98 - Feeding Tubes Flashcards
How to optimise coaxed feeding (4)
Warmed
Aromatic foods
Appetite stimulants
Use tongue depresser to place bolus in the mouth
Where should the syringe for feeding be placed in the dogs and cats mouth?
Dogs = Between buccal surface of cheek and molar teeth
Cats = Between upper and lower incisors
Issues with coaxed feeding (5)
Aspiration
Stress
Food aversion
Needs to be repeated
Difficult to meet RER
Which patients can be fed via an OG tube?
Technique
Neonates
Critically ill patients (rarely)
Technique
- Measure last rib to nose
- Lubricate tube
- Advance into pharynx until swallows
- Advance to premeasured discarnce
Why would you choose NO vs NG and visa versa?
NO
- In theory, reduced regurgitation and reflux oesophagitis as tube does not cross lower oesophageal sphincter
- Recent study = no difference in complications
NG
- Avoids malpositioning
- Allows gastric decompresssion
When is NG/NO tube contraindicated?
- Abnormal GAG reflex
- Oesophageal dysfunction
- Coma
- Conditions increasing risk of aspiration
- Persisant vomiting
2 Disadvantages of NG/NO tubes?
- May not voluntarily eat when in place
- Small diameter requires liquid diets
Complications with NG/NO tubes
- Epistatxis
- Dacryocystitis
- Sneezing/Rhinitis
- Premature removal
- V+/D+ due to diet
- Aspiration if displaced into pharynx
- Reflux/oesophagitis
- Prone to obstruction
Technique for NO/NG tube placement
4-5 drops Proparacaine/Lidocaine into each nostril and nose tilted upwards
5-6 French PU/Silocone tube
Distance measured from mid thoracic oesophagus to 7-9th rub makred
Passed through ventral meatus
Once in the ventromedial cavity, push nares dorsally to provide straight path for tube
Maintain head in neutral when enters pharynx
Watch for swallow when enters oesophagus
Advance to predetermined distance
Check in place
Suture to skin/glue to hair close to nostril and then nasal midline just rostral to eyes
Name 4 methods of confirming NG tube placement
- Inject 5-10ml air and auscultate for borborgymus
- Inject 3-5ml sterile saline and check for cough
- Survey radiograph
- Capnography
Indications for pharyngostomy tubes
How long can it be maintained for?
Pathology of the oral cavity
* Infection
* Neoplasia
* Trauma
* Wounds
Weeks- Months
Contraindications for pharyngostomy tubes
- Pharyngeal trauma
- Oesophageal disorders
- Vomiting/regurgitation
Give an advantage and disadvantage compared to NO/NG tubes?
Advantage = Large
Disadvantage = Unwilling to voluntarily eat with pharyngostomy in place
Generally outdated due to O and G tube usage
Complications with pharyngostomy tubes (9)
- Nerve damage (blunt dissection)
- Tube kinking
- Tube placed too cranially
- Interference with epiglottis (coughing, dyspnoea, aspiration)
- Laryngeal obstruction
- Reflux/oesophagitis if enters stomach
- Regurge/vomiting
- Local infection
- Premature displacement
What size and type of tube should be used for pharyngostomy?
Small dogs = 8-14 French
Large dogs = 12-28 French
Type = Silicone or red rubber (soft tubing)
> 14 French can be fed blenderised diets
Technique for pharyngostomy tube placement
Measure to 7-8th rib
Remove blind end of tube to avoid entrapement of food
Placed under GA in either lateral
Finger placed in mouth caudal to epihypod and most dorsal point of pharynx
Jugular raised to visualise and avoid bifurcation between maxillary and lingofacial veins
Incision over finger ~5-10mm long
Blunt dissection using Curved Kelly’s down to finger
Pushed through pharyngeal wall
Premeasured tube passed from oral caviy to distal oesophagus
Flared end passed from oral cavity through dissected region and adjusted so correct length
Assessed on laryngeal exam
Secured with finger trap and dressed with light padded bandage
Flushed with water and caped when not in use
Feed in sternal or standing with head elevated
Which structures should be avoided on dissection of the pharynx when placing a pharyngostomy tube (6)
Carotid
Jugular branches
Vagosympathetic trunk
Hypoglossal n
Glossopharyngeal n
Salivary glands
Advantages and disadvantages of O tubes
Advantages
- Low aspiration/laryngeal obstruciton risk cf pharyngostomy
- No concern for peritonitis through premature removal cf G or J tubes
- Easy to place and large tubes can be used
- Can be removed any time
Disadvantages
- Difficult to place in obese/very large patients
Contraindications for O-tubes
Oesophageal stricture
Megaoesophagus
Vascular ring anomalies
Oesophagitis
Oesophageal neoplasia
Name 4 Methods of O tube placement
- Manual (Unassisted) Transoeophageal Advancement
- Needle assisted percutaneous placement
- Tube assisted percutaneous placement
- Percutaneous feeding tube applicator
What is the advantage of manual Otube placement?
