Hello, my name is Leslie Moore, and I'm a senior nurse at Vets Now in Macclesfield. I'd like to welcome you to this webinar, webinar vet webinar entitled Nutrition and Feeding tubes. Addressing nutrition early on is really important for emergency and critical care patients, as it can make such a big difference to their recovery.

It can sometimes get overlooked a little when patients have had complex medical conditions or surgeries, so it's important that as veterinary nurses, we take the lead in planning the nutritional requirements of our patients. So many of our patients are anorexic before even being hospitalised. Anorexia can be defined as the loss of desire for food before calorific needs have been satisfied, and there are many reasons for this, as outlined.

These include underlying disease. Emotional stress. Disorders of smell and taste, and it can be changes in the local environment of the mouth and the nose.

And old age also does play a significant role here. We all know that our older patients and sometimes their level of appetence does fall for various reasons. Malnutrition of the gastrointestinal tract decreases cell turnover and mucosal mucus production, which thereby decreases the barrier function and surface of the GI tract and results in malabsorption of nutrients.

The absence of intraluminal nutrients also decreases blood flow to the gastrointestinal tract. So the complications of malnutrition are really widespread, including longer hospital stays and increased mortality rates, which is why it's so important that we get patients' nutritional requirements correct. There's no real key single finding or biochemical marker to determine nutritional status, but we really do first need to consider the length of stay of our patients, and no patient should really go without nutrition for 36 hours.

So we need to have a think about how long they haven't eaten before they present it to the hospital. So it's always worth speaking to the owners and certainly in the in the initial consult about how long it's been before they've eaten when they actually arrive at the at the clinic. And then we also need to have a look at body condition score in our patients.

And looking at a body weight reduction, so a 5 or 10% reduction that's not due to dehydration would be a serious indicator here. So, body weight can be falsely elevated or it can be falsely reduced, and body weight changes, they, they can be quite significant really. So if you can consider the body condition score of your patients, .

And I'd always encourage you to do this along with taking a body weight for your patients. We should be weighing our hospitalised patients at least once a day, and quite often with cats, I'll weigh them twice a day, especially if they're on fluids just to make sure we're not getting fluid overload. And we may need to consider, falsely elevated or falsely reduced body weights, as I've said for things like ascites or edoema or dehydration.

We should also consider the nature or, and the diagnosis of the injury and how and how long the animal's been affected for. So here's one of the body condition scores. I think most people are using this now, this is the 1 to 5 or the 1 to 9.

I prefer the 1 to 9 because it gives you a little bit more movement in your numbers, but for people that aren't used to using this, so. A body condition score of 5 would be our ideal weight for patients, where from above they've got a nice waistline, and from the side without pressing too hard, you can feel some ribs. At the top end of the spectrum you've got 9 where they are obese and from above their waist is is rounded out and you just can't feel ribs when you press and then a body condition score of 1 at the other extreme would be.

An extremely underweight patient. It's really important as well to get information from the client regarding diet history, especially in 24 hour hospitals. It's not really a question that you can ask an owner at sort of 3 o'clock in the morning.

So admit questionnaires are often quite useful for this and asking what what the patient usually likes to eat and also. Out what, what would be a treat for them or something that's really tasty. So, and, and also really important not to assume that every patient's going to eat wet food.

There are some patients that will only eat dry food, so keeping a good stock of, of things in. And I'm sure everyone's got their own tried and tested methods for, getting our patients to eat. And do, and, and you've got various things in the clinic, that you can do this with, but it is, it is a really important question to ask owners and I've certainly been caught out on occasion by by not knowing what, you know, trying to selection of things then to be told they don't eat dry food.

So I just want to talk a little bit about hypermetabolism. It's a state of increased metabolic activity when the resting energy rate goes over 110% and can often occur in anorexic patients, and especially those that have, Experience trauma or sepsis or bones or are in an advanced disease process. Protein metabolism is a really important factor here.

It can lead to muscle and lean body mass catabolization. Protein is really important in ECC patients as it's needed to repair tissues, produce antibodies and other inflammatory processes. So how are we going to approach nutrition in our patients?

