scott@vtx-cpd.com
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Replying to Christina Frigast 04/05/2025 - 11:36
Hi Christina,
That all makes perfect sense, and I completely agree. Feeding tubes remain underutilised in many settings, even though early nutritional support has clear evidence for improving outcomes and potentially shortening hospital stays. While cost is often cited as a barrier, it rarely reflects the true balance between timely intervention and the morbidity associated with delayed nutritional support.
The recent JAVMA paper by Freilich and Jugan (2025) underscores this point. In their retrospective review of 295 dogs and cats, the median time to feeding tube placement was two days, and only 18 percent of patients had specific feeding instructions recorded in the medical record. Earlier placement—particularly of nasogastric tubes—and weekday admissions were associated with shorter delays, while initial use of oesophageal tubes or weekend admission prolonged time to feeding initiation.
Regarding contraindications, I tend to avoid nasogastric or nasoesophageal tubes in patients with active vomiting or uncontrolled regurgitation, significant nasal or upper airway trauma, marked coagulopathy (especially if epistaxis could be difficult to control), reduced mentation without a protected airway, or high aspiration risk in the absence of safe positioning. That said, for borderline cases, I’ve used very slow trickle feeding via syringe driver to monitor tolerance and reduce the risk of reflux or regurgitation, which can be helpful as a stepwise approach.
The 2024 JSAP study by Camacho and Humm provides further reassurance about the safety of both nasoesophageal and nasogastric tubes. In their randomised controlled trial of 97 animals, tube misplacement into the respiratory tract occurred in just 3.1 percent of cases, and most complications during placement were minor. There were no significant differences in vomiting or regurgitation rates between the two tube types once placed. Although radiography remains the gold standard for confirming placement, the study noted that negative pressure at the thoracic inlet and capnography may offer useful adjunctive confirmation.
However, rare but serious complications do occur. A 2023 JAVMA study by Odunayo et al. described 13 dogs that developed pneumothorax following NG tube misplacement into the tracheobronchial tree. Of these, five died or were euthanised, and most required thoracocentesis or thoracostomy tube placement. The overall incidence was low (0.3 percent of nearly 4,800 placements), but it highlights the need for vigilance and rapid response to respiratory compromise following placement.
As for oesophagostomy tubes, the 2019 JVIM study by Nathanson et al. reviewed complications in 225 patients (123 cats, 102 dogs). They reported an overall complication rate of 44 percent, with similar rates in cats and dogs. Most were minor, but infectious complications requiring surgical debridement occurred in a subset, and three patients were euthanised due to severe tube-related issues. No particular patient characteristics predicted complications, so consistent monitoring and client education remain critical for managing these patients safely at home.
Altogether, I think the evidence supports earlier and more confident use of feeding tubes, ideally starting with NG or NE in hospital and transitioning to E-tubes if prolonged support is expected.
I always say to owners that the placement of an oesophageal feeding tube often gets you out the hospital quicker!
All the best,
Scott 🙂
Hi Kath,
Thanks for starting such a great discussion. One thing I’ve always wondered about is the potential for CO₂ buildup in makeshift oxygen cages. I know commercial units are designed with airflow and venting in mind, but when we’re improvising with taped-off crates or incubators, how much of a concern is that accumulation? Have you ever seen clinical signs that made you suspect CO₂ was becoming an issue, or do you take any specific steps to prevent it when using DIY setups? I’d be really interested to hear your thoughts on that.
Scott
Replying to Neus E. 28/04/2025 - 10:34
Neus!
We are so lucky to have you join us!
Thank you for being brilliant!
Scott 🙂
Replying to Neus E. 28/04/2025 - 10:33
Thank you so much for sharing this!
Scott 🙂
Replying to Neus E. 28/04/2025 - 10:31
Hi Neus,
Thanks so much for jumping in, completely agree with all of this. Diagnosis and targeted treatment are absolutely the priority, and I also tend to reserve specific albumin supplementation for cases where the clinical signs (rather than the number) really demand it. I think your point about using plasma more for oncotic support and to reduce crystalloid volume in SIRS-type patients is key. And yes, nasogastric tubes are such a practical way to get early nutrition in without needing full anaesthesia—great option while stabilising before considering anything more invasive.
Really helpful summary.
Scott 🙂
Replying to Jane Sedgewick 30/04/2025 - 11:05
Hey Jane.
I agree that from a safety and convenience perspective, using the full 100 mg gabapentin dose per cat makes a lot of sense, especially when compounded formulations aren’t an option. Most of the evidence we have supports 100 mg as both well tolerated and clinically effective for mild to moderate stress reduction. I haven’t seen any meaningful changes in bloodwork parameters (including T4) following a single dose, and the recent hyperthyroid study also supports that it doesn’t interfere with testing. So unless there are concerns about sedation depth or underlying disease, I think sticking with 100 mg is very reasonable for most patients.
On the Bonqat front, we’re in the same boat. It’s great to finally have a licensed option, but the cost and cascade considerations are tricky. As you say, sedation is technically listed as a side effect, but in the context of pre-visit anxiety or fractious hyperthyroid cats, that’s often exactly what we’re hoping for. I do wonder whether we’ll see more targeted studies directly comparing pregabalin and gabapentin head-to-head, which might help justify broader use (or not).
Would be great to hear if anyone has used Bonqat consistently and how it compares clinically in terms of onset, depth of sedation, and owner perception.
Have a great weekend.
Scott 🙂
Sarah!
Always such a joy to have you join us!
Thank you so much for your support, we really appreciate it.
Let me know if you have any questions.
Scott 🙂
Replying to Hayley O. 01/05/2025 - 14:12
Hello Hayley!
Thank you for the question. I am really interested to