Hello and thank you so much for choosing to watch this webinar. My name is Sarah Kaney. I'm a UK based specialist in feline medicine and delighted to be speaking to you today on the topic of support of poor appetite in cats.
We're all extremely familiar in being presented with cats with a poor appetite. Sometimes the cause of that poor appetite is very much known. Other times not at all.
But all of these cases do at times benefit from us taking steps to support their appetite. And that's really the focus of this session. So I'm going to look at how we assess appetite in cats, how we calculate their energy requirements, when we need to worry, why we worry, and what steps we can take to support appetite and food intake in our patients.
So a good starting point in terms of our topic is RER, the resting energy requirements. This is a measure of our cat's calorie requirements per day, and as indicated by the acronym Resting Energy Requirements, this is the calorie requirements of a cat at rest in a thermonutral neutral environment. So a very active cat that spends a lot of time outdoors, perhaps, you know, climbing trees, running around, hunting, etc.
Will have higher calorie requirements. The RER is just a starting point, but certainly for hospitalised patients, it's an appropriate starting point as well. And as you can see, there are a number of different equations that we can use to calculate RER, some that are perhaps a little bit more accurate than others, particularly that nasty mathematical equation in the middle, body weight to the 0.75 times 70, which is the most accurate for very small cats and kittens.
But a really good one just to remember in your daily practise is This bottom one, I find this really easy to remember, 50 kilocalories per kilo per day as a starting point for our cat's energy requirements. And because many pet foods that are available, you can now quickly look up online their calorie content. You can see even for those situations where the carer says, Well, my cat is eating, you know, one pouch of this, or You know, one packet of dreamies per day, you can actually work out relatively quickly what their calorie intake is.
And that 50 kilocalories per kilo per day. Actually it's pretty close to the accurate RER as shown in this table here where we've got body weight of cats on the left hand side, and accurate RER in the middle column, and then the estimate that 50 kilocalories per kilo per day in the right hand column. You can see it's really within a few calories for for most situations.
So it's an easy starting point to to just get you a broad brush assessment of that cat and its calorie needs. And we worry about poor appetite because there are so many negative consequences of poor appetite and especially of complete anorexia, stopping eating completely. And I've listed the most important ones on this slide.
I'm sure you'll be very familiar with these, but short-term consequences do involve things like dehydration, electrolyte imbalances, so cats are very dependent on potassium in their food to maintain normal kalemia. Young kittens, hypoglycemia is definitely a a a risk with any loss of appetite, even very short term. And then more long-term consequences do include a negative impact on immune function, healing, wound repair.
Increased drug reactions, and of course for that, that cat potentially shut in a shed, unable to, to access food, life threatening complications like hepatic lipidosis. If you look in a textbook and are wanting guidelines of when to start nutritional support, this is generally what you will see, so. Complete loss of appetite for 3 days or longer is absolutely going to be causing some of these damaging consequences, but also any cat that has lost a large amount of weight rapidly or conversely that over a long term period is eating significantly less than the energy requirements, so less than 85% of resting energy requirements, potentially applicable to, for example, a cat with chronic kidney disease that has just persistent poor appetite.
Cachexia, protein losing conditions like severe exuderative skin disease, Pyotthorax would be another example of a, you know, really protein consuming condition. And clearly starting with that first one of the, the 3+ days of anorexia, if our client comes to us on, you know, after day one saying my cat's stopped eating, we're not going to send them away and say come back in another 2 days. We're going to start at that point to assess that patient, to look for causes of that poor appetite, and potentially to provide some empirical support.
