VETTECH U 2024 / HOUSTON, TX
LIFELINES: THE CRITICAL ROLE OF TUBE FEEDING (CONT.)
Sponsored by
SATURDAY AM • SEPTEMBER 21
KARA M. BURNS, MS, MEd, LVT, VTS (NUTRITION) PRESIDENT, PET NUTRITION ALLIANCE
are altered, increasing the chance of complications. In addition, feeding should be delayed until preexisting fluid and electrolyte abnormalities are corrected to avoid exacerbating gastrointestinal hypoxia secondary to increasing cellular metabolism, and to prevent hypophosphatemia and hypokalemia related to refeeding syndrome. HOW SHOULD THE PATIENT BE FED? The gastrointestinal tract needs to be fed. The gut receives an overwhelming percentage of its nutrition from the chyme passing through it. In the small intestine, enterocytes utilize lumenal glutamine preferentially as their source of metabolic fuel. 6 The colonocytes prefer butyrate, a short chain fatty acid formed by fermentation of lumenal carbohydrates. In the absence of these fuel sources, the gut epithelium slows growth and replication resulting in atrophy, necrosis, and increased risk of bacterial translocation across the now abnormal gut barrier. 3-5 A key to prevention of this potentially serious problem is providing nutrition support to the gut. The rule of nutritional support is “if the gut works use it”. Force feeding sick, hospitalized animals is not ideal and is the best way to create food aversions. Force feeding is an inefficient feeding method resulting in more nutrients on the patient and the healthcare team member rather than in the patient. Typically feeding will not provide a significant percent of needed calories and will lead to a false sense of accomplishment and continued inadequate intake. Similarly, appetite stimulants are seldom successful in causing meaningful increases in food intake. Pharmacologic stimulation of appetite is often short-lived and only delays true nutritional support. Appetite stimulants should not be used to manage hospitalized animals when more effective measures of nutritional support, such as placement of feeding tubes, are more appropriate. Appetite stimulants may be considered in recovering animals once they are home in their own environment, because the primary reason for loss of appetite should ideally be reversed by discharge. As with many drugs, appetite stimulants also have negative side effects, such as behavioral changes associated with cyproheptadine and sedation associated with diazepam, and therefore should be used with caution.
An indwelling feeding tube is the method of choice if enteral assisted feeding is necessary for more than two days. 4,5 After an indwelling tube had been placed, feeding is easier and less stressful. Nasoesophageal, esophagostomy, gastrostomy, and jejunostomy feeding tubes are the most commonly used. In animals undergoing laparotomy, placing gastrotomy or jejunostomy feeding tubes should be considered. The decision to use one tube over another is based on the anticipated duration of nutritional support (e.g., days vs. months), the need to circumvent certain segments of the gastrointestinal tract (e.g., oropharynx, esophagitis, pancreatitis), clinician experience, and the patient’s ability to withstand anesthesia (very critical animals may only tolerate placement of nasoesophageal feeding tubes). 7,8 NE tubes are generally used for 3 – 7 days. Polyurethane tubes and silicon tubes may be placed in the caudal esophagus or stomach. An 8 Fr tube will pass through the nasal cavity of most dogs. A 5 Fr tube is more comfortable in cats. Anesthesia or tranquilization is not necessary (use topical ophthalmic anesthetics to numb the nasal cavity). These tubes can be used in patients considered anesthetic risks. • Pharyngostomy and esophagostomy tubes vary from 8 to 16 Fr and may be place in patients with disease or trauma to the nasal or oral cavity. These tubes can be used for long-term in hospital or home feedings. Gastrostomy (mushroom-tipped, 16- 22 Fr) can be placed either intraoperatively or percutaneously. • Any tube that has been placed in the esophagus or stomach generally allows for bolus type meal feeding except in patients that vomit after each feeding. These patients will benefit from a slow continuous drip administered by a pump or gravity. • Jejunostomy tubes (J-tubes, 5-8 Fr) are placed within the small intestine either surgically or endoscopically and are appropriate for cases where the stomach and proximal duodenum must be bypassed. Ideally food is administered at a slow, continuous drip delivered by a pump. FEEDING TUBE OPTIONS: •
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