Hi everybody and welcome to my talk. My name's Sam Taylor, I'm a feline specialist working in the UK and I'm gonna be talking to you about cats that won't eat. I like this phrase, and this is a picture of, of one of my cats, and I want to convince you really how important nutrition and eating is to cats both physical and mental wellbeing.

So in this talk, we're gonna talk a little bit of background about cats and eating cos that's important to understand. Why it's so important that cats eat, and we'll talk about things like nutritional assessment, particularly hospitalised patients, appetite stimulants, and then feeding tubes. Now, I've got a lot to get through in this talk, so, we have got some resources and information for you that I'll recommend, if you want to read any more.

And my message really is that don't hope they will eat tomorrow, instead act today, and that's my, my motto really for assisted feeding in cats. So in, so I'm calling it inappotence in this talk, but it obviously can be called hypoorexia or anorexia if they're not eating a thing. And it's quite a common reason for cats to come to the vets, and there are a few reasons for that, often surrounding what feeding means to owners.

So feeding is quite important to owners and so whereas they may ignore some signs of illness or put it down to ageing and this type of thing, inhapetence and and refusing their food is something that is likely to bring them in to see you. And this is good because for cats not eating is a bad thing, it's a worse thing than it is for dogs. There are reasons for that to do with their metabolism, which we'll talk about in a moment.

And then cats, they like to be complex, don't they? And there's often multiple causes, for not eating. So what I want to convince you is that it won't just be the fact that they have pancreatitis.

There may be other contributing factors that you can really help control. And so the approach to it is often multifactorial, involving the way your practise runs as well for hospitalised patients. But when they eat, we love it, so it's something we need to focus on.

A shameless plug here, we have produced some guidelines which provide really everything you need to help with cats that don't eat. So we have an article which has a lot of doses that you might find useful for antiemetics, prokinetics and appetite stimulants, but we also have, a guide to placing NO tubes to placing O tubes and a guide for owners and practise staff for caring for a cat with an esophagostomy tube. As well as that, we've got a couple of handouts for owners.

Now all of this you can find on the link that I've got on here. It's an absent cat toolkit. But if you just Google the ISFM guidelines on an absent cats, you'll also find all of this information and your owners can find their documents there or via the International Cat Care website.

So there's everything that you need, you don't need to spend hours teaching owners how to feed through tubes, we've got everything for you. OK, ooh, I was pressing backwards. So when the cat refuses food, I've mentioned to you that it is something that owners worry about.

It's also something that can be a little bit more complex because we all have those owners that when the cat doesn't eat, they sort of follow them round the room with a a a can of tuna. They offer them multiple different meals. And so there are some ways in the owners can actually unintentionally reinforce food refusal.

And we occasionally see the odd case where it is purely behavioural. It may have started as something path pathological, an underlying illness that's then become a food aversion and all reinforced by the owners. But it is important to manage it and to focus on it because owners that they, they perceive success sometimes and they perceive health, perhaps not unreasonably, based on their cat eating.

And so they can easily lose faith in us if the cats are still not eating despite our treatment. And it's very easy to add med after med after med, and we'll talk about that in a moment, how that can actually worsen things. And we know that cats are terrible at drinking, it's not their main thing.

And if you have a cat who normally eats wet food, they will get a lot of water from their food. And then if they stop eating, they can become dehydrated, which then is a vicious cycle of not wanting to eat. Another aspect of it is that a cat that's not eating is very hard to medicate in some situations cause the owners can't hide the meds in the treats or in the food.

And so this can be very stressful for the client because they just can't get the medications into their cat. So there's quite a lot of little sort of little sort of shoots that come from inhabitants that pervade all different areas of owners and the cat's lives. So the consequences really of of cats not eating being more significant than another species is is around their their unique metabolism, and we know that they are, they're dependent on protein, you know, they much prefer to use protein as both an energy as an energy source, and they can't really down regulate that urea cycle.

They're not very good at turning it off, when they don't eat. And so this means that when the, you know, when they don't eat, we, we get some processes that are ultimately deleterious. So that includes depletion of any energy stores and then a conversion to gluconeogenesis, and they'll start to basically digest their muscles.

So we, we start to use lean tissue because they're not so good at using other sources of energy. And we know that when they're ill, if they have a disease or they have any inflammation, that actually that process is worsened, so the, again that that protein sort of metabolism cycle is, is almost accelerated and you'll get a rapid loss of lean tissue. There may be other negatives .

From that apart from just loss of muscle mass, and we know that that kind of catabolic state is very bad for wound healing and it might even increase gut permeability so you can get translocation of bacteria. So you can see how actually the primary disease process has causing its own problems, but then the secondary inhabitant is really affecting recovery and potentially prognosis. So some other consequences when we think about both cats and the owners from two different sides.

I made this diagram so that we can see it from from different ways. I've mentioned compliance to medications. It's even possible that you have accelerated euthanasia decisions based on inhapetence.

It causes them great anxiety and dissatisfaction. And they may even decline further workup because they perceive the cat as as being so unwell. And for the cat, we said we've got an effect on immune system and therefore an increased risk of sepsis.

Our wounds won't heal, so your beautiful surgical incision, that you stitch together won't heal as well. And that includes internally if you've done an ex lap, for example, for enterotomy or you know, whatever that procedure was. The cats themselves were weak, hepatic lippidosis is a well recognised consequence of of fasting.

