1. No category

How to Use Feeding Tubes in Cats
Susan Little, DVM, DABVP (Feline)
Bytown Cat Hospital, Ottawa, Canada
[email protected]
http://drsusanlittle.net
Managing the anorexic cat involves both identification of the underlying disease process and provision of
nutrition and other supportive care. Hydration, electrolyte status, pain, body temperature, vitamin B status, and
nausea should be evaluation and appropriate interventions undertaken. Some cats can be coaxed to eat with
simple interventions, such as warming the food and hand feeding. However, other patients will need assisted
feeding to improve nutritional status. Typically, it is recommended to begin assisted feeding within 3 to 5 days of
the end of voluntary food intake, but some seriously ill cats will require earlier intervention. Enteral feeding is
preferred whenever possible as it maintains gastrointestinal health, and is safe, convenient, and cost-effective.
Early institution of tube feeding has a better outcome than waiting until the patient has end stage disease or is
debilitated.
NASOESOPHAGEAL OR NASOGASTRIC TUBES
Nasoesophageal (NE) or nasogastric (NG) tubes are easy to place and safe. They are typically used for short-term
nutritional support (no more than 2-3 days) or for administration of an osmotic laxative (such as PEG) for
treatment of constipation or preparation for colonoscopy. Only liquid diets can be fed using NE or NG tubes.
Contraindications to placement of NE tubes include the inability to swallow or lack of gag reflex. Complications
may include rhinitis, esophageal reflux, aspiration, inadvertent tube removal, or obstruction of the tube.
NE/NG tube preparation and procedure
1. Sedation is only required for fractious patients
2. Place 0.5-1.0 mL 0.5% proparacaine hydrochloride into one of the nasal cavities and tilt the head upward
to encourage the local anesthetic to coat the nasal mucosa
3. For most cats, use a 5 Fr radiopaque polyvinyl feeding tube or red rubber catheter
4. Measure the length of the tube along the side of the cat from the tip of the nose to the last rib.
Measuring to the last rib will place the tip of the tube into the stomach. If placement in the distal
esophagus is desired, pull the tube back 1-5 cm. Mark the proximal end of the tube with tape or
permanent marker.
5. Lubricate the tube with 5% lidocaine jelly and keep the cat’s head in a normal position. Insert the tube
caudoventrally and medially into the nasal cavity. The tube should pass into the oropharynx and
stimulate a swallow reflex; then advance the tube to the predetermined mark.
6. Inject 3-5 mL sterile saline into the tube to confirm placement. If the cat coughs, remove the tube and
place again. If the clinician is still uncertain, placement can be confirmed with a lateral thoracic
radiograph. Secure the tube to the lateral aspect of the nose and also at the zygomatic arch or forehead
with sutures and butterfly tape or surgical adhesive. An Elizabethan collar may be placed to prevent
tube removal by the cat.
7. Fill the tube with water and cap it when not in use to prevent intake of air, reflux of stomach or
esophageal contents, or occlusion of the tube with food.
ESOPHAGOSTOMY TUBES
Any patient with a catabolic illness or malabsorptive disease (e.g., neoplasia, chronic intestinal or pancreatic
disease, moderate to severe renal insufficiency, protein-losing enteropathy, hepatic lipidosis) that is at risk of
malnutrition will benefit from having a large bore feeding tube in place to provide balanced nutrition. As well,
cats that have been partially or totally anorexic for 3 or more days (ingesting less than 85% of resting energy
requirement), and those that have lost over 10% of body weight (not due to dehydration) will benefit from
nutritional support. E-tubes are also used for cats with conditions that mechanically interfere with prehension of
food or swallowing (e.g., oral, pharyngeal or esophageal problems).
Advantages:
 Tubes are well tolerated by cats and they can eat with the tube in place.
 Diets that are nutritionally complete and balanced may be administered through large bore tubes. This
includes commercial diets designed for tube or assisted (syringe) feeding as well as blenderized
prescription or maintenance diets.
 Use and care of tubes is easy and readily learned by clients.