So we always say that if the gut works use it, nil perros does increase the risk of gastrointestinal complications because it changes the gut flora. It also decreases GI motility and blood flow, and it impairs barrier function. So this is why we always try to feed through with our vomiting and diarrhoea patients.

We don't advise periods of starvation anymore. It's it's much. Better if you can advise clients at home or or even in the hospital to just feed very little and often, even if that's just a teaspoon of food, because if you, if you starve the guts, then you do get those those negative changes in gut flora and GI motility, which can cause further complication and also delay the healing process.

So there's a number of key considerations to nutritional assessments. So firstly is assessment of GI function. So is the patient, has the patient got vomiting or diarrhoea?

Has it had a major GI surgery? Are we looking at ileus or malabsorption? So secondly, are other organs impacted?

So is this a renal patient? Have we got hepatic failure or an issue with the pancreas? Is the patient gonna tolerate a feeding tube, as we know some patients just won't, and also in some patients it is contraindicated.

We need to assess the patient's risk of pulmonary aspiration. Are they conscious? Are there issues, with the, larynx or the oesophagus that might cause a problem here?

Have we got vascular access, so do we need to consider parental nutrition and also, the need to assess the patient's fluid requirement and tolerance. We also just really need to make sure we avoid making the patient's illness any worse. So again, just be very careful if they are unable to swallow.

We don't want to cause any sort of aspiration. If they've got respiratory disease, it might be very difficult for them to eat. And also concurrent disease processes, so we all know we're not going to give high fat food to a patient that's got pancreatitis, .

We need to consider protein in our renal and liver patients, so diet is, is really important factor. So just to recap, what diet are we gonna be looking at? Are we looking at enter enteral or parenteral feeding, what current and existing diseases they've got, and are we gonna consider tube feeding?

But really importantly, don't, don't wait and see if you're awaiting a diagnosis, . Look at sort of symptomatically what's going on and start planning a nutritional plan with your, in conjunction with your vet and make sure you're using care plans for when you hand over to other members of the nursing team and nutritional plans as well. .

But yeah, the main thing is, is don't wait and see because if that patient's been anorexic, you could be waiting more hours just sort of adding to the, to the already existing problems. So moving on to feeding tubes themselves, so when we might consider a feeding tube, is in those patients that we know are anorexic, so a partial or total anorexia increase in 5 days. I'd actually argue that you probably need to consider it after 3 days, because we are starting to get a compromise of, of, of the gut at that point.

So if we're anticipating anorexia, so that could be that they're gonna be having surgery or for . Those patients that, we know for other reasons might, might not be, be wanting to eat after, after an event. So weight loss, significant weight loss of, of over 10%.

So if a cats, 4 kg cat loses, sort of 400 grammes, that doesn't sound a lot, but in terms of their body weight percentage, that is 10%. So again, that's why I do tend to weigh cats a lot more often, just to keep an eye on those, those, fluctuations in weight. So we may have increased losses.

So, we've already mentioned the importance of protein in healing. So for example, patients with burns are going to have increased, protein losses, and increased requirements in patients with things like sepsis and extensive wounds. And maybe those patients where we need to bypass a certain area of the gastrointestinal tract, so it could be a patient with burns in their mouth or an issue with their stomach or pancreas and that might be another indication of when to use a feeding tube.

So, Assisted feeding or voluntary feeding, I won't spend too long on this, I think, I think, as I've said before, we've all got tips and tricks of how we like to get our patients to eat, and I think we all know just to be quite mindful of syringe or force feeding as it can be quite negative on our patients. In some situations we might need to consider it certainly for a client if cost may be a factor. But I know it's something that, that I use very cautiously with patients.

I'd rather try other means before I start syringe, syringe feeding them. You may also want to consider, or the vet might want to consider adding in an appetite stimulant, before sort of trying to syringe feeding, and that can sometimes actively encourage a patient to eat on their own. So tube feeding, so I'm mainly going to focus on nasoesophageal or nasogastric and esophagoomy tubes today, just because they are the main two I would say that we use, in practise, not to say, we don't use the other two, but I think, on a, on a daily basis that the top two are the ones we're mainly using.

