ESOPHAGOSTOMY TUBE JOURNAL CLUB

Aim

• To identify the nature and prevalence of complications following o tube placement and whether any cat factors influence this 

• Hypothesis was immunocompromised cats and those that had tubes in place the longest would be the most susceptible to infection 

Materials and Methods 

• Case selection 

• placement of o-tube, date of placement, complications, date of removal 

• Exclusion 

• date of removal was not recorded 

• Data collected

• Case signalment

• Body weight 

• BCS

• Dx 

• Date o tube placed 

• Make of o tube, gauge of tube 

• Antibiotics used 

• Presence and nature of complications 

• Whether discharge was present at the stoma site and the date the discharge was identified at the stoma site and the date the infection was noted 

• Culture and in vitro antimicrobial sensitivity profile

• Whether the cat had a systemic infection present 

• Whether the cat had a systemic infection present 

• Whether the cat was receiving glucocorticoids or oncolytic agents 

• Whether the cat was discharged from the hospital with the tube in place 

• The date the tube was removed and whether intentionally or not 

• Whether the cat was euthanized with the tube in place or not 

• Calculations 

• Time from presentation to the referral centre to tube placement (days) 

• Number of days from tube placement to discharge being noted around the stoma site injection (where applicable) 

• Number of days that the tube was left in place 

• Discharge defined as secretion from the stoma site which was culture negative or in which cytology did not identify intracellular bacteria or if no culture or no intracellular bacteria identified defined as a secretion that resolved spontaneously without topical or systemic antimicrobials 

• This was not considered a complication if the only finding identified 

• Clinically relevant infection was defined as signs of stoma site inflammation in which bacteria were culture or in which intracellular bacteria were identified on cytology of the discharge or antimicrobial therapy was necessary to achieve clinical resolution 

• Categories of disease 

• Gastrointestinal 

• Hepatic 

• Pancreatic 

• Traumatic 

• Neoplastic 

• Respiratory 

• Cardiac 

• Urogenital 

• Septic 

• Infectious 

• Other 

• If the cat had more than one o tube placed only the first o tube was included in the study 

Results 

• 248 cats 

• Median age 7 years 7 months 

• Median weight and BCS 4kg and 4 

• Most tubes placed on the day of presentation or the following day 

• Type of tube - surgivet, mila , cook or portex 

• Most common tube 19Fr, 14 Fr 

• 162 cats that survived (162/248 65.3%) the tube was in place for a median of 11 days (range 1-93 days) 

• 78/162 (48.1%) experience a complication 

• 86/248 cats that died  (34.7%) death occurred at a median of 4 days after presentation and 11 of these cats had a complication associated with their o tube 

• Complications associated with having an o-tube in place reported in 89 cats (35.9%) of all cats 

• The most common complication was dislodgement of the tube 

• Entirely removed by the cat 19.1%

• Dislodged by the cat necessitating removal 12.4%

• Dislodge by the cat after repositioning and re-suturing 9%

• No cat had more than 1 complication recorded 

• Infection associated with the tube was the second most complications encountered in the study 33.7% 

• An additional 45 cats had a discharge at the stoma site that was self-limiting and did not necessitate treatment 

• The median time to stoma discharge as 6 days (range 1-62 days) 

• Additional complications 

• Vomiting in regurgitation of the tube 7.9% 

• Tube blockage whether it resolved or not 7.9%

• Individual cat complications 

• Temporary laryngeal paralysis 

• Focal oesophageal rupture 

• Irritation of the tube site despite grossly normal appearance of the stoma 

• Displacement of the tube causing a pharyngeal obstruction 

• Inflamed stoma in the absence of infection 

• Dry discharge at the tube site in the absence of infection 

• Mucoid discharge surrounding the tube 

• Sterile necrosis surrounding the stoma site 

• Vomiting following tube placement 

• Anitmicrobials 

• Given to 167 cats while their o-tubes were in place - 85 before tube placement and 82 after tube placement 

• Remaining 81 cats did not receive antimicrobials while their e tubes were in place 