And the other factors that I've already mentioned. So that's sort of nutrition and fasting, but actually the effect on body condition. We know from multiple studies in humans and in cats that having a lower body condition is associated with a more negative outcome, because probably we've had further progression of disease and that negative process of metabolism leading to.

Frailty, and sarcopenia and these type of conditions that you'll be familiar with. And I've got a couple of graphs here. So on the left we can see, a, a poorer survival in cats with lower body condition in lymphoma.

And then on the right, a comparison with some human work where undernutrition in older people leads to a poorer survival when they have chronic kidney disease. And the same in cats shown in this graph here, so smaller cats, you can see if they weigh less than 4.2 kg, then their survival time is reduced.

So we need to pay more attention to nutrition is the bottom line, and actually when you look at the WSAVA nutrition guidelines, they have proposed and well, decided that nutritional status is the 5th vital sign after your TPR and your pain assessment. And it's of particular importance in cats in your hospital or cats who are very sick, and certainly if you're seeing a lot of hospitalised patients or you're seeing a lot of sick cats, it needs to be part of your process. I think it needs to be incorporate incorporated into admission.

And a lot of clinics now are really good at this, they've got some questionnaires, so we encourage it as part of our cat friendly clinic to have questionnaires so that you know the cats a bit better, but this is particularly important regards their nutritional preferences, especially if they're going to be staying in the hospital. And it's about looking sort of at risk factors and helping you identify the cats that need your intervention and the ones that that can be, you know, left a little longer. And so this nutritional assessment really should be performed in every patient.

Now I know you're gonna be sceptical about that, you've got short consults. It may not be something you're gonna do in a vaccination history, although some would argue that we should do it literally every time we see the patient. But what we do need to do as a minimum is thinking about their diet, thinking about their weight and body condition score.

And then in the sicker patients or the hospitalised patients, you're going to start to look at risk factors. And these might be things like GI signs, low albumin, or having a more chronic disease. And I'm sure you're all familiar with body condition scoring, but actually it's something that is not always performed.

I'll show you some data on that in a moment. Another thing you may not be familiar with is muscle condition scoring, cos with this lean mass loss that they have, this, this protein metabolism, they can still be a bit chubby and have that belly, that sort of hanging down belly, and their weight may not change significantly, but they could have poor muscle condition score and I think you guys are. This from your, particularly your older cats with CKD for example and OA, you know, those type of patients.

But it can be really useful to have an assessment of the muscle condition of the cat. It's something I'm getting used to to trying to remember to, to do. I, I would often do it in a less specific, less, sort of objective fashion.

But I think for you guys it's, it's important to, to think of in those sicker and older patients. What we have produced in the guidelines, courtesy of Dan Chan is a a nice sort of tool that helps you identify cats that need nutritional support. So this is again, it's not every patient, but it's your sicker cats and it's your hospitalised patients.

And what it does is it raises a red flag that it needs to be on your list of. To deal with. So if you have a patient with two or more high risk factors, and those are more prolonged inapetences, weight loss, a lower body condition score, and a long course of illness expected, these type of things, but obviously we've got moderate risk factors as well that we need to consider.

So this is something when you are taking a nutritional history to to think of and we talked to our, our sort of interns about this as well, and that's that owners may describe inhabitants in different ways and they may, Perceive it in different ways. So there's a difference between being fussy and eating nothing, leaving food when they used to just eat it all, not asking for food when they did previously. So these are all important parts of a nutritional history, as well as simply knowing what the cat normally eats.

Something that we encounter occasionally in our hospital when we haven't quite got it right is a cat that is seems to be completely inappotent that's being offered most beautiful expensive Sheba, and gourmet soup and tuna and cooked chicken. But actually the cat's used to eating. Dry food.

So to those cats, they can be very fixed in their habits and fixed in their food preferences. And that lack of flexibility in food preferences can be worse in times of stress. So if the environment is stressful, they want to eat their normal food.

So that's something that's that's worth thinking about. And I've put a few other bits and pieces on this slide, things that we will ask about, and that's things like changes in in environment, changes in behaviour, because people don't notice lethargy in the same way as they do dogs that are taken for walks. Things like GI signs and obviously if they are going outside, that may not be be noted.

One of my big sort of take homes I hope from this talk is that every cat that stays in your hospital should have a nutritional history taken and should have their body weight, body condition score, and a calculation of their energy requirements. Now, perhaps not for your young cat that's coming in for a spay. I'll accept that you, you know, you haven't got the time to do this type of thing.

But for any hospitalised patient that's staying overnight, for example, you need to know how much they need to eat, because otherwise you have no idea of how much in proportion of what they should be eating, that they are eating. All of this information is in the guidelines as well, so I'll refer you back to that. But think about your, your hospitalisation, your, documentation.

So what do you have to work this out? Do you have space? This is not something you want scribbled on a, on a Post-it.

It should be standard, and it should be something that nurses are very happy and willing to do for the hospitalised patients. This is a key part of nursing. And it, it just means that you, you really think about, about what they're eating.

And we, this is an example of a hospital sheet that is used at the hospital where I work, but actually it's a, it's quite a nice form and we will be producing it via ISFM later this year for people to use. But it means that for your sicker patients and your hospitalised patients, you've got all of that information in front of you and it's recorded really effectively as well. And it means that ideally each day you can work out what percentage of their RER they are eating and quickly notice those that are deficient.