So when we're deciding which tube we're going to use, we need to consider a number of factors. Ultimately the veterinary surgeon will make that choice, but I think it's important for us to have some input. And it also, depends on what diets you've got in the building as well, which I will kind of talk about a little bit, but sometimes that does have an impact on your choice of, tube, as does the anticipated duration, and how long you're gonna need the tube in place for, your comfort level as well if your veterinary surgeon placing the tube, your nursing staff and actually.

Administering tube feeds and the client because sometimes we do discharge patients back to the client with a tube in place. So it's important that it's the right one and that that they're going to be able to manage it. And each type of feeding tube does come with its own advantages and disadvantages, so I will talk a little bit about those as well.

So, just in terms of of supplementation, so if it's a patient where you feel, it's gonna be a shorter term supplementation, then an NO or an NG tube, so 3 to 5 days, that might be, your preferred choice. Middle duration. So an O tube, that's they're actually my favourite O tubes.

I think they're very, very versatile, so we, we place quite a lot of those, that's now in my clinic. And then your longer duration might be gastroomy or again your O tube, that can be in patients for, longer durations of 3 weeks and upwards. So your NO and your NG tubes, so the tube is placed in the stomach, and, from the nose to either the cordal oesophagus, .

For the NO tube and the NG tube ends in the stomach, but they're both inserted in the nasal passages. It's a you can only really get a quite liquid diet through these tubes because they're quite narrow, obviously because they're going in through the nose. So that is, is one of the disadvantages, .

And you can use from like a 3 French gauge and your neonates right up 2 and 8 French gauge in your larger dogs. So it's worth having a selection of different tubes within the clinic. So the advantages of NON NG tubes, they are easy to place.

We can do them as as registered veterinary nurses. They're really good for patients that are at risk from being sedated or anaesthetized because you can do it conscious, it can be a little bit fiddly, if they, if they're being quite wriggly, but it can be done conscious. They, they are good for very critical patients because of that reason.

But also, sometimes very critical patients are, relatively collapsed, so you, you can, get them in quite easily. The diet is, is, is, it's relatively expensive. It depends which 11 you're using.

Things like, liquivite are quite often used, and one of the Royal canon ones we all talk a little bit about, that they're quite good for, these tubes. But yeah, some patients do find them really irritating and will start pouring at them and certainly it's not unusual that you'll come back to the kennel and and find that they've, they've just not tolerated it and they've pulled it out. But again, because you can place them conscious if you feel like you can, replace the tube, and we'll try again.

It is, it is a thing that you can, repeat if necessary. So the, the tubes, as I say, they're my favourite. They're, they're really versatile and I think they're quite safe and effective, and I think they're quite comfortable for patients as well.

And certainly if you're considering sending an animal home with a tube, these are these are ones that are known with education from the nursing team can manage at home. So they're placed surgically, so the patient does need to be anaesthetized. They're placed from the cervical oesophagus to the caudal oesophagus or stomach.

So if you keep in practise some medium to large bore, 12 to 19 French gauge, tubes, these are the size, size, differences that you're that you're gonna use, and you have got a wider range of foods you can use with these tubes because they are, a wider gauge, so you have got a variety of different foods that you can use. So they are for the veterinary surgeon they are reasonably easy to place it's a short general anaesthetic and as I said, they are very well tolerated. They're particularly useful in patients that require assisted feeding over several days and they're really useful in patients that have got facial trauma, so our cats that have fractured their jaw, they're really useful in those sorts of patients, and we would place them quite regularly in, in those patients, although it's amazing that some of them will actually actually eat even with a fractured jaw.

The, oh sorry, I should just say the disadvantages of those are they can become dislodged in the mouth and pieces can be chewed up and swallowed and aspirated and also tube blockage is a risk with them. So you just need to, as nurses, that's why really good care of the tube and the patients needed, and I will just come back onto that a little bit later. So we should be any tube we've got in place, we should be checking and cleaning the stoma daily and replacing any dressings.