 Tubes may be left in place as short or as long as is warranted by the patient’s condition. They may be
removed at any time, within days of placement if the cat is eating readily or after 6-18 months.
 Removal is easy and does not require sedation or anesthesia.
 Unlike gastrotomy tubes, there is no risk of peritonitis.
 No special equipment is required.
 Unlike pharyngostomy tubes, there is no risk of coughing, laryngospasm, or aspiration.
 Unlike NE/NG tubes, a wide variety of nutritionally balanced diets appropriate for feline nutrition may
be used. The tube is not in the cat’s range of vision and is better tolerated. It can also be maintained for
a longer period.
 No long-term complications (such as esophageal stricture or diverticulum, esophagitis, or subcutaneous
cervical cellulitis) have been reported.
Potential complications:
 A brief anesthetic is required.
 The patient may remove the tube before it is warranted. It may, however, be readily replaced without
further sedation once a stoma has formed. Local anesthesia will be required to replace the purse-string
suture and Chinese finger tie.
 If the tube end is too far distal and enters the lower esophageal sphincter, reflux esophagitis may be
anticipated.
 Occasionally, a patient may vomit the tube. If it is bitten off and swallowed, it will need to be retrieved.
If not bitten off, it can readily be removed and replaced, as above.
 E-tube placement is contraindicated in patients lacking esophageal motility, such as those with
megaesophagus, in those with pre-existing esophageal inflammation, in patients with persistent
vomiting, and in any patient with a risk of aspiration.
Supplies needed:
 Size 14 to 24 Fr. (largest bore that can comfortably be placed in the patient) red rubber feeding tube or
silicon e-tube (e.g., Mila)
 Clippers, blade, surgical scrub and alcohol
 Sterile gloves
 Sterile pack containing: curved, blunt-tipped forceps, scalpel, #10 blade, sterile 2X2 gauze swabs, needle
driver, scissors, thumb forceps
 Surgical field drape and towel clamps




3-0 nylon suture with swedged-on cutting needle
Antiseptic ointment
Bandage materials and swabs OR Kitty Kollar with protective pads (www.kittykollar.com)
Multiple-use injection port
E-tube preparation and procedure:
1. Provide anesthesia and place an endotracheal tube, maintaining anesthesia using inhalant gas.
2. With the patient in right lateral recumbency, shave the mid cervical region of the left side of the neck
from the angle of the mandible to the thoracic inlet.
3. Surgically prepare the shaved area, noting the location of the jugular vein so you can avoid it during tube
placement.
4. Measure and mark the tube so that when it is in place, the tip of the tube will lie at the level of the 7 th9th rib (the distal esophagus).
5. Slightly extend the neck.
6. Insert the curved forceps into the mouth turning the tips laterally so that they raise the skin of the neck
midpoint of the prepared area. Avoid the jugular vein.
7. Palpate the tip of the forceps and, using a scalpel blade, make a 5-10 mm nick over the parted tip.
Gently push the tips through the skin (blunt dissection of the muscle and esophageal mucosa may be
used) to grasp the tip of the marked tube.
8. Pull the tip of the tube rostrally so that it exits the mouth.
9. Release the tube from the forceps and turn the tube around so that it is turned back on itself, heading
down the esophagus. Using your fingers, gently push the tube down the esophagus straightening out the
curve so that it is going straight down the esophagus. When it is correctly in place, the tube outside the
body will flip forward and it should slide back and forth a few millimeters, confirming that it is straight.
Visually inspect the oropharynx.
10. Line the mark on the tube up with the skin so that the tip is at the 7 th-9th rib. Place a purse string suture
leaving both ends of suture long. Using both long ends, place a Chinese finger tie to trap the tube in
place. Trim the suture ends.
11. Take a lateral thoracic radiograph to confirm correct tube placement.
12. Cut the long end of the tube (if using a red rubber tube) just to the point that is the right diameter for
the injection port to fit. Fill tube with 3-6 mL of room or body temp water and cap tube with injection
port.