• A single antibiotic was given to 121 cats while 31 cats received 2, 14 cats received 3 and 1 cat received 4 

• An infection was documented after the placement of o-tube in 30 cats 

• 19 had culture performed of which 1 recorded no growth and was diagnosed on cytology and failure to resolve spontaneously 

• 1 organism in 12 cases E.coli n=5, streptococcus canins or beta haemolytic streptococci  n=2 , Pasteurella multocida n=2 , enterococcus spp n=1 , staphylococcus n=1 , pseudomonas aeruginosa n=1 

• 3 cats has 2 organisms isolated ecoli and enterococcus spp n=2 , Pasteurella multocida with staph aureous n=1 

• 2 cats had 3 organisms identified strep , enterococcus and E.coli and candida spp , enterococcus and e,coli 

• The remaining cat had 4 organisms cultured methicillin resistant staphylococcus ,e coli Pasteurella multocida and Pasteurella pneumotropica

• Mila feeding tubes, cats with a discharge at the stoma site and those receiving glucocorticoids or chemotherapy agents had an increased odds of developing a clinically relevant infection necessitating treatment 

• Cats that died had a decreased odds of developing an infection requiring treatment 

Discussion 

• Complication rate of 35.8% increasing to 48% in cats that survived to discharge 

• Most frequent was tube displacement followed by a clinically stoma site infection 

• No cats died or suffered from severe morbidity related to the tube that was not remedied by its removal 

• Stoma site infection was the second most commonly encountered complication occurring in 12.1% of cases 

• Most common infections involved commensal organisms rather than primary pathogens or environmental organisms E.coli and Enteroccus spp were the 2 most commonly isolated bacteria these are normal commensals of the GIT tract 

• O-tubes predisposes to infections with opportunistic bacteria 

• The normal antimicrobial protective mechanisms of the skin are bypassed once th tube is in place 

• It also creates a connection between the 2 populations of flora that are naturally separated, altering interactions and potentially allowing overgrowth of certain populations 

• O tube will cause local tissue irritation, precipitated by chronic micro-movements and foreign body reaction 

• Self-trauma secondary to discomfort or irritation, could cause secondary wounds or damage to the tube , gross or microscopic allowing bacteria to colonise more readily and potentially from antibiotic resistant biofilms 

• It is likely that immunosuppression secondary to underlying disease might play a role in development of infection 

• Administration of glucocorticoids or chemotherapeutic medications was associated with an increased odds of developing a stoma site infection 

• Unexpected finding with a higher rate of severity of infections with glucocorticoid or chemo - hygiene 

• Mila tubes higher odds of development of an infection 

• Gauge of tube did not influence the odds of infection 

• But view with caution as tube manufacturer and gauge were not recorded in all patients 

• Cats that died were at a lower risk of o-tube complications including stoma stie infection - cats died after a median time to stoma site infection but median time for infection was 6 days 

• The length of time that the tube was in place whether the cat was discharged home with the tube still place and the underlying disease process were not associated with an increased odds of infection 

• Limitations 

• Retrospective 

• Lack of standardization of tube placement 

• Lack of record keeping 

• Stoma site care not standard 

AIM 

• Compare continuous to intermittent feeding at delivering prescribed nutrition in hospitalized canine and feline patients 

• Because intermittent feedings allow for fewer interruptions of nutrition due to diagnostic and therapeutic procedures out hypothesis was that intermittent feeing would result in greater delivery of prescribed nutrition than continuous feeding 

• If true this difference could later the way clinicians prescribe feedings to their patients 

• The secondary aim was to determine the frequency of GIT complications associated with enteral nutritional support

Materials and Methods 

• Dogs and cats with NE and or NG tubes between 2002 and 2007 

• Inclusion if NE feeding tube placement was documented in medical record and the tube was used for enteral nutrition for a min of 24 hours 

• 24 hr periods of nutrition were recorded for each patient 

• 24 hr periods in which the patient voluntarily ate , received concurrent parental nutrition  or received both intermittent and continuous feeding were excluded 

• Other type of feeding tubes e=were excluded because the caloric content of the food delivered through these tubes was often impossible to determine from retrospective review 