Larger tubes can be placed compared to other techique
(12-30 French)
This is our standard technique
Describe the needle assisted percutaneous placement of an Otube
- Long curved forceps placed into midcervical oesopahgus
- Tips of foreps opened slightly
- 14G needle inserted ito the oeophageal lumen between the tips and **directed distally **
- Small catheter placed through the needle into the lumen to the desired location
- Needle left in place or adaptor end of the tube excised for needle to be removed
Needle in place risks damage to the end of the tube
Describe the tube assisted percutaenous placement of an Otube
- Rigid PVC tube with obliquely cut end placed transorally and pressed against the oesophageal wall
- 2-3mm incision made at the proposed site
- 18 G catheter inserted through incision into the lumen
- Needle is removed and tips of carmalt placed in the hub of the catheter and forced through oesophageal wall into the lumen of the guide tube
- External end of guide tube lowered so catheter falls out
- 14G tube with stylet passed down the guide tube and grasped with intraluminal tips of the carmalts
- Carmalts withdrawn and guide tube removed
- O-tube with stylet tip is sutured to the tip of the 14 G transoral tube
- Transoesophageal tube withdrawn, pulling the Otube within it
- Suture cut, O-tube slowly withdrawn until can be directed caudally
- Stylet removed and advanced to position in distal oesophagus
Describe the percutaenous feeding tube applicator method of O-tube placement
Trocar tipped ELD applicator
End of applicator contains sheathed trocar
Placed through oral cavity into mid-cervical oesophagus
Small incision made through skin and SC over tip
Trocar advanced through oesophageal wall and incision
Tip of feeding tube sutured to eyelet of trocar, retracted and removed from mouth
Suture cut and sylet inserted into side hole to faciliate redirection of the tube in the distal oesophagus
When are G-tube contraindicated?
Gastric disease
Persistent vomiting
Oeosphageal dysfunction
Abnormal mentation
Which tubes can be used for G-tube placement
Pezzer
Malecot
NOT foley (tip degenerates in acid)
14-28 French
Pezzer = Normal mushroom tip
Technique for surgical G tube placement
Ventrolateral region of left bodt wall caudal to the last ribs
Kelly placed through musculature to subcut and skin incised
Mushroom tip passed through body wall
Purse string suture placed in proximal half of left gastric body
Stab incision in centre of purse string into stomach lumen and mushroom tip pushed through
Purse string tied
Stomach sutured to body wall with simple continous or interrupted (we use box sutures as per image)
Encircled with omentum
Finger trap to secure to skin
For paracostal - grid approach several cm caudal to last rib, stomach grasped with babcocks and brought to incision
Describe peg tube placement
Right lateral recumbency
Stomach distended
Position guided by endoscopic light
Over the needle catheter placed through skin into stomach
Suture threaded through catheter and grasped by endoscopic forceps and pulled out through mouth
Over the needle cannula placed over suture and tied to G tube
G tube pulled into the stomach out of the gastric and body wall
New suture threaded into the tube as a back up in case dislodged
Pulled through body wall and secured with an external flange
Mushroom tip presssed snugly against the gastric mucosa
Describe the Tube-assisted percutaneous non-endoscopy gastrostomy technique
Angled semi rigid tube placed to level caudal to last rib
Tube palpated through abdominal wall
Flared end pressed up against the stomach and left abdominal wall
Over the needle catheter placed into tube tube lumen
Needle removed and heavy gauge suture passed back through tube and out of the mouth
The rest as for PEG tube placement
Similar technique with metal tube, angled at 45° with flared tip
(See pic)
Describe G-tube placement with a ELD device
Outer cannula
Inner trocar
Placed into stomach to beyond last rib
End of device palpated to ensure no intervening organs are present
Trocar placed from inner sheath and exits gastric, abdominal wall and skin
Suture tied around trocar which is retracted via the mouth
Suture attached to mushroom tipped catheter and dawn back in to the stomach and through the body wall again as for PEG
How are low profile G tubes placed
Obturator applied to elongate the mushroom tip
Lubricated and advanced through fistula
Obturator removed
+/- External skin sutures to secure
Describe the standard surgical approach for enterostomy tube placement
Tube pulled through stab incision at site of approximation
1.5-2cm antimesenteric incision made through the serosa and muscularis of the intestinal wall
Mucosa perforated at aboral end of incision and feeding tube inserted and advanced for 20-40cm
Seromuscular incision closed over the tube with 3/0-4/0 absorbable sutures
Mattress or purse string around the tube at orad seromuscular exit site
Tube secured to external body wall
Alternatively placed as for G tube with purse strings
Describe the Needle-Assisted enterostomy tube technique
Purse string placed
12-14G hypodermic needle advanced obliquely in aboral direction
Advanced sub-serosally for 2-3cm before entering the lumen
Tube advanced through needle 20-30 cm aborally
Second needle passed from skin thourhgh body wall and used as guide to pass tube thorough
Feeding tube passed though bevelled end to exit the abdomen and catheter adaptor placed
Intestine sutured to body wall
Tube secured to skin
Describe how a gastroenterostomy tube is placed
Distal surface of G tube cut off
Enteral feeding tube placed through the lumen
Advanced into the distal duodenum/proximal jejunum