Especially important, of course, to intervene at an earlier stage in kittens and in very vulnerable cats, perhaps the elderly cats, the cats with concurrent diagnoses that we know are going to worsen their ability to cope with a short term loss of appetite. And so our initial assessment of our patients is, is going to through our history and our physical examination, looking for obvious complications such as, for example, dehydration, but also looking at what the or listening to what the owner is saying in terms of the duration of the poor appetite and perhaps other clinical signs like vomiting. Is going to guide us as to whether we feel this is a cat that needs to be admitted to the hospital for support and investigations or whether this is a cat that, you know, is having some sort of health blip and perhaps some outpatient support will be sufficient to see, you know, if, if that's enough to get the cat back on track, you know, the cat that perhaps has has hunted and eaten a slightly dodgy mouse and just feeling a little bit unwell as a result of that.
The longer term, obviously the, the poor appetite is and the more additional clinical signs of ill health, the more likely we are going to need to, to look at that patient more closely, to do some blood work, to do some imaging, for example. But some of the outpatient things that we can do, depending on the situation and and whether it feels appropriate would be, for example, that perhaps that older cat, maybe to give some subcup fluids. I would say empirically something like 80 to 100 mL of lactated ringers or Hartmann's solution subcutaneously.
We can spike that with a bit of potassium. So we can add, for example, 20 millimoes of potassium chloride to a litre of fluids, and that is, you know, a perfectly appropriate amount to give subcut. We can also use things like neuroppotent antiemetic, which has also some impact in terms of visceral analgesia for cats that we suspect of having.
You know, perhaps, gastritis, pancreatitis, the milder cases that we think might be acceptably managed at home. And beyond that, other support methods, well, we might look at is pain a possibility. And again, if, if we're not worried about hydration or renal function, then we might have options including meloxicam and Rabenioxi, but.
If we are concerned about renal function, then we would, and certainly if we're concerned about dehydration, we would choose not to, to use a non-steroidal in that acute scenario. We might prefer alternatives perhaps buprenorphine by the oral transmucosal route. And then we might give owners advice on tempting foods, hand feeding, for example, gently warming the food, the sort of nursing tips that someone might be able to employ at home.
We might also at this point consider an appetite stimulant, and there are a lot of products that have been at one time or another used with the remit of stimulating appetite in cats. I've listed as many as I could think of on this slide, but I'm going to focus on the ones that, the ones that work and the ones that are authorised. So, we, we have at the top of the list, two authorised.
Products. So mirtazapine, Mitaz, probably everyone listening to this will be familiar with because it's has had an authorization for use in cats for several years now. But Capramin, I'm also going to talk about that more recently in the UK has an authorization for support of appetite.
And so I'll I'll talk more about it, how it works and how it potentially can be of great value in supporting the inappetent cat. But first of all, just a little bit. More about mirtazapine.
This is something that I think the world of feline medicine it's probably, probably been using for, I'm going to say 15 to 20 years. I don't know who first discovered that that this, this product was an effective appetite stimulant in cats. Mirtazapine interacts with a number of receptors, some of which I've included on this slide, and some that I have not included on this slide, but.
The impact on cats is that it has some anti-nausea impact, a little bit of antiemetic impact, and it is also appetite stimulating. And as I've mentioned, we now have this transdermal preparation that's been authorised for a number of years and is very effective. It's been studied in healthy cats and also cats with chronic kidney disease orally and also transdermally.
And the general dose is 2 milligrammes once a day for cats that don't have any renal or hepatic issues. But a dose reduction generally suggested for your, your kidney and liver cases, 2 milligrammes every other day, every 48 hours. Although some kidney cats will tolerate it once daily, but I would certainly start every other day, before, trying that out.
And, generally well tolerated at those doses. So adverse effects, I always warn the owners about vocalisation and agitation, and my description of that would be that in extreme cases, the cat will be meow, meow, meow, following the owner around, so they might eat, but they don't sit still, they don't seem to settle, they don't want to sleep. This is something that is, I think, pretty rare, with mirtazapine at the doses quoted on this slide.