• All patients received 1 kcal /ml veterinary liquid diet thru the NE tube 

• Date - age, species, total days in hosp, total days of enteral nutrition provided via NE, intermittent or continuous method of feeding and frequency of GIT complications 

• The number of calories prescribed for each 24 hr period and number of calores delivered for each 24 hour period were calculated from the medical record .  any interruption or discontinuation of enteral nutrition was recorded 

• The % of prescribed nutrition delivered (PPND) was calculated as a number of calories delivered in 24 hr period divided by calories described 

• IF the patient received nasoenteric feeding for >1 day then the mean PPND per day was calculated on a per patient basis 

• The number of 24 hour periods in which PPND equalled 100%  was also recorded 

• Frequency of gastrointestinal complications was calculated on a per patient basis 

RESULTS 

• 91 animals , 205 days (24 hr periods) of NE feeding 

• 37/91 Dogs 40.7%

• 54/91 cats 59.3%

• Dog age range 2months to 14 years median 8 years 

• Cats 1 yr to 16 years with median age of 8.5yr 

• Median number of total days in hosp for all patients was 8 days 

• Median number for enteral nutrition was 2 

• 56(61.5%) of the 91 patients were fed continuously and 35(38.5%) of 91 were fed intermittently 

• 33/54 cats were fed continuously, and 21/54 cats were fed intermittently 

• The median PPND was not significantly different between patients fed continuously 99.p% and patients fed intermittently 

• Feline patients received a median PPND of 100% range 47.9-133.1% 

• Continuously fed cats received 100% 47.9-100% of prescribed nutrition and intermittently fed cats received 100% (62.5-133.1% of prescribed nutrition 

• Continuously fed animals received 100% of their prescribed nutrition which was not significantly different from intermittently fed animals who received 100% of their prescribed nutrition on 51 out of 87 days (58.6%) 

• 29% of patients vomited during enteral nutrition, 26% had diarrhoea , 5% of patients regurgitated 

• 30.7% of patients that experienced vomiting during enteral nutrition were vomiting in the 24 hours prior to starting enteral nutrition 

• 50% of the patients with diarrhoea recorded had diarrhoea in the 24 hours prior to enteral feeding 

• No patients with regurgitation during enteral nutrition had regurgitation prior 

• The frequency of GIT complications in each grp species and method was not significantly different 

• Both grps has 28.6% vomiting and continuously fed grp had 25% Diarrhoea and the intermittently fed grp had 28.6% diarrhoea 

• 7.1 % of continuously fed grp had regurg and 2.9% of intermittent fed regurg 

• Dogs had higher incidence of regurg and diarrhoea than cats 

• All 5 patients that regurg were dogs 

• Out of the 205 days of enteral nutrition the delivery of nutrition was stopped 26 times due to vomiting 

• Regurg interrupted feeding twice and diarrhoea once 

• Other reasons for stopping feeding include dislodgement of naso-enteric tube, surgical procedure, diagnostic procedure , high residues , clogged tubes, blood transfusion , dyspnoea, hypersalivation 

DISCUSSION 

• Study shows that suggest that the method of nutrition delivery via naso-enteric tubes does not affect the PPND to veterinary patients 

• In this study the subjects received a median of 97% of prescribed calories regardless of the feeding method used 

• No difference in GIT complications rates are found between patients fed continuously and patients fed intermittently

Aim 

• describe the use of feeding tubes in a population of sick cats with appetite disturbances 

• recorded the underlying disease process type of tube used (NE or O tube) and the associated complications 

• report the clinical outcomes (survival and return to voluntary food intake) in this population 

Materials and Methods 

• 2015-2020 for at least 24 hrs 

• Recorded signalment, duration of anorexia, BW, BCS, PEX , bloods, dx , type of feeding tube , concurrent oral administration of mirtazapine, occurrence and nature of any complications , time from onset of anorexia/hyporexia to presentation at the uni in days , time from presentation at uni to feeding tube placement , time from feeding tube placement to spontaneous return of appetite and total duration of feeding tube utilisation 