And actually, it's something that we had a look at in a study recently working with Alex German and we, we wanted to know how often people weigh cats. And actually they weigh cats quite frequently. So, you guys are doing a great job at weighing cats.

Nearly all cats are weighed in consultations. But actually only 25%, or under 25% are body condition scoring. And interestingly, when cats are sicker or they've lost weight or they're chubby, that's the time that we tend to record body condition score.

And interestingly, you guys are more likely to record both weight and body condition score in the morning rather than afternoon or out of hours. And that may be to do with time pressures and case, you know, case management, cases that you've got to look after building up. But it, it's, it's an interesting point, something that we can improve on.

So pretty good at weighing cats, not so good at body condition scoring, and not so brilliant at doing nutritional assessments. And this is a nice study that was done from the RVC and they looked at knowledge and attitudes, in both vets and nurses at veterinary clinics, and they acknowledged that nutritional assessments were not done routinely, they were infrequent. They tended to be done on sick and thin patients rather than other patients.

. And time limitations and lack of knowledge of the assessment were were part of the issue really. So we can see that, you know, these are quite large proportions of clinics that are not calculating RERs, or only calculating them when cats seem to be unwell, which does miss a population that could be at risk of malnutrition. And things like, you know, performing a nutritional assessment, some people do, but there's, there's room for improvement.

It's only less than half that are always asking about dietary regime. And I know, very aware of the issues of of time pressures, particularly in, well, actually around the world. I mean, I'm more aware of it in the UK but I know it's an issue everywhere with staffing.

And there's things like this can fall to the bottom of the list. So target the patients where this is, this is really important. Now our guidelines are focused on hospitalised cats, but a lot of it is very applicable to to your outpatients as well, and to owners, as I say, that's why we produced an owner document about this, so you can always send owners away with that if you're short of time because it provides information for them on how to offer food, etc.

So I've got here some some non-specific factors that are associated with inappotence, and this is from our guidelines. I'd want you to think of inappotence in terms of the direct effects of the underlying disease, but the complications those diseases may cause, as well as the environment. So the big ones are stress, ileus, or what we probably should call gastrointestinal dysmotility, pain and nausea.

And there are other factors that you may not think about like dehydration and electrolyte abnormalities, constipation, and all of these are probably linked, things like adverse effects of medication, which can be direct on appetite. Many antibiotics, for example, can knock the appetite. But also the horrible taste of some meds.

So if you're going, you know, using some of the particularly disgusting medications and thankfully we don't use it very much now, but things like Zantacx or ranitidine, you know, and liquid metroflagyl, metronidazole, you know, these things, if, if anyone has ever bitten into a metronidazole tablet by mistake, I had them for my wisdom teeth. Oh, horrendous, you would not eat after, after that. So these are just some of the small things that we need to think about.

Yes, it goes, you know, without saying that you're gonna treat the underlying disease, but I want you to look at a few other things, and this is particularly important if you work in a hospital and you've got patients in for more than overnight. And that's things like reviewing medications as I've mentioned already. And I often, people joke cos I go into the hospital when it's my days and often cross off a lot of medications.

It's very easy if you have a cat that's not eating to pile them on, so it's not eating. We'll get some oppotin. It's not eating, we'll give it some on, we'll add ondansetron.

It's still not eating, we'll add mirtazapine. We've now got multiple medications mixed together, and I'm not saying that they're wrong, but I think you need to have review the case, certainly when you're getting above 3, you know, medications, maybe they're also on steroids and antibiotics, now we've got 5. You see what I mean?

Stress management, both at home and in the hospital, pain recognition and management, and I, I mentioned to you about dys motilities. So these are all the things that I want you to, to think about and work from the diagram I showed you a moment ago. Now some cats are recovering and they don't have a disease that's impacting their appetite, and they simply will not eat because of anxiety and fear.

And these are often cats that don't use the litter tray as well, for example, you know, they're cats that hide and don't want to be, don't want to be handled, so they're cats with both fear and anxiety. And so this means really not hard to see that anxiety can directly impact recovery from illness. I haven't got time to bore you with cat friendly clinic information, but I hope, that you, those of you listening, if you're not a cat friendly clinic that you might have a look at the scheme.

Because we're trying to aim for it to be a practical scheme to reduce anxiety and fear and improve cat handling in the hospital. It has the side effect of reducing staff injury as well, which is very nice. So things as simple as minimising and or hopefully avoiding exposure to dogs, quiet and calm surroundings, and gentle and respectful handling are really important.

So a few things that that are just must haves. Every cat in the hospital must have somewhere to hide. There's no excuse for not getting a a cardboard box out of the store.

You know, this is not something that is expensive and it's not something that takes time. If a cat is hospitalised and it's sitting on a vet bed, no, it's not good enough. There is multiple, multiple evidence and studies to show a reduction in both stress and disease in shelters when cats are given.

Somewhere to hide and some evidence from veterinary clinics as well. So they need some, this is the top of a, a litter tray, so we use some of these, they're quite nice. They just come, I bought a few, covered litter trays and you just take the bottom off.

And it, it just, you know, makes a huge, huge difference. Ideally, they also have somewhere to perch, so that you might use the cat's protection hide and perch type boxes. But you can use a cardboard box that they can sit on the top of, or even just their basket in the cage with a blanket over it.

As I say, I spent a lot of time talking to you about that, but I'll run out of time. So we'll move on a little bit. Nausea, you need to assume it if you don't see it.