But occasionally in, in, some more fragile cats you, you can see this, and I would always tell the owner in advance because these are, side effects that will resolve as, as the product wears off, and they generally are not what I would call medically significant, so they can be a little bit. Disconcerting for the carer, but, generally not of massive concern to the patients. And whilst other side effects have been reported with mirtazapine, again as listed here, overall, it's a very safe and effective product.
If you are interested in doing a deeper dive into the literature, then a couple of studies just shown on this slide, which would be the two I would probably focus on if, if this is of interest. To you, looking at the, pharmacokinetics and also looking at the impact in terms of, of weight gain. The, the second study being a double blind placebo controlled study, that's evaluated this product.
Miritaz has an authorization just to be used for 14 days, and that is, you know, a limitation in terms of its, its utility for many of the patients that, would benefit from appetite support. But that's strictly speaking is, is its authorization currently. And of course, being a transdermal product, it's really important that we do explain to owners that they need to wear gloves when applying it to the patient.
Although the leaflet shows a gloved finger adjacent to the box being being used and a line drawing on, on the finger. Actually find as per the video on the slide just now, easier to draw a line on the box, wipe the line off, and then you have a little blob of mirrortaz, which is much easier, I find, to spread on the ear than this long line, which sometimes is longer than the cat's pinner. But perhaps that's just me.
So in terms of dose recommendations, it's, it's 2 milligrammes once daily for, for the majority of cats, but every, every other day, forgive me, in cats with CKD or liver disease, although, as I say, some CKD cats will tolerate it daily. So, if you need more appetite support and the cat is tolerating the product, then, then that can be done, but again, that's, that's your clinical decision, off, off licence, recommendation. And we alternate which ear is used just to, to minimise any possibility of, of irritation with the, the product being applied to the skin of that, the hairless surface of, of the pinna.
So what about Cara Mollin? So this is in the UK Allura cat. In North America, it's Allura, I think possibly in Europe as well, hence this Packshot, which is, is not going to be the same as the product we will have available shortly in the UK.
And this is a very clever product in that Caramrellin is a ghrelin agonist and ghrelin is the hunger hormone. So it's produced in the gastrointestinal tract when the stomach is empty and it signals to the brain that you need to eat. So it's a really nice sort of clean mode of action, if you like, in terms of stimulating appetite.
Also does have some interactions elsewhere that are anabolic, so, growth hormone release, via the pituitary stimulating IGF-1 production in the liver and that's leading to, weight and muscle gain, which is, which is a positive and potentially as well some, certainly some, thoughts that this does have some anti-inflammatory immunomodulatory impact as well. It has been authorised in some countries, including the United States for I think a few years now. I'm trying to remember when I first used it, but I, I have obtained it under a special import certificate to use in my own patients here in the UK.
And there is also a dog product called Entice, which is a much nicer name for an appetite stimulant, but obviously the dog people stole it. So in terms of dosage, it's once a day, 2 milligrammes per kilogramme. It's the cat's product has a vanilla flavour.
About 20% of cats do experience drooling on administration of this product, and this is thought to be because of ghrelin receptors in salivary tissue. In my experience, this, this drooling is, is not generally very dramatic at all. The cat can just look like it has a moister mouth, to be honest.
It's not something that I would describe as, as, as, as too disconcerting. But again, I have told clients about this because I think it's, it's definitely better to be forewarned. And the company have suggested that keeping the allure in the fridge also improves acceptance.
Ideally we dose it directly by mouth, and that has the best impact, but if need be, it can be given in a small amount of food, although that probably is, is us going a little bit off licence. And then at the bottom of this slide you can see, just a sort of snapshot really from a published study looking at Caramorellin in cats with unintended weight loss where you can see that the treated cats gained significantly more weight. In fact, the the control group lost weight over the over the study period.
And Allura, the Allura cat has a long term authorization for use in cats. So it is authorised for for cats to be on it for months, years, whatever they need, which is, which is definitely an advantage. I think the the authorization in the UK as well will be more broad than just for CKD.