• Appetite disturbance was qualified as anorexia or hyporexia 

• Anorexia - complete loss of appetite and hyporexia to partial loss of appetite 

• Return to voluntary food intake refers to as soon as the cat started to eat spontaneously even if the RER was not achieved 

• Cats with voluntary food intake were divided into 2 groups <50% of RER or >50% of RER 

• Disease groups - GIT , hepatic, pancreatic, triaditis , neoplastic, respiratory, cardiac, urogenital , haematological endocrine, respiratory cardiac, infectious 

• Neoplastic if cat could not be entered into the above categories 

• Other if disease not classified, non dx was unknown or if 2 disease processes most likely to contribute to inappetence 

• When body appetite disturbance was <5 days the amount of food provided was progressively increased to reach 100% of RER after x days with x corresponding to the number of days of anorexia 

• When anorexia had been >5 days the RER was gradually increased until full RER at day 5 

• 4-5 meals per day varied with cats tolerance 

Results 

• 112 cats with 118 tube placements 6 cats included twice at 2 visits 

• Median age was 9 years , BW 3.8 kg median BCS 4/9

• 83% had an NE tube placed and 17% an o tube 

• Of the cats with o tube 65% had previously been managed with NE tubes 

• Median time of appetite disturbance prior to admission was 7 days 

• Main biochem abnormalities are increased ALT 65%, hypoalbuminemia 48%, hyperbilirubinemia 59% , anaemia 49% , hypokalaemia 41% and hyperglycaemia 41% 

• Main disease GIT 13.5%, hepatobiliary 11% and upper urinary tract in 11% 

• BCS was significantly lower in NE tube grp 

• NE grp -digestive 15.3% and upper urinary tract 12.2% 

• O tube hepatic 50% and upper resp tract 30% 

• Complications overall occurred in 18.6% 

• NE complications 15% 

• O tube complications 43% 

• O tube after NE tube complications 31% 

• Spontaneous return of appetite before feeding tube removal occurred in 56/118 cases 47% including 50% cases in NE grp and 35% in the o group 

• Median time before return to voluntary food intake 3 for whole population NE was 3 days and O tube was 14 days 

• The amount of food of ingested was recorded in 48 cases for the return of voluntary food intake 

• <50% in 46% and >50% in 54% 

• 33% of cases received mirtazapine but not associated with return to voluntary food intake or amount ingested 

• The decision to remove the tube occurred in 75% of cases the other 25% died or were euth 

• Global population time to removal was 5 days , 4 days for NE grp and O grp 33 days 

• Of those 75% of cases with tube removed 98% survived to discharge and the survival rate was 72.9% for the 112  cats included and did not differ between the NE and the o tube groups 

• Survival was similar among disease categories 

• Resolution of anorexia was positively associated with survival 

• Of the 32 cases that survived to discharge that did not experience voluntary food intake before tube removal follow up was available for 12 37.5% return  to appetite 66.7% in median time of 2 days and last 4 remained anorexic 33% - 2 were euth an 2 another tube placed within 72 hours 

Discussion 

• Complications 18.6% of cases 

• Spontaneous food intake occurred in half the population before the tube was removed 

• Large population survived to discharge 72.9% 

• When return to voluntary intake was observed 54% of cats ate >50% RER

• Time before spontaneous food intake was significantly shorter in NE grp 

• Survival did not depend on disease tube type but was positively associated with resolution of anorexia 

• Median BCS and body weight were significantly higher for cats in o tube grp  - hepatic lipidosis?? 

• Duration of appetite disturbance did not alter between groups - more likely tube was chosen over other parameters such as BCS 

• Voluntary eating occurred in 48% of cats while the feeding tube was in place 

• Quantity of food <50% RER 46% and >50% RER in 54% 

• Mirtazapine did not appear to act on qualitative return to voluntary food intake nor quantitively ie <50 r >50 % RER ingested 

• Complications  overall 18.6% , NE 15% - removal most common , o tube complications was 43% - stoma site infection 14.3% and partial dislodgement or complete removal (28.6%)