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Placing nasojejunal feeding tubes in dogs by fluoroscopic technique | VETgirl Veterinary Continuing Education Podcasts

In this VETgirl online veterinary continuing education podcast, we review a new technique of placing nasojejunal feeding tubes in dogs. In critical care, the pendulum has swung to the side of enteral feeding over parenteral nutrition in both human and veterinary patients. However, when so many of our critical patients are vomiting or regurgitating, and the risks associated with surgical jejunal feeding tube placement may not outweigh the benefits, do any non-invasive options for enteral feeding exist? Or is our only option total or partial parenteral nutrition? The critical care and interventional radiology group at Michigan State University College of Veterinary Medicine (Beal at al.) developed a novel technique for placing nasojejunal feedings tubes in critically ill dogs using fluoroscopic visualization and wire guidance. Sounds interesting, right?

In this study, 26 dogs underwent fluoroscopic and wire guided nasojejunal tube placement. These dogs were hospitalized at MSU for various disease processes including parvoviral enteritis, peritonitis, acute kidney injury, and aspiration pneumonia requiring mechanical ventilation. For tube placement, all patients were placed under general anesthesia or heavily sedated in left lateral recumbency after topical lidocaine was applied within the right nostril. A cut-tip red rubber catheter was placed into the stomach; through this catheter, a wire was passed. The red rubber was removed (while leaving the wire in place), and an angled hydrophilic catheter (e.g., Berenstein) was placed over the wire. The wire and catheter combination was then guided through the pylorus and duodenum. Ultimately, the wire was advanced into the jejunum and the Berenstein catheter was removed. You may ask why pass the Berenstein catheter just to remove it? It is because the catheter provides stiffness to allow for passage of the wire through the turns of the gastrointestinal loops. After the wire was well positioned within the jejunum, a cut tip 8 Fr. 107-137.5cm commercial feeding tube was passed over the wire and the wire removed, leaving the feeding tube within the jejunum. Placement of the feeding tube was then confirmed based on injecting a small amount of contrast into the feeding tube and confirmation with follow-up radiographs. In this study, transpyloric passage of the tube was possible in 92.3% (24/26) of patients. Of the 23 dogs that had radiographs for review, 18/23 had tubes appropriate positioned within the jejunum, 4/5 had the tube within the caudal duodenal flexure and 1/5 had the tube located within the ascending duodenum.

So, what can we take aware from this VETgirl podcast? Results of this study show us that practice really does makes perfect, as 100% of patients had successful tube placement within their jejunum using this technique in the second half of the study compared to 60% in the beginning of the study. There was no statistically significant difference in procedure times between the early and late study patients. As for once the tube is in? Post nasojejunal tube placement complications included epistaxis in 2/26 dogs and sneezing in 3/26 with 2 of those dogs having enough sneezing to cause nasojejunal tube dislodgement. 40% of tubes (2/5) that were positioned in the duodenum migrated orally into the stomach or were removed by the patient. For tubes that were positioned in the jejunum, 27% (3/11) migrated but did not move more oral than the stomach. So it’s important to realize that these nasojejunal may become NG tubes after all, while requiring heavy sedation or anesthesia in the process. Once the tubes were in place, patients were fed a commercially available elemental diet via constant rate infusion (CRI) (remember that any patient being fed post-pylorically will not secrete pancreatic enzymes in response to feeding, so the diet used should not be intact proteins, and instead essential and non-essential amino acids, carbohydrates, and fats). The incidence of gastrointestinal complications like vomiting, regurgitation, and diarrhea was the same in this population of patients before and after nasojejunal tube placement, so no major difference was observed.

Sounds great, right, if you have fluoroscopy, wires and catheters? For most of us, we don’t have this available, but it’s nice to know that our patients can be referred to a veterinary specialist for easy jejunal tube placement without the need for surgical intervention anymore!

Know that nasojejunal feeding is an important option for enteral feeding, especially in critical patients that are vomiting or regurgitating. This study describes a non-invasive fluoroscopic and wire guided method to place nasojejunal tubes in a group of hospitalized dogs. Success of post-pyloric placement of these tubes improved with operator experience, which is important to remember when starting to perform this or any image guided procedure – interventional procedures take a lot of practice! Complications with placement and use were mild, and these tubes were used for a median time of 3.3 days for feeding. What about pros and cons of this study? Well, the clinician who placed all of the nasojejunal tubes has over 5 years of experience performing interventional procedures, so the success of and amount of time for placement of these tubes in less experienced clinicians will likely vary. However, if the caseload and equipment is available, this safe technique could be a very useful asset to your critical patients! Another limitation of the study is that, due to the retrospective nature of the paper, standardized intervals of radiographs to document tube position, reason for tube removal, and details about patient tolerance of the nasojejunal tube could not be objectively determined. In conclusion, the use of fluoroscopic and wire guided nasojejunal tube placement in dogs for post-pyloric feeding may be in its infancy, but it is a technique that warrants further investigation and experience, given the importance of enteral feeding in critically ill patients.

References:
1. Beal MW and Brown AJ. Clinical experience utilizing a novel fluoroscopic technique for wire-guided nasojejunal tube placement in the dog: 26 cases (2006-2010). J Vet Emerg Crit Care 2011;21(2):151-157.

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