In the United States, it has an authorization specifically for supporting cats with CKD. And of course the combination of food intake and also the anabolic impacts of the product are both appealing from a CKD patient perspective, but many other cats as well that will benefit from long term appetite support. Cyproheptadine, I just wanted to mention very briefly because whilst I pretty much don't use this at all, anymore, if any of you are tuning in to this webinar from outside the UK and perhaps have, don't have access to either mirtazapine or Capra Morell.
Then this might be something that you do have access to and it certainly does stimulate appetite. It's not as effective as, as mirtazapine or capramrein, but I have used it widely in the past. A dose of 1 to 2 milligrammes per cat, can be given once a day or twice a day and generally well tolerated.
it's, I'd I'd say the main disadvantage really of it is, firstly, the frequency that it's needed, and secondly, that it often is not as effective as, the authorised version. So it would absolutely not be my first choice, but just mentioning a case helpful to, to some listeners. And then the other things on the list that original slide of listing appetite stimulants included diazepam, oxazepam, which I would not recommend as an appetite stimulant in cats, mainly because they're not very effective and you have a very sort of, because the muscle relaxant impact, you have a sort of very floppy cats that is, it, it, it's not, I, I think just, yeah, not a very ethical, appetite stimulant to use.
Way back as well, there were concerns about idiosyncratic, hepatotoxicity in cats receiving diazepam. I think there is some debate as to whether that that was the case from that original data, but nonetheless, I think the appetite impacts of diazepam are just not very good. The cats tend to just faceplant into the food but not actually ingest very much of it.
B vitamins, well, I would say if you can assess B vitamins in chronically inappetent cats, that is very helpful. But if assessing them is outside the budget, but you can afford supplementation, then that, that certainly is, something that I would recommend. Whether or not, you know, B vitamin supplementation.
Per se is stimulating appetite. I, I think probably not, but certainly if the cat does have low B12 levels, then poor appetite may be a consequence of that. So ensuring that their, their B vitamin levels are topped up is probably no bad thing.
Steroids often do increase appetite, but the reason that they're crossed off the list here is because they are very profound medications with potential for side effects, but also importantly in your patch that you don't know what the cause of the poor appetite is, the steroids may well mask your ability to do so by their potent anti-inflammatory impact, so they would not be a good choice. Anabolic steroids, I haven't used for a very long time, in the, the context of, of supporting appetite. Excuse me, because I didn't find them terribly effective.
But, but some of the, my older colleagues, including myself in this as well, may, may have more fond memories of using anabolic steroids and kidney cats and finding them helpful from an appetite perspective. But I, I really think that the authorised products are far, far superior. And then lastly, progestogens are crossed off the list really because whilst they can increase appetite, they have a very bad side effect profile, diabetes, mammary neoplasia, for example, so we definitely don't want to go down that route.
So what are the indications for using an appetite stimulant? Well, it's really important that we don't just reach for these in every inappetent cat, that we do fix whatever fixable things we can do. So treat the pain, treat the nausea, .
Manage the all of the fixable things, correct that dehydration, correct that hypokalemia, before you reach for that appetite stimulant. But after you've done those things, certainly they can be helpful for both inpatients and outpatients. Also for, for changing diets.
So cats that we want to encourage, for example. It might be a gastrointestinal or a dermatology case where we want to feed that cat an exclusion diet. Sometimes an appetite stimulant can support us to, to change that cat onto a diet that is not familiar and perhaps not their first choice.
But they, they can be helpful in that scenario. So the otherwise healthy cat, shall we say, . Definitely very helpful short term, during our diagnostic workup, but long term in many cats with with chronic diseases, thinking again of of cats like that have chronic kidney disease.
So a lot of different situations in which they can be extremely helpful. And so, in my clinic at the moment, I'm using a lot of Miritaz, short and long term with in and outpatients. Obviously the long-term use is off licence because it is only authorised for 14 days.
