A while back I recorded a podcast on nutrition in sick animals with Dan Chan DACVECC DACVN, Head of Emergency and Critical Care (ECC) at the Queen Mother Hospital for Animals, Royal Veterinary College, UK. The podcast is linked to at the end of this blog post. One of the things we discussed in that podcast was the use of syringe feeding.
I recently received an email from an RVC graduate who is now working in practice in which she wrote:
“I had a question after listening to the podcast 'Nutrition in sick animals'. It is about syringe feeding, the hospital I currently work in routinely syringe feed, being an RVC graduate I am on the fence in regards to this issue after being taught at the QMH not to syringe feed.
My question is in certain circumstances I can see why syringe feeing can be useful and I was just wondering how the QMH overcome these situations without syringe feeding.
My main example is if a patient in the hospital is too nervous or sometimes scared to eat, you have tried hand feeding and encourage the owners to come in and feed them, possibly even attempting appetite stimulators (e.g. mirtazapine). What would be the next step if the animal still refused to eat? In this instant would placing a feeding tube be the next step?”
To which I replied focusing only on enteral (not mentioning parenteral) nutrition:
“Nice to hear from you and glad you are listening to the podcasts. In answer to your questions, what I would say is the following...
So obviously the reason that one might be considering syringe feeding is because you are worried that the patient is not receiving sufficient nutrition and that this carries potential adverse effects - as discussed in the podcast. Then you have to ask yourself whether syringe feeding is a strategy that will be able to improve this situation as always using a risk/harm-benefit assessment:
- So on the benefit side, it may result in the patient receiving more nutrition; it is also cheap and does not require any fancy equipment or much in the way of skilled training to do - although clearly people need to know what they are doing.
- On the risk/harm side, it is extremely unlikely that you will be able to give the patient their calorific requirement via this route - but you could say, reasonably, "well something is better than nothing".
- But even more on the risk/harm side is the negative experience for the patient: if as you say the patient is already too nervous or scared to eat on their own, will syringing food into them help their state of well-being more than if they just did not get any nutrition? If the patient is really not compliant and requires restraint/forcing clearly this is even worse - but I am sure (most) people would not push it that far. And of course they may not be eating because they feel too ill or nauseous so making them is not very pleasant and they can develop food aversion - as Dan says, whenever having food is a negative experience this is a risk.
- And then there is the risk - albeit I don't think a very big one - of aspiration. And we need to bear contraindications in mind, e.g. facial injuries, inability to swallow etc.
BUT there are certainly animals where one or two episodes of syringe feeding seems to prompt them to start eating on their own - whether it is because they overcome their nervousness or some other psychological or physiological 'block'. And so in suitable cases where all you are trying to do is to see if you can kick-start the patient to eat themselves, then trying this once or twice at a push does not seem unreasonable - but very much on an individual case by case basis bearing in mind everything I have said above about that individual patient's circumstances, what your intended purpose is and what the risk/harm-benefit assessment is.
What I would do if the patient was not willing/able to nourish him/herself adequately would depend on the patient in question...Options:
1. If the patient is doing well in all other respects other than lack of nutrition, then although we understand and support the need for early nutrition, on this individual occasion we may choose to just tolerate the status quo. This would typically be a patient that we anticipate sending home very soon and in which the morbidity was not significant (e.g. say a post-TPLO patient or something like that).
2. Same as option 1. but actually can we send the patient home sooner than we maybe would have otherwise to see whether things improve? This might for example mean a different analgesia strategy to go home with but can we make it happen? Are the clients willing to provide more home care than originally discussed?
3. And yes in a number of cases where nutrition is insufficient and the patient is nowhere near ready to even trial home discharge, feeding tube.
I might be wrong but I imagine there are more patients in category 1. or 2. where you work in first opinion than say at a tertiary referral centre like the QMHA.
Feeding tubes of whatever sort are obviously going to cost more than syringe feeding but there may also be some cost-saving in quicker healing and recovery. Also the vast majority of patients tolerate the tubes and the feeding well. Naso-oesophageal less so than oesophageal/gastric but even so. And placement will require anything from mild sedation to general anaesthesia depending on the tube in question.
Often we will place feeding tubes - especially oesophageal - pre-emptively if the patient is having anaesthesia for a procedure and we anticipate that they are unlikely to eat and nutrition will be an issue. So for example the surgeons might place an oesophagostomy tube when they are fixing fractures in RTA cats on the basis that the benefits of having the tube there outweigh the fact that we may not use it. BUT we also have cases where the patient is eating something on their own but not enough and we can then use the tube to top up their intake.
Does that help at all?”
I am as always very interested to hear your thoughts on this.
The podcast episode in question can be accessed here.
AND if you would like a PDF document entitled Top Ten Tips on Nutrition in Sick Animals derived from this podcast PLEASE CLICK HERE