Yes, there are cats that may have dro and exaggerated swallowing and turning away from their food. But I think we've got to make an assumption that it's present in some conditions. And remember, nausea can be a side effect of medication, so some humans are incredibly nauseous on opioids.

Yet most of your cats that are having surgery, well I hope all of your cats that are having surgery are on opioids. And I almost feel we, we approach. A position where our surgical patients would benefit from more potent as part of their pre and you know, their, their sort of perio-operative management.

And we are moving that way where we give, we will give anti-emetics to a lot of our anaesthetized patients, as they will do in humans because of the well recognised effect on on appetite and nausea. Yes, cats with GI pathology and pancreatitis, for example, are going to be, you know, no-brainers for having some anti-easy. And there are options.

Cerenia often does the job or premax one, that's I forgive me using trade names Mropotin is going to be, you know, your first port of call. Now metoclopramide does have a place here. Metoclopramide can complement and work well with some of these other drugs because of its additional pro kinetic effect.

And then Ondansetron is used by a lot of people these days. Do remember that ondansetron can also cause some adverse effects. It can cause, for example, constipation.

So it's just something to to think about again, any drug we use, those adverse effects. And pain scoring, I hope you're doing this in your clinic. There's an example of one, the feline grimace scale, but there are other scales available.

And I think again if you're doing, you know, more than a tiny bit of surgery or maybe even if you're doing a tiny bit of surgery, you know, on your hospital sheets, pain scoring has got to be part of that. And owners can even use the Grimmer scale at home, there's an app that they can download and they can use that at home. So I've told you about this a little bit, I, you know, bored you with it in the last few slides, but it's just to encourage you to, to avoid polypharmacy, and to think about those undiagnosed drug interactions, to think about those cats that are on, you know, lots and lots of drugs.

Omeprazole is a drug that has very few indications in feline medicine. So it's not something that I think you should be using very much, and there are, there's some very nice reviews if you want to read about that. Some of them are open access about, recommendations for the use of antacid drugs.

And, you know, really, omeprazole can cause nausea and diarrhoea in some cases. It's also another drug to give. So it, you just think about these things and whether there is a true indication for drugs and I'm blaming omeprazole and being a bit mean to it, but it is one that's often used without clear indication.

Things that I mentioned, the horrible tasting ones. Gabapentin is a great drug, but actually it is in liquid, it's quite hard to hide the taste of it. So it's something that you may use the liquid for, and I, you know, I really hope you do because the liquid products are really, really nice.

And they've tried to hide the flavour with chicken and things like this, but, it doesn't always work. So think about it. So when you should you be intervening, I've asked you to do a nutritional assessment and in that we talk about kind of duration of inhabitant.

And a question for you here, I suppose, when do we worry about hypoorexia, when do we worry about reduced intake? And I've put a few suggestions on here. And you know, actually the, if you look at the evidence, we, we have a sort of arbitrary 3 days, but the reason I want you to think about that nutritional assessment is because.

If 3 days of eating less than your RER might not be as significant for one cat as another. So a debilitated cat, you know, that makes a big difference. Perhaps for an obese cat that's at risk of a higher risk of hepatic lipiddosis.

The reason for this kind of arbitrary 3 days is, is a lot of it based on this paper that showed that fasting affected lymphocyte function, and that's just one part of it really, isn't it? So there, there's information in the guidelines all about this, but we think about this 3 days, and that means that a lot of cats that you see in a consult probably have already not been eating very well for 3 days, so they, they are already at risk of malnutrition. And what I want to you to take home is this, this message about not waiting for tomorrow.

I'm as guilty as this because you don't want to start putting feeding tubes in if you don't have to. They cost money, they cost time. And so you might think, well, let's, let's just try the appetite stimulant, let's just try a different diet.

And so what I say is don't rely on hope or tuna. You know, think about the negative effect of fasting is having on that patient. There are soft adapt soft adaptions as I call them, and they're, I'm not saying you shouldn't do this and you shouldn't try this, but what I'm saying is don't try for days and days before you intervene because actually if you're placing a feeding tube, you can still try these things.

So things like warming food up to body temperature, you should be providing small meals that you, in general, the advice would be to take away after half an hour. The exception being some cats that we call secret eaters, so they like to eat particularly at nighttime when there's no one in the ward. And so for those cats you might want to leave the food down.

And then appetite stimulants certainly have a place. They can be quite useful and it's, it's certainly something that we do use. But if we use them in a cat that's nauseous, for example, they just won't work.

So the people say, oh, you know, Mirtazapine didn't do anything. It's probably the case as well, and that a cat required more intervention. And painful cats, you can give them buckets of mirtazapine, they're still not gonna eat.

Actually, mirtazapine itself probably has some anti antiemetic and even possibly a slight pro kinetic effect. So it's a, it is a good drug choice, but you're going to see something else for nausea in the really, you know, the, the pancreatitis GI cases. So again think about compliance, I'm boring with this but it's another tablet.

And some people worry about it sort of masking illness or something like that. It it won't, it just won't work, to be blunt, if you have a severe underlying illness. There are a few that are not appropriate to use, so things like prednisolone as an appetite stimulant alone, but it's a nice side effect if you're treating an underlying disease.

I don't like using benzodiazepines as appetite stimulants because I think they're they are effective, but what they can do is be so effective that the cat will then eat a large meal and then feel hideously nauseous. So imagine if you feel sick, you don't want to eat. And then you're injected with something that's particularly applicable to the injectable benzodiazepines.