But there are many, particularly older cats with, with chronic kidney disease that have, you know, really only kept going as a result of, of having, good appetite support. Also can be very helpful, in, in other cats really just while we're trying to work out what the cause of their poor appetite is. Sometimes for those, what I would call it, you know, the funny blips, the cat that's just a bit unwell but bounces back relatively quickly, but we want to help stimulate appetite.
So we can, again, this is, I'm sure considered off licence use of the product, but, I will sometimes dispense Miritaz into a 1 mil syringe. And 0.1 of a mil is our 2 milligramme dose of mirtazapine.
So that's what's in the syringe there and when you squeeze that out onto the line, it's a bit of a bumpy line, but you can see that that corresponds with that. So that's potentially a dose that the owner can go home with. I've used less Alluricat because up until January of this year or perhaps December of last year, but very, very recently, I'm recording this in February, it wasn't authorised in the UK so I was obtaining it for named patients using a special import certificate.
Nonetheless, we have used it, I would say, you know, a reasonable number of times in the hospital, and, we have used it in some short term situations as well. So, some of the cats that have had, you know, very treatable issues but have just, not been, recovering in terms of their appetite quite as quickly as we would like. We have used it in that context.
So this little cat here, I forget precisely what, what his, Clinical complaint was now, but, he's having his auricat on the left. And then I didn't return to the ward soon enough really in terms of witnessing his eating because the second video, which I'll click play on, it just, this came after he'd, I think already eaten a pouch of Felix, but he was still sort of troughing away. So quite a nice, you know, immediate, impact.
This is him eating about, I'm gonna say 40 minutes, half an hour, 40 minutes after he'd had, the Allura cat. On the right-hand side, there's a picture of one of my patients that had an not common but it does happen sometimes a reaction to Miritaz. So you can see the erythema, some ulceration on the underside of the ear flap and that has necessitated withdrawal of that therapy.
So that's another situation when we have used Allura so far. But now that it does have an authorization, and I think shortly will be available via our routine wholesalers, I'm, I'm looking forward to using it in more of those long-term cases that would benefit from the anabolic impact of, of the allure as well as its appetite support. We'll look forward to really seeing what progress we get with this, this new and exciting product in, in the coming months and years.
Conversely, we want to not use an appetite stimulant in some situations. So cats that are actively vomiting, that are severely sick, that are still in pain, that have lis, these would all be examples of situations where, where we want to, avoid using an appetite stimulant. We really need to sort these issues out first.
And on their own, appetite stimulants are not always enough. So there are situations, plenty of situations where, appetite support is initiated, but it's not enough to really get the cat back and eating again. And this is where assisted feeding or tube feeding really comes into play.
Syringe feeding, in my book is, is generally a big no no. The nurse in this picture just syringing a little bit of water into the cat, so not syringe feeding it. However, syringe feeding, is generally very poorly tolerated, but it's also usually, I would say, impossible to achieve a full nutritional, support via syringe feeding.
If we think of that. 0 kilocalories per kilo requirement per day. A 4 kg cat needs about 200 calories.
That is 200 mL of most of our liquid diets. It just isn't possible to syringe that into the cat and for the cat to tolerate it. And a big risk of it being counterproductive, leading to food aversions, also a big risk of aspiration.
So this is something that I'm generally very, very against. Occasionally I have, have owners who, you know, potentially the the the breeders who are insistent that they can provide this sort of support at home. But often we have a, you know, really stern sort of words and discussion before, I would, really give any sort of blessing for them to, to continue to do that.
The main tubes that we're going to place from an assisted feeding perspective are nasoesophageal feeding tubes and esophagostomy feeding tubes. And each of these does have their own pros and cons and situations when when one is an advantage over another. The main advantage for the nasal tube is that you don't need to sedate or anaesthetize the cat to place it.