So for the 1st 24 hours we don't feed anything to allow seals and adhesions to form. With gasttrootomy tubes, we're always gonna aspirate prior to feeding just to make sure there's nothing present in the tube. And we always want to flush the tube with .

Sort of room temperature water prior to feeding, just observe for any coughing or wretching and I I think you can see in patients if they when you flush it with water, if there's any sort of intolerance, they will give you . Give you signs that that that there's something not quite right. And if you, flush the tube with water after feeding and just try and keep that column of water in the tube in between feeds rather than actually being any, any of the feed left in the tube, that's always really, beneficial.

So select your food, I know sometimes when the, when the tins are open or something, they go into the fridge, but remember to bring it up to, body temperature or room temperature before giving and it's, it's not very nice to give to give it to them when it's really, really cold. We tend to use one of the Royal Canon diets, the recovery one, as it's really easy to calculate, and it can be used in as small as a 3 French gauge tube. But we also stock, as I've said, things like liquivite and we've got ERA as well, which is also quite a useful one, it's quite densely calorific.

If you, so what we would do is, get our feeding plan and calculate the RER and then divide the, feed into 3 days, . We do that because if you start with the full RER straight away, it can make the patient feel quite nauseous and it can also make them vomit. So what we do is on day one, we would feed 3rd, day 2, 2/3, and day 3, the full concentration of the food.

We usually would do it over 4 to 6 hours, but I do always make sure that my nursing team do put a period in throughout the night where we don't put a feeding because it's really important for these patients to get some rest as well. So there's probably like a 34 hour period on a night shift where we, where we'd stop the feed just to ensure that they get some, some good rest as well, because that's also a really important part of the healing process. So that's just the, if you've not seen it, it's, it's been out a couple of years now I think, but that's a really good diet that we use for our patients in the hospital, .

And that comes in various different guises. There's a recovery one which is the main one we that we use, but there's a renal one, there's a low fat one, and there's a GI one as well. But that one's really easy to calculate as well for your patients.

So when will we consider disconnecting tube, a tube feed? I think the most important thing is just don't do it too early. It's like IV catheters, just don't remove them too early.

Better to remove it just that little bit too late. But when you know your patient's eating really well, itself, ideally for 5 to 7 days, but certainly, if you're happy that the, the patient's eating quite well, then that's the time to consider discontinuing. And also when the underlying disease process has reversed in the patient.

So just to move back onto the resting energy rate, so the easiest calculation is the one at the top really. So it's 30 times your body weight in kilos plus 70. So for a 20 kg dog.

That would be, 30 times 20 plus 70. So that's 670 calories, required. That calculation underneath, that's absolutely fine to use as well.

It does come out with a very similar figure, . And we should always use the body weight of the patient that we've got regardless of whether they're underweight or overweight or any other considerations that they might be. And as I've said, keep monitoring that weight and that body condition score as well.

So back in the day when I was training, we used to have the, these illness factors as well, that we used to have multiples in for, and I remember learning those for my exams, but we don't really look at those anymore because . They've resulted in overfeeding some patients and some further complications, so they're really considered to be detrimental now, so we just use that straightforward calculation and work to that. So I think anybody that can remember they were some of the, they were some of the multiples, but if you're still using those on any of your nutrition sheets, then there's no need to anymore.

You can, you can stop doing that and just use the RER. So potential complications with tubes, as we've already said, you can get clogging in the tube, you can get cellulitis, they can cause vomiting and diarrhoea. We can get fluid overload, changes in electrolytes, and I'd always make sure you're monitoring the electrolytes of your patients when they're hospitalised.

Peritonitis, and you've also got the risk of refeeding syndrome. So overfeeding, we should be really cautious about this, especially after a long period of anorexia or weight loss. Overfeeding, especially overfeeding of carbohydrates can contribute to respiratory acidosis, and it can contribute to increased patient morbidity.