You're injected with a benzo drug and then you eat a massive roast dinner and pudding with crumble and ice cream, and then that effect wears off and your underlying disease and nausea and stress are present and you've got a big belly full of food, it's just horrendous. So I'm not keen on that. People talk about propofol, but yeah, we don't want to use propofol in appetite stimulant.

Well, that may explain why some cats will eat after anaesthesia. And B12, it probably isn't an appetite stimulant unless they are deficient, and certainly if they're deficient, you should be aggressively correcting it, because it will affect appetite. So I think the message there with appetite stimulants is they can be very useful, but we need to think about when we use them.

And so particularly I would use them when things have been managed, but they're still not quite eating enough. So they're eating some, but not enough. They, maybe I want them to eat a bit more to maintain their hydration, maintain their.

get some medications into them, and it sounds a silly reason to use appetite stimulants, but sometimes that can be helpful. And then the owners can medicate easier and then everyone is a lot more positive and, and we can move forward. So sometimes there's cats that show an interest in food, but their their intake is inadequate and you'll know that by working out your RERs.

Or perhaps, you know, outpatients, in outpatient situations, you certainly can use it earlier in the course of disease while you're waiting for results and investigating. And we have a product licence in the UK, Canada, USA, and I think some in Europe as well is, is Mittas, and that's a transdermal ointment. Now it's quite expensive, so if you have a cat coming in with a dodgy appetite, your client is not necessarily going to want to, to, you know, buy, a whole tube of diazepine.

So some people use it, they take one dose out, so they'll apply a dose in the consult and whilst they're investigating and waiting for results, because then the cat will feel better, eat, be hydrated better, etc. So these are things to think about. They certainly should form part of the management of chronic illness, and I think they have a great use in chronic kidney disease, pancreatitis, and these type of of conditions.

And I've mentioned about facilitating compliance to medications, hydration. Also think about them in transition to novel diets that you want them to eat. So renal diets are a great example or hydrolysed diets in GI cases.

And food aversion is a thing, so when cats are, you know, they, they eat a food or see a food while they feel really unwell, it can very much knock their appetite. But once that illness is involved has has resolved, they can continue with that. And neophobic patients, those are cats that are, they don't like new foods, new textures and tastes.

It can help with overcoming this. Well, for example, a good example would be a cat that has been fed an inappropriate diet, but that a diet that they're, you know, they like. A raw diet is a good example there, cats that eat raw diets are going to sometimes find the transition to a commercial diet if they need it for health reasons, quite difficult, and appetites can be, appetite stimulants can be very useful here.

Mirtazapine I keep talking about there, there are other ones available and I had a photo of it earlier, but it's going to be mirtazapine that you use mainly. And you don't need me to tell you how it works, I mentioned it's potential anti-emetic effect, which could be very useful. Adverse effects you usually would only see with very high doses.

And there are multiple studies often looking at looking at cats with there's one nice study looking at cats with all different diseases and there are other studies looking at cats with chronic kidney disease showing an increased appetite and less vomiting and and weight gain actually. OK, in the last part of the talk, I want to talk to you about feeding tubes in cats, and I'm gonna start by asking you a question. How often in your clinic do you place feeding tubes?

And the answer might be never if you don't see that many cats, fine, I'm not gonna tell you off, but if you are hospitalising cats, then I think the answer needs to be occasionally, and if you're doing, working in a larger centre that's doing a bit of surgery, you know, doing, yeah, the X laps, the liver biopsies, or you've got more than more hospitalised patients, then you need to, you need to think about why you're not doing it more frequently. The most commonly placed feeding tubes are nasal in the UK nasoesophageal tubes, although in other countries nasogastric tubes are placed more frequently, and we'll talk about pros and cons. And O tubes.

So in our clinic we place a lot of O tubes and I know that a lot of the bigger first opinion clinics will also place O tubes quite frequently as well, and that's fantastic. J tubes and things, and actually peg tubes, peg tubes will place occasionally but not very often, to be honest, even in a referral setting, because O tubes are, are really great. Yeah, J tubes are are ginostomy tubes, which I actually have never seen placed, so not something you'll use very frequently.

So let's start with NO tubes or and same would apply to NG tubes. They are easy to place, but they are for short-term nutrition. Particularly useful in a cat that's too unwell to have a GA to have an O tube placed, so I think they sort of a place in more chronic disease.

It's just that you, you so you might use that to, to start to get them stable enough. . We will place some unconscious cats in the majority of cases, but some people prefer to have some sedation on board.

We may just be able to use oral gabapentin or Borphnil for example. They, as we had a debate when we were writing the guidelines about how you secure them, and different clinics will secure them in different ways. So I am happy to use tape and glue because I think it's very quick.

Some people like to use ELA and then sutures, and other people, and as you can see on the images here, will use staples again after using either some Elet or sort of, feel that it's not painful, or the cat's got some other analgesia on board. For some cats, it will deter them from voluntary food intake, they really hate having stuff on their face. And so that's when an O tube can be more useful because they can have their little kitty collar on and they can carry on eating as normal.

If you do place a nanotube, some cats will need a a harder plastic collar, but I don't like hard plastic collars. There's few circumstances that I'll use them. And we find that in the vast majority of cases, we are happy with our soft collars.

