging and aspiration pneumonia (from improper placement).
After each use, rinse the NG tube meticulously with water to decrease the risk of food clogging it. The same should be done for any feeding tube described in this article.
Esophagostomy tubes (E-tubes) are a bit more complicated, but can be used in general practice. You will need a red rubber catheter or feeding tube (12 Fr for cats and 12 to 18 Fr for dogs), clippers, scrubbing supplies, scalpel, long curved hemostats, tape, sutures, needle holder, catheter cap, and sterile gloves.
Place the anesthetized patient in dorsal recumbency. Aseptically prepare the ventral cervical area, from the larynx to the lower cervical region. Pass curved forceps into the esophagus until you can feel the tip just caudal to the larynx. Make a stab incision over the tip of the forceps. Next, grasp the tube’s tip with the forceps and remove both through the mouth.
This leaves you with the wide end (the feeding end) outside the neck and the narrow end (the internal end) outside the mouth. Use the forceps to grasp the end exiting the mouth and direct it into the esophagus.
The tube should stop at the caudal end of the esophagus. Ensure proper placement by taking a lateral radiograph. To secure the tube to the patient, use a tape butterfly or a Chinese finger trap suture.
Cap the catheter’s end to prevent leakage, and place an E-collar or a bandage around the animal’s neck. Advantages of E-tubes include a larger diameter, resulting in less clogging and the lack of need for specialized instruments.
An E-tube can stay in for months when properly maintained. A minimum of two weeks is required for a fistula to develop. The main disadvantage of using an E-tube is the patient requires general anesthesia.
Phayngostomy tubes are similar to the esophagostomy tube, but their placement is trickier and has more potential complications. Since there is no significant advantage over E-tubes, they are rarely recommended.
Gastrotomy tubes (G-tubes) are placed intraoperatively or percutaneously. An “intraop” mushroom-tip catheter is placed through a stab incision in the gastric fundus, and secured with a purse string around the stoma. Four-quadrant preplaced mattress sutures are attached to the body wall. The tube exits through the skin, where it is secured with a Chinese finger trap and suture tape. Low-profile tubes are available to prevent premature removal.
The advantages of using G-tubes include their large diameter, which results in less clogging. Further, no specialized instruments are needed when placing one. And lastly, a G-tube can stay in for months when properly maintained. The main risk it poses is internal leakage from the gastric stoma, which leads to peritonitis. A minimum of two weeks is required for a fistula to develop.
Percutaneous endoscopic gastrotomy tubes (PEG tubes) require an endoscope to place them, along with aseptic preparation supplies, stay sutures, purse string sutures, over-the-needle catheter, and mushroom tip G-tube.
Aseptically prep the abdomen of the anesthetized patient and place the G-tube by using the light at the end of the endoscope to mark where to enter the abdominal wall and the stomach. Insert an intravenous catheter. Thread the suture through the catheter into the stomach.
Grab the suture to remove it and the endoscope through the mouth, making sure to leave enough suture outside the body wall. Remove the catheter from the body wall and feed the oral end of the suture through the small end of the tube.
Transfix the suture to the end of the G-tube. Next, withdraw the suture coming out of the body wall to feed the G-tube into the stomach. Continue until you get resistance.
Feed the tube through the original hole and secure it to the skin to ensure a tight fit against the body wall and to help prevent leakage. Cap the tube to prevent leakage.
To remove the tube, cut it as short as possible and allow the end to be evacuated by the gastrointestinal (GI) tract. If the patient weighs less than 20 lbs. (9 kg), it is ideal to remove the tube with an endoscope, as the cut end may cause an obstruction. PEG tubes are beneficial in that the esophagus does not have to be functional and they can be left in for an extended period.
The main disadvantages are they require an endoscope and there is a risk of peritonitis due to potential leakage or a tube becoming dislodged.
Jejunostomy tubes (J-tubes) require a laparotomy. To place one, you will need stay sutures, purse string sutures, a red rubber catheter (8 to 10 Fr for cats and 8 to 24 Fr for dogs) and an 11-blade. Preplace a purse string suture on the antimesenteric border of the jejunum.
In addition, preplace a stay suture on either side of the purse string to secure that portion of the jejunum to the body wall.
Make a stab incision in the body wall, lateral of midline. Place forceps through the wall, grasp the J-tube’s small end, and pull it into the abdomen. Make a stab incision in the middle of the purse string area with an 11-blade. Feed the catheter into the jejunum, going caudally. Tighten the purse string around the catheter and tie the stay sutures to pull the jejunum against the body wall. Use butterfly tape or a Chinese finger trap suture to secure the exterior portion of the catheter to the abdomen. Cap the catheter to prevent leakage.
Put an E-collar on the patient to prevent it from chewing out the tube. A bandage can be placed to further decrease the risk of the tube accidentally dislodging.
A J-tube can be used on patients who are vomiting or who have gastric obstruction. Further, it provides minimal stimulation of the pancreas.
The main risks are dislodging and peritonitis. Importantly, a J-tube cannot be removed for at least 10 days after placement, due to risk of leaking at the stoma. Small red rubber catheters have to be used, so there is a risk of clogging. An infusion pump can be used instead of manual boluses to prevent vomiting or abdominal pain.
Gastrojejunostomy tubes (GJ tubes) are newcomers compared to the other options. Similar to G-tubes, they are placed surgically or with an endoscope. Essentially, a J-tube is inserted into a G-tube. A major benefit is GJ tubes do not require an enterotomy and they are a good option to consider after pancreatic or biliary surgery.
A GJ tube provides access to the small intestine initially, until the J-tube is removed. (The G-tube remains in place.) It can be used for weeks to months longer, without the need for a second intervention. G-tubes and J-tubes typically share the same potential complications.
Chosen wisely, feeding tubes are convenient, overall relatively safe, fairly easy to place, affordable, and are well tolerated by patients and clients alike. Patients get better quicker, hospital stays are shorter, and therefore clients’ bills are a little more manageable. Happy patients and happy owners… What more could you ask for?
Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his websites at www.DrPhilZeltzman.com and www.VeterinariansInParadise.com. AJ Debiasse, a technician in Stroudsburg, Pa.., contributed to this article.
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