So Again, this is why we, with the feeding tubes we start at the 3rd and build it up very, very gradually, and. Anything that kind of upsets our, our patients comfort as well and increases the risk of diarrhoea and vomiting, then we try and try and mitigate those risks as much as possible. So overfeeding patients, it can also result in refeeding syndrome, and this is quite a complex condition, but it's characterised by changes in the patient's electrolyte balance, most commonly hypokalemia, hypophosphateemia and hypo magnesia.

Now hypophosphateemia is probably the most significant disturbance that you'll see, . It refeeding syndrome is basically a a description of multiple metabolic disturbances. When you start to reintroduce nutrition into a malnourished or starved patient.

We quite often, as I've said, we'll monitor the, the electrolytes in, in these patients, and especially in cats, it's, it's, it's something that's again because of the lower body rate and, and the metabolism, it is a higher risk. For our feline patients. So again, we just need to make sure that we're very carefully monitoring, those electrolytes, and it might even be that we need to add in supplementation of potassium or phosphorus for those patients.

Another risk of tube feeding is aspiration pneumonia, so patients are at a higher risk, are those with. Impaired mentation, neurological injuries, a reduced or absent cough or gag reflex, and patients that are also receiving ventilation. So again, this is why it's really important that every feed that we check the positioning of the tube and make sure that the patient's comfortable with the feed as well and isn't exhibiting any signs that there may be any discomfort for them.

So if you're unable to flush the tube and you're concerned that it has obstructed, just make sure that your diet that you're using is suitable for that tube and it's not too thick, and you may need to further dilute it down. And as we've said, don't let the the the feed sit in the feeding tube. We should have that column of, of, lukewarm water after every feed, .

Or whenever the GI contents are aspirated as well. So you can, if you do get a blockage in the tube, you can kind of massage the outside of the tube, whilst sort of at the same time flushing it with some water. Or I know some people like to use, a Coca-Cola type based drink, to do it with, but I've quite often found just with, with, some water and and some gentle massage, it will, dislodge any blockage that you've got there.

So just to summarise, Ideally, our patients should remain at a stable body weight during the hospitalisation period. So any fluctuations that you're concerned about, you should be discussing with your veterinary surgeon. You need to consider, I'd say you'd need to consider nutritional support for every patient that you that you hospitalise, but certainly with those that are going to have an inadequate food intake for 3 days or more, and again consider how long it was before they were hospitalised, that they were inapetent or anorexic as well.

Using the guts is always by far the best method of nutritional support, so use that wherever possible. Consider the diet that you're using. So, energy concentration, you must maximise, you need to maximise it, and also, just be very careful with your electrolyte balance and monitor it very closely, especially your potassium, your phosphorus, and your magnesium.

Also, just consider patients' comfort levels as well. So if you remove any stressors to encourage patients to eat, so we have like little loos for cats to hide in. We make sure everything's kept very clean for them, so the minute, you know, as soon as they've used their litter.

It can be very difficult to keep litter trays and food bowls, the distance apart, you know, you'd have in the home environment, but just keeping those very clean, they could be barriers to patients eating as well. So your patient's comfort should be at the forefront of your mind at all times. So just to conclude, so, get discussions regarding nutrition discussed very early on in the hospital period.

So if you can consider the nutritional status of the patient, any injuries that they've received, any alterations in metabolic conditions, any requirements for fasting periods, for example, surgery, and the provision of continued nutrition once the patient has been discharged. After all these factors have been considered, you can plan and execute in a nutritional plan, and you can decide on any, additions to feeding tubes that you might feel might be appropriate at that time as well. I would say that, they're certainly not used as much as feeding tubes aren't used as much as they could be in practise and early discussions regarding these, I think you find that if you, if you've considered them very, very carefully.

And discuss them with the client, they can play a really major role in the recovery of these patients. So please do consider nutrition as much as you would, medications, and other parts of your care plan. Thank you for your time today and if anyone does have any questions, I know this is a recorded webinar, but I'm happy for my email address to be passed on, if anyone does have any questions.

Thank you.