Complications are pretty unusual, but they are easily obstructed, and that would be the most common complication of these tubes is dislodgement and obstruction. And because they are narrow and bore, you can't put loads of different diet. You're gonna be limited to the liquid foods.

So as I say, if you need longer term nutrition and they're stable enough for it, consider an O tube instead. Nasal disease, having said that, it, these can be useful for flu cats. Obviously we're gonna anaesthetize their nose and a cat that's got terrible nasal disease you wouldn't use it for, but there are some flu cats where it can still be very, very useful to top them up with nutrition for their recovery.

And really apart from liquid meds, so you can give liquid meds, I shouldn't say you can't give medications, you can't give crushed tablets, but and and thinner liquids, just watch with very thick liquid medications, dilute them. As I say, some cats don't like them as much as others. In other countries, when we were writing the guidelines, we really found that people preferred NG tubes.

And when you look at the, the studies, there aren't very many. There's one quite nice study looking at NG tubes in cats with pancreatitis with very few complications. And in one dog study, they compared NO and NG and found no difference.

The concern has been, if you're not familiar with it, the concern has been traversing the lower esophageal sphincter and getting reflux, but actually these are such narrow bore tubes that it's unlikely that's an issue. So I think you can place either, and I, we tend to place NO we tend to place NO almost exclusively, but the advantage of NG is that you can suction fluid from their stomach. So I think we should consider it.

For example, if we have a postex outpatient with ileus, you know, that the stomach is full of fluids, some of the hepatic lipiddosis or hepatic disease, pancreatitis cats, for example. I love esophagostomy tubes, I love them and we have a guide for you on how to place them, which is very detailed in the resources that I mentioned to you. We've got a video and in the guidelines themselves, we have some information on it.

But you need a GA and so the cat needs to be stable enough for that. We don't want them to have things like coagulopathy, so if you had a really severe, hepatic lipiddosis, you would potentially want to give vitamin K before you place the tube. There's not that many circumstances where you would have a coagulopathy in cats.

It means you can give loads of meds, you can crush them, put them down. You can liquidise most diets and put them down the tube because the bore is larger. And importantly, you can send them home, and so you can send them home quicker and we want cats out of hospitals.

It's not many cats that are not stressed by being in hospitals. And you can leave them for months. So for example, my colleague Daniel Gamel will place them for management of her mycobacteria cases and leave them in for you know, ages during that 6 month treatment to facilitate medication.

You can, important to check the placement, obviously, and there are various ways to do this, which we have in our info. And we've got some nice videos of, of caring for esophagostomy tubes as as well. And it's something that can be really, really satisfying actually in a clinic for nurses to to be in charge of nutrition, and they are brilliant at maintaining and managing such tubes, to be honest with you.

And you can see us here using a tube. So that when we're placing them for longer term management, we'll place them shorter. There's some advantage to leaving a length on it because you can step away from the cat, you're not very close to them, which can reduce stress as well.

OK. So I can't go through again, haven't quite got time of how to place a no tube, but there are kits available and there are various, different ways to place them. The majority of people will place them with long forceps.

So for example, this is using the long carmelt forceps, and this is the technique that we chose to show in our guidelines because it's the one that's the most straightforward and and can be very easily done in any clinic. But as I say, some people do like the kit introducer kit, so I'm just not so familiar with them. You can, you secure them with a finger trap and you can use them immediately and you can remove them immediately if you need to.

I mentioned kitty collars here, that's the, the fabric collar you saw in some of my images, but there are actually now other companies that make the fabric collars. OK. What about complications?

Well, er, you can get complications with tube placement. Thankfully they don't seem to be very frequent, and the most frequent again, are tube dislodgement. And I think we get that more in cats where we have tightened the sutures too much, .

Where the sterile technique has fallen down perhaps. So we've really tried to get better at the suturing of them to avoid over tightening, for example, and we change our gloves and re-clean the site, especially if you, you've had your hands anywhere near the cat's mouth, for example. So usually it's better to have someone else go in, do the sort of mouth bit of the cat or just swap your gloves.

And in a couple of studies here of quite large numbers of cats with O tubes, it was cats that were on steroids or chemo that had the most complications, which it makes sense, doesn't it? It can cause this local cellulitis or infection, haemorrhage I mentioned in coagulopathic patients. What you can see very rarely is nerve damage because we are in the proximity of some important structures.

And so this is a cat that had developed Horner's syndrome after placement. Now that resolved after the tube was removed and we are. It was a neuropraxia, or it can be to do with swelling at the site.

So these are the type of things that you could see. Obviously, if the tube is dislodged and the cat is fed via the tube, then they can get aspiration pneumonia. And that's why we must be meticulous with our checks of placement and owners will have to do that before every time as well, and it's all detailed in our videos.

If you do get an infection, if it's very severe, you might need to remove the tube. In most cases you can manage it. So again, if I have a lot of puss, I'll swab it for culture.

But in the more mild cases, what we'll do is increase the frequency of cleaning and redressing the tube, and we use these sort of antibiotic impregnated discs. Now they're. Devilishly expensive and that's one of the issues.

So what you can also do, and and a cheaper version of that is to use an iodine cream, which you can get quite easily. They're quite cheap. Owners can even buy them in the pharmacy and a little, and, and a, a simple, a swab.

So put the iodine cream on the swab and then that sort of is in contact with the, the site. This cat here actually has a pretty clean Otube area. But it's something to to think about.