So for cats that are really, really ill, we can place one of These and we can start feeding. And if the nutritional demands require tube feeding for a long period of time, we can get them into a better place so that they're then well enough to have that short anaesthetic for an esophagostomy tube, for example. So very helpful for that.
Also, if you do see very severely constipated cats, then you can place a nasal tube to administer laxative solutions. So the PEG 3350, Protocols which are very effective in clearing severe constipation without the need for a general anaesthetic and clear out also helpful prior to endoscopy if you're doing colonoscopy to clear the colon. So, there is a, you know, good rationale in being confident and competent in placing nasoesophageal tubes.
From a feeding perspective, they are not very popular with cats because they do have to wear some sort of a collar to to protect the tube. They also have a very small lumen, so you can only use liquid food in them, certainly don't risk anything remotely lumpy. So they tend to be really just good for for short-term support.
Quite common for the cat to have a little bit of ocular discharge the same side, as the, the tube is placed as well. So in terms of your your equipment for this, you need a nice soft, flexible tube, polyurethane or silicon tube between 4 and 8 French gauge, some lubricant jelly, some topical local anaesthetic. I use the one that the ophthalmologists have in little single use, .
Dispensers, then an empty syringe, a syringe that has some sterile water in it, some suture material, or, glue and tape, some gloves for yourself, and a collar, and of course your cat. This is the model with ill for this. So we start by locally anaesthetizing the nostril.
So just put a few drops onto and inside the nostril. If you are right-handed, you will generally find it easiest to pass the tube via the left nostril. So that's as shown in this picture.
So you put a few drops in, wait 30 seconds or so, put a few more drops in. Usually within a couple of minutes, that nostril is nice and numb. Whilst that is going on, you can measure your tube.
With our feeding tubes in the UK we tend to, terminate all of them in the oesophagus, but strictly speaking, the the soft, nasal nasal tubes that we use, we can terminate in, in the stomach. And if you have a patient with, with gastriccilis, that can be an advantage because then you can aspirate, those contents, and before, feeding the cat. But we do tend for most of the time, the, the tradition here has been just to terminate all feeding tubes, in the oesophagus.
So we measure typically to the 8th to the 10th rib and put a marker on the tube. Then lubricate the tube and then you want to hold the tube as far away from the tip as you can whilst still maintaining some control over it. And the reason for that is really because the cat normally might move the head slightly when you place that tube.
And if you hold it too close to the tip, then you'll just find the cat is going, you know, the tube is going in and out of the nostril. Whereas if you have, if you're holding it 4 to 5 centimetres away, you can sort of launch a length of tube, through the nostril, so far enough so that if the cat does move a little bit, it doesn't come out completely. You eventually immediately.
And then once you've passed it, and you're comfortable that, you're, you're in roughly the right place, you can have a nice little pause. The cat often is not bothered by having a tube coming out. It's obviously still a bit locally anaesthetized.
And then you can check your, your tube placement by firstly aspirating, and you should encounter a vacuum, so there should be no, Lots of air that are coming back through that, and then you can inject some sterile water and you should either see nothing or perhaps see the cats swallow or perhaps hear some gurgly sounds in their stomach if you are listening with a stethoscope. I would say I don't routinely check tube placement, particularly for cats that are. Very conscious and normal, in terms of their neurological function, but if ever placing these under sedation or in a debilitated cat, I would always confirm placement radiographically because those cats obviously can be more vulnerable, to the, the tube going down into the trachea.
So if in doubt, do check tube placements, these, all these tubes will be visible radiographically. And then once you're happy with your tube position, you can then fix the tube in place. So, this is an old set of photos of mine.
I don't use the, the glue method anymore, but that for a long time was what, what I did use. I, I now tend to, to mainly suture, which is very well tolerated and you don't get the sort of, hair burning off bald patches, for the, for the cats after the glue experience. And then ideally a soft collar as well that's comfortable for the cat to wear and you can start feeding straight away.
