Feeding tube placement

Naso-oesophageal Tube placement - Equipment (image of NO tube)

• Soft rubber (preferably silicone) nasogastric tube

• Local anaesthetic drops (used in the eye) - proxymetacaine

• Water-soluble lubricant

• Gloves

• Tissue glue

• Elastoplast

• Syringe and sterile water

• Pen

Naso-oesophageal tube placement

1. Measure the tube between 7-9th rib and mark the length

2. Administer local anaesthetic into the nose

3. Insert the feeding tube ventro-medially into the nostril

4. Check placement

5. Secure in place

Naso-oesophageal tube placement - Measurement

Make sure the tube is sat in the oesophagus not through the pylorex sphincter - can get reflux of stomach acid

Mark with pen or tape

Naso-oesophageal tube placement - Local anaesthetic

• Local into the nose → Tilt head back with nose towards the sealing

• Goes down the nasal cavity

• Wait for this to work (5-10 mins)

Naso-oesophageal tube placement - Aim vento-medial direction

• If there is resistance, stop and try again

• Swallowing indicates correct placement

• Once the marker has been reached, check the placement

• Draw back with empty syringe - negative pressure = in oesophagus, instill sterile water

• If in the wrong place = coughing

Securing naso-oesophageal tube

• Comfortable - tape not interfering with vision

• Can use tape, glue or sutures to hold in place

Oesophagostomy placement - Equipment needed

• Anaesthetic equipment

• Clippers

• Surgical scrub/spirt

• Long curved arty forceps

• Scalpel blade and handle

• Suture material, needle and needle holders

• Tube of suitable size

Oesophagostomy feeding tube placement

• Surgically prep the area - measure the tube

• Measure the feeding tube to the 7th to 8th intercostal space and mark the length

• Placed curved artery forceps into the mouth and down the oesophagus - incise over the end of the forceps

• Grip the end of the feeding tube with the forceps through the incision and draw this out through the mouth

• Redirect the feeding tube down into the oesophagus until it reaches the marker made

• Secure in place with a Chinese fingertrap suture

Oesophagostomy placement

• A ‘special vet’ is available for use costing around £200; Van Noort Technique

• The Van Noort set makes the procedure easier as the tube is introduced into a sheath directly into the oesophagus in the right direction from the start

• This means it doesn’t need redirecting from the mouth

Gastronomy placement

• Patient positioned in right lateral

• Endoscope used to to into the stomach - pushed against the stomach wall and light seen externally

• Placed on the left-hand side

Jejunostomy tube

• Not frequently used

• Used where the upper GI tract needs to be bypassed

• Needs to be on a constant rate infusion (CRI) as no holding capacity in the jejunum like there would be in the stomach

• Must be a liquid diet

• Suffer from diarrhoea with this as its not fully digested, difficult to meet energy requirements

• Minimum 4-day placement

Feeding tube care

• Patient must wear a buster collar

• Care of stoma site

• Flush the tube before and after each meal

• If blockages - flushing with carbonated drink or flush and suction with warm water

• Keep tube clean

• Ensure correct RER calculated

• Gradual feeding 1st 3 days

• Ensure food is appropriate and warmed or at room temperature

• Do not allows dried food to accumulate around the opening

The feeding tube will be dressed with a non-adhesive dressing, this needs to be ..

Changed daily and cleaned with chlorhexidine - wear gloves and hand hygiene

Why is flush used when caring for the feeding tube?

• Check the placement

• Prevent blockages

• May need replacing

We should ensure that the food is the correct consistency to put down the tube, it may be necessary to add more water to some diets when using smaller tubes. However, what must be taken int account if doing this?

The loss of nutritional valve when adding more water, making more meals necessary per day to give the patient the correct RER

Complications

• Tube obstruction

• Premature tube removal or dislodgement by patient

• Food contamination

• Vomiting

• Diarrhoea

• Site infection

• Peritonitis

• Electrolyse changes

• Refeeding syndrome

Refeeding syndrome - patients at risk

• Anorexic >3-5 days

• Metabolic condition (diabetic ketoacidosis or hepatic lipidosis)

• Metabolic disturbances due to nutrition being reinstated

Refeeding syndrome

• Get metabolic disturbances due to reinstitution of nutrition

• Change from protein digestion (catabolic state) to carbohydrate digestion (anabolic state)

• Shift of electrolytes leading to clinical signs

• Go from protein digestion for energy - catabolic state to carb digestion - anabolic state

• Releases insulin and causes electrolytes and glucose to shift from extracellular space to intracellular space - shift of electrolytes

• Muscle weakness, cardiac arrhythmias, respiratory depression, haemolysis and death

How to avoid refeeding syndrome

• Recognise ‘at risk’ patients

• Do not exceed RER → feed 1/3 day one, 2/3 day two and full amount day three/four. Monitor patient closely!

• Feed high fat, low carb diet is patient has not eaten from more than 5 days

• Monitor phosphorus, potassium, magnesium and PCV/TS twice daily

• Supplement electrolytes if needed (IV or oral)

• Monitor patient closely

Parental nutrition

• Parental nutrition is the provision of an animals nutritional requirement intravenously

• It use is becoming more common in referral veterinary hospitals

• Usually use a central line

• Central catheter is used i.e. Jugular catheter

• Possibility of septicaemia so good sterile catheter care is essential

• Good care of catheter site and environment needed - food prime for bacterial growth is contaminated

If the patient is on parental nutrition , what must they have done?

Blood samples need to be taken tice daily perhaps more often depending on the patients condition and checked for blood glucose, acid base and biochemistry

Partial parental nutrition

It is difficult to meet the total energy requirements, so often Partial parental nutrition is used rather than total parental nutrition

What is parental nutrition comprised of?

Solutions of sugared, fatty acids and amino acids are used all of which are highly osmotically active so they can only be ‘tricked’ in - must be on a CRI