13. Apply a small amount of antibacterial ointment around the stoma. Cover the tube site with a sterile
dressing and bandage loosely or use a Kitty Kollar.
14. When the tube is no longer needed, simply cut the purse string suture and pull the tube out. Suturing
the opening is not required; it will contract and epithelialized over 2-3 days.
HOW AND WHAT TO FEED
Calculate the number of calories needed per day and convert this to mL of diet required/day. The diet should be
one that can be fed through a syringe. For adult cats, the starting point for daily resting energy requirement
(RER) is calculated by the equation [30 x body weight in kg + 70]. Multiplying by an illness factor is no longer
recommended as it has been associated with higher complication rates. The amount fed should then be
adjusted according to monitoring of body weight and body condition score. The daily caloric intake should also
provide a minimum of 5 g protein/kg body weight and this may be met when using recovery or convalescence
diets due to their high fat and protein content. For kittens under 2 kg (4.4 lb), it is more accurate to use the
equation [70 x BW (kg) 0.75] to calculate RER.
Feeding can begin as soon as the patient has recovered from anesthesia, but remember that the stomach
capacity may be reduced and gastric tone and emptying may be slow due to anorexia. The maximum per feeding
should not exceed 20-30 mL/kg (about 50% of stomach capacity) to avoid over-distension and vomiting. The
amount fed should be introduced gradually, taking 2-3 days to reach the expected daily intake. The daily
requirement should be divided into 5-6 feedings. Before and after each feeding, the tube should be flushed with
5-10 mL of lukewarm water. The bandage should be removed and the tube site checked once daily, with a new
sterile dressing placed.
Once the cat is voluntarily eating about 60% of its daily requirements, tube feeding can be gradually decreased.
The tube should not be removed until the cat is consistently maintaining adequate nutritional intake on its own.
When the tube is no longer needed, simply cut the purse string suture and pull the tube out. Suturing the
opening is not required; it will contract and epithelialize over 2-3 days.
TRICKLE FEEDING
Divide the daily volume in half for a twelve-hour period. Place this 12-hour quantity into a used empty fluid bag
via a 16G needle on a large syringe (e.g., 20 mL syringe). Fill the (used) IV line with the food and run either by
gravity drip or as a calculated volume through a syringe pump at a set rate. If the food is stiff and difficult to
syringe, warm the calculated volume in a bowl gently in the microwave until the fat softens adequately. Discard
the used bag after 12 hours and start the next feeding period with a new, used fluid bag and line to prevent
bacterial contamination. Food should always be fed at body temperature.
DISSOLVING CLOGS IN FEEDING TUBES
All types of feeding tubes may become clogged with food. Flushing the tube well with warm water before
administration of food and again afterward can help prevent clogs. Various solutions have been recommended
to dissolve food clogs, including plain water, carbonated beverages, cranberry juice, meat tenderizers in water,
etc. In a recent study, the solution that performed the best was ¼ tsp pancreatic enzyme powder and 325 mg
sodium bicarbonate dissolved in 5 mL water. The next most effective solution was plain water.
RESOURCES
Web tutorial:
Washington State University College of Veterinary Medicine, Small animal Diagnostic & Therapeutic Techniques,
Nasogastric tube placement: http://www.vetmed.wsu.edu/resources/Techniques/nasogastric_tube.aspx
Recommended reading:
Bexfield N, Watson P: How to place an oesophagostomy tube, Companion:12, 2010.
Chan DL. The inappetent hospitalised cat: clinical approach to maximising nutritional support. J Feline Med Surg.
2009; 11: 925-33.
Delaney SJ. Management of anorexia in dogs and cats. Vet Clin North Am Small Anim Pract. 2006; 36: 1243-9, vi.
Michel K. Management of anorexia in the cat. J Feline Med Surg. 2001; 3: 3.
Parker VJ and Freeman LM. Comparison of various solutions to dissolve critical care diet clots. J Vet Emerg Crit
Care. 2013; 23: 344-7.
Wohl J. How to place an esophagostomy tube. Clinicians Brief. 2003: 39-41.