Before we move on to talking about feeding, we'll just talk about placement of esophagostomy tubes. I'm sure many of you are placing these. They're very, very popular in practise now with good reason.
They're generally really straightforward to place. They can stay in for Long period and their diameter is much larger, so it means that you could, you've got a little bit more flexibility as to what you can feed. You're not limited just to the liquid diets.
The cat can still eat voluntarily. They tend to be much better tolerated. So, the cat that, was getting a feeding tube in, in this series was a cat called Merlin, who had, nasty herpes.
He had tongue ulceration. He had, you can see a lot of salivation in that picture on the left. And he He was dropping food.
He was really not, not coping with eating at all. So although he was quite keen to make a go of eating, it, it just, it just wasn't working for him. So placing a feeding tube, absolutely, the right thing for him.
Placing a feeding tube does need an anaesthetic, so that is one of the downsides. And, there are some potential complications as well. So dislodgement, cats, you know, vomiting the tube up, stomocyte infections are, are possible.
So it's, it's really important to be as clean as possible in placing them, but especially mindful in cats that are either cancer patients or on glucocorticoids in terms of a higher risk of stomocyte, infections. The equipment you need for this, is, again, your nice soft tube, 10 to 14 gauge though this time. Really important that these do terminate in the oesophagus because they're bigger tubes.
You can't have these finishing the stomach because they just will be too irritating to the cat and will cause it to wretch and vomit. So really important they do terminate round about the 8th to the 10th rib. Sometimes cut the, the tip of the tube off to, to reduce, blockage depending a little bit on, on the tubes that's, available at the time.
And you can use your, your marker pen obviously to mark, where you think your, your tube should be coming out. And then you want some curved forceps. things, your sterile kits, essentially, your drapes, your scalpel, you still need a little bit of lubricant gel, ideally from a passing a tube, through the mouth perspective, and then suture material and a dressing.
So we usually place these on the on the left side of the neck because that's the side where the oesophagus is, is, present. It it's not impossible to place on the right hand side if there is an issue on the cat's left neck. So that, that certainly can be done.
But generally we would do, place the tube so it's coming out of the left neck. So this is the area that we want to clip and prepare. And then once you're, you're clipped and prepared, you have a colleague pass the curved forceps through the cat's mouth, down the oesophagus, so that they're sort of halfway between, the, the jaw and the thoracic inlet.
And then push the forceps, the curve of the forceps outwards or uppermost towards you, essentially, so that the skin is tented over those forceps and then you as the surgeon. Well, me as a sort of surgeon in this, situation, not normally call myself a surgeon at all, but then I cut over those forceps and then you can gently winkle them through and create a bit of a hole, and then you will place your feeding tube into the jaw of your forceps. Not really as shown in this photo, but it's, it's so hard getting photos of these moments in, in practise, but ideally you want your tube in line with the jaws of the forceps, so that's, I'm sure we would have, had to reorientate this because otherwise it's a bit of a you know, tricky one to pull back through that small incision, which essentially goes through the skin and through the esophageal wall.
And then you pull that tube through that incision and then keep pulling until the tube comes through the mouth. So you end up with something like this, obviously different, different tube, where you can see the tube is going through the skin into the oesophagus and then the wrong way up the oesophagus, as in coming out of the mouth. And then the only fiddly bit is really tends to be this bit where with a little bit of lubricant and long fingers, plus or minus using some forceps, you need to reorientate the tube so it is facing the right way.
So essentially push it down that oesophagus and often if you just jiggle a little bit with the the the tube that is exiting the neck, you'll then feel a, you know, a prang as that tube then flips to facing the right direction. And then you can take some radiographs to check your, your tube positioning. So, the left hand picture, that's where, where we want our tube to be placed, and I would highlight when you're taking these X-rays, always include the exit point of the tube.
So you can see that there's, I mean, this, this cat is intubated. There's obviously no. Overlap with with the trachea, but also you can see that the tube is going straight down.