Here's a particularly horrible O tube O-tube abscess. Now this is unusual, and these are the type of cases that may need surgical debridement, but it, it's unusual and I I've listed on here some of the things I've mentioned for prevention. Obstruction, that's, that's a problem, as I mentioned, particularly with the NOs.

And so to get over that it it it's really flushing well. The ones that we've had block are ones where we've been a bit silly and we've got it a bit wrong and we tried to put medication down for example. So flushing with body temperature water before and after.

And then for the O tubes leave a sort of bit of water in there, basically in the tube, that's not a problem if you do that. And there are ways to manage obstruction, and there's actually a study on this looking at the best things to remove an obstruction. Actually pancreatic enzymes in bicarb were the most effective.

But everyone will talk about using Diet Coke or Coke to go down the tube. I just always worried that it's going down the tube into the cat's stomach that's kind of or or their oesophagus, which is not what they need. So most of the time, flushing and aspirating with warm water will do the trick.

Sometimes you will have to remove NO tubes because of obstruction. So when should you place a tube? This is something that we wanted to include in the guidelines because I think it was really important.

And actually cats consuming less than 80% RER for 3 days, which, as we said before, is probably a lot of patients at your first consult. You guys in First Opinion will have cats as well with jaw fractures, for example, or synthesis, damage from from falls and things like this, where they just can't eat. OTube is just awesome because then you can feed them, you can medicate them, no problem.

And I want to mention when you can predict undernutrition, so I have occasionally regretted not, I don't think I've ever regretted putting a tube in, I've regretted not putting a tube in. When I've had a cat that's eating pretty well, but they are going for multiple GI and liver biopsies, and I know I'm gonna have a couple of days where they're recovering, and we do our absolute best, but they're gonna have to be on opioids, etc. We now would generally place an O tube at that surgery.

It takes 10 minutes up at the end of the procedure and then you know that you can give food, you can give fluids, you can, the owners can look after them, they can go home. And obviously those patients at risk of, of malnutrition, and I've mentioned their, their utility and medication compliance. And I really want to encourage you and get you to take home from this talk that early use of feeding tubes can actually really reduce hospitalisation.

And you can place them in any noses. So you see this Persian here, I don't think a Persian can cope with a Nano, but the Persian can cope with a Nano. Now we did have to use a plastic collar because the trouble is he has no nose and so he could rub it on things and and dislodge the tubes.

So, as much as I hate the plastic tubes, occasionally we have to, we have to use them. And that was a cat with some weight, significant weight loss due to GI disease and it really helped his recovery. And I said, we can send home with these tubes and the complications are usually minor, but the choice of tube and the choice of whether you place it, you know, I'm very aware is gonna depend on the individual case and finances and things like temperament.

So some cats are very intolerant of NO's and they're much better if you just have an O tube in, you've got your little collar on, no problem. And it depends what diet you want to use, obviously, given what we've discussed. So as mentioned, your, your choices are gonna be limited with the NOs, you're gonna be looking at recovery diets, but there are a few situations where a recovery diet is not suitable.

The only situations would be things like renal cases and hepatic encephalopathy, where you want less protein, and there are liquid renal diets that you could use. And as I say, if you are feeding liquidised diets down an O tube, just make sure they're very well liquidised, . I still find that some of the hydrolysed diets don't liquidise very well and that's annoying cos at the moment in the UK we don't have a liquidised hydrolysed diet and we yeah I wish we did.

But most of the ZDs and things you can and the decre hydrolysed diets for cats, you, you really can liquidise. I think the dry diets like Pura HA can be more challenging to get down those tubes. You usually can in in dogs, but in, in the smaller cat tubes, they are a little more challenging.

And how much, this is something I want to talk to you about because it's very tempting to, you know, especially if you have a cat that's been in absent, like, get the food in, get the food and the cats we want to feed the cat, you know, a bit like, as I discussed by a colleague in a talk the other day. I heard her talking about people from concentration camps that had been fasted for a long time and or having very poor nutrition for a long time and when they were fed her, she sadly died from refeeding syndrome. So we do have to think about refeeding syndrome, although in itself, I have to say I think it's uncommon, .

We know that overfeeding is associated with negative negative outcomes in humans, and that's a concern in ICU human patients, for example. So the message is start slow, build up and look at tolerance. So if we're having nausea, we will split it into more frequent small meals, for example.

And if we have cats that have been faster for a long time, so that classic cat shut in the garage, those are the ones that are at risk of re-feeding. And those we would start on perhaps 20% of RER and it would take us 5 days to get to the, to full RER. The other message I want to give you is feed for their current weight.

So again, we have evidence that overfeeding, feeding for ideal weight in skinny cats and humans actually can overfeed them and have negative results. Sadly, a lot of that research comes from anorexic people where they were fed for their ideal weight rather than their. Current weight, which can lead to diarrhoea, electrolyte abnormalities, and, and sort of multiple things.

So, while you have that hospitalised cap with you is not the time to try and correct their body weight. You can do that once they are discharged from the hospital and you you sort of reassess. And so you're gonna be constantly reassessing these patients.

Illness factors used to be talked about, sort of, you know, feed them 1.2 times RAR, 1.1 times RAR, and that's not something you want to do.

And the only thing I will say is that in young kittens, this can be quite challenging because they do need sometimes 200% of adult RER, so you may want to take some further advice on them, but again, building up slowly and watching for effect, adjusting, adjusting, adjusting depending on their response. So think about sort of meal volume as well, so we have some arbitrary kind of amounts that you shouldn't really feed above, but it does depend on the case. So if you have a cat with a jaw fracture, then that cat was not in not inappotent before you placed the feeding tube.

And so for those cats you can, and they don't have GI disease either, so those cats you can probably give larger, less frequent meals which will make life easier for for the owners as well. Whereas actually some cats that have delayed gastric emptying, for example, will need really feeding 8 times a day, you know, very regularly, and that can be quite, quite nursing intensive. You can feed using a, a constant rate infusion.

And that is something that we we we do very occasionally, and they tend to be for the really sick cats with for example acute pancreatitis where they just have really, really slow gastric emptying and they just can't really cope with bowlers feeding. And then, you know, have a look at at fluid balance as well, you need to make sure we're not over, often we're giving, they're on fluids, we're giving them fluids through the tubes and their urine is super dilute and we say, hold on, we can just back off here on the on the IV fluids for example. So a few tips here on cat friendly tube feeding, and this is something we explored a little bit more in the guidelines as well, and that's about allowing a cat to relax before you start, making sure they've got somewhere to hide.

Some cats might want to hide their heads. Other ones are happy to sit on their on their owner's knee and things like this if they're being fed at home. But what we don't want to do is force to restrain them in order to feed them because then they're gonna be anxious and fearful and they're gonna be more likely to regurgitate, for example.

So feed them slowly and look for signs of of discomfort, er, backing away, licking their lips, exaggerated swallowing. Now some of them will do a little bit of that because it's an unusual sensation. So they'll lick their lips a little bit or they might swallow a couple of times, that's fine.

But obviously if they, if they look really nauseous then we might have to slow our rate of feeding as well. Make sure that the food's warm but also stirred well, so we tend to, well, I think I had a picture of it actually, we tend to warm our food up in, in warm water, and then agitate it to make sure there are no cold bits or, or hot bits. I know people do kind of microwave foods and things, but it just worries me you're gonna have real hotspots.

And then just obviously following all of our cat friendly clinic principles, this is a this little cat that you'll see in a lot of my images had a jaw fracture and was being fed via his tube. What I don't want you to ever do is syringe feed. There are very, very few cats that will tolerate syringe feeding without stress.

Now sometimes you might say, well, I've had a case and it was absolutely fine. But what I would say is that some of those cats could be in, they could be stressed and in, you know, emotional discomfort, but they are compliant and that's still going to potentially cause things like food aversion, so. They, you know, I mean it, it, a horrible case that someone was telling me about the other day of a a cat post dental treatment and wasn't eating very well and was syringe fed and aspirated and died.

You know, this does happen. It's just not something that we should be doing. And other things people talk about is which I've done when I did some nursing before I went to uni, you know, is putting in the food, put the AD on their feet so they have to lick it.

It's a bit futile, to be honest, they're not going to get enough calories that way. We might feel a bit better. And people might say, well, that sort of starts them off and gets them eating, but I don't think they, they rarely would eat a full meal then, you know, just because you put the stuff on their feet.

It, it, you know, and, and to them that could cause them some anxiety because it's an odd thing to to happen to them. So yeah, I don't think that's a good idea. In summary, and I know we've covered a lot in this talk, and I apologise for rattling through it, but I really wanted to to get some of these messages across to you, that yes, in absence it's caused by the primary underlying disease, but particularly in hospitalised patients, there are other factors at play.

And it's something we need to act on and sort out because it affects recovery. And I just want you to think about nutritional assessment. I know that everyone's very busy and you're not gonna be doing that for your, lame cat or your, you know, necessarily for every vaccination appointment and things, but it's really something we should consider in our sick and older patients and it can be a a huge benefit.

It just helps us see what needs to be done. And just want to give you the confidence to intervene rather than leave it for another day. As I say, you can always remove the tube if they start eating.

You can take it out and with some nasal esophageal tubes, you might actually have to remove it because they won't want to eat while it's in. So you sometimes will have to remove it to sort of test the appetite really. With O tubes, that's one of their beauties.

So we had a case the other day, it was a diabetic cat that had . It needed a it's gallbladder taken out, it was full of stones. And in that cat, for example, it was eating very well, but we placed an O tube at surgery, and that meant that the owners can medicate the cat, they could sort of top up the cat so that it could still get it's insulin and, When it went, it didn't eat that night, and I think as soon as it went home, I sent it home quite, quite quickly, it ate everything, and so we just kept it in for a week to allow them to give the antibiotics that the cat needed, and they said that was super, super helpful because they would have felt awful trying to peel, you know, trying to peel a cat when they're in recovery from surgery.

So there are these situations where, you don't need it so much, but you can always take it out. So that cat would just removed it when she came back in for her kind of 7 day post-op check. So just think about that and think about giving your cat somewhere to hide.

Think about the layout of your cage, you know, food away from water is a is a big one, so ban the double bowl is what we always say. So food away from water and away from the list tray. And that's hard in a small cage, but it is possible.

And because you're now gonna have a lovely place for them to hide, you can almost use that to kind of divide the space as well, which can be really useful. So all of these factors together will help us look after these cats sort of no matter what the cause of their underlying inhapetence is. And you know, I will shamelessly plug our guidelines because we hope we've provided you with everything you need to manage these cats yourself and for your clients as well, and how to place the tubes and how to manage them as well.

And I hope you find it all really useful. Thanks very much.