Sometimes these tubes are so beautifully soft and flexible. They're very good at doing a sort of loop the loop in the proximal oesophagus. So make sure you include all of the tube in your image.
And you can see then with the, the top right image that that tube is going too far. It's into the stomach, it's gonna cause a lot of irritation. So that is a no.
We want to back it up so that it is more like the, the 8th to the 10th rib. That is fine. And that's where we then can, re-prep that area, so the tube exit point, to clean it again, having taken your X-ray and moved the cat a little bit.
And then suture in place with a with a sort of your Roman sandal suture either close to the, the tube exit point or Danielle, as shown in her picture on the right hand side, likes to just suture through the periosteum of the wing of the Atlas to anchor that tube, but not to have sutures too close to that tube exit point. She also likes these bio patches, chlorhexidine or, povidoniodine impregnated patches. But, any sort of light dressing and, and, you know, nice wound care, is fine.
And then you can just bandage with your, your, soft band and your vet wrap, not too tight, of course, or you can get these very posh kitty collars that have Velcro attachments and owners quite like. So last decisions of what to feed and how much to feed, the easiest things to feed, to use are the liquid diets, and, I use a lot of the Royal Cannon food because it is just so easy. They have a renal formulation as well as a recovery formulation, and it is one calorie per mal, so it makes the maths really easy, but there are a number of options, a number of other products that that you might prefer, and it's absolutely fine.
The next step, of course, is to To calculate what are the, the cat's energy requirements. So calculate their RER, and Merlin actually at this time, there was a bit of an availability issue with the, the Royal Cannon diet. So we used, Hill's AD to which we added water and mixed thoroughly, again, getting about 1 calorie per mL.
And then what we usually do is start on day one with a third. Of the nutritional requirements spread into 6 meals. And day 2, we increase that to 2/3 of the nutritional requirements, and day 3, increase that to the full requirements.
So, day one, you're having small meals with, with a flush of, of water. We usually top up the, the total volume that we're going to be giving, which is 180 mLs. Just with water, so you're still giving the same sort of size of meal on day one to day 3.
It's just that it's mainly water on day 1 and it's, it's, pretty much all food on day 3 with just a little bit of a flush either side. We can still offer food voluntarily, so the cats with the O tubes, they tolerate them well. You can see this a few days later, Merlin's feeling more comfortable.
It's still struggling a little bit, but you know, it's, it's definitely things are on the mend and, and similarly, cat on the right hand side is a, a, a patient with FIP that needed it, tube feeding is now feeding, feeling a lot better and eating voluntarily. So in summary, this is a very frequent problem that we're presented with. We ultimately do want to know what is the cause of the poor appetite so we can support that in a very targeted way.
But, there are many patients with, with chronic illnesses that need long-term appetite support, and also many cats that just need short-term appetite support whilst we work out the cause of their poor appetite. We don't want to just assume we, we can give appetite stimulants to them and that will solve the problem. We need to make sure that we do correct things like dehydration, hypokalemia, pain, acidosis, nausea, etc.
Etc. So find all the fixable things that we can, then reach for the appetite stimulants. Mirtazapine is the, the main product I've used up till now because it is the has been the only authorised one in the UK.
So Capramin now, Euricat is authorised and I will be using it, more routinely in my patients now that I don't need a, a special import certificate. So that is, is gonna be very helpful, and also with its, anabolic impacts as well. It will be good to see what, what extra benefit we can achieve with that.
And of course for those patients that need assisted feeding, it can make all the difference to their recovery. So I hope that's been helpful. Please also do consider visiting my website where you can find lots of free to access, resources and I am happy to be contacted as well if you have any questions or if you, if you do want, a PDF of, of slides, then please do get in touch but just to tell me when you're listening to, to this webinar and where you're listening to it so that I, I can identify the right presentation for you.
Thank you once again for, for selecting this webinar. I really hope that you've found it helpful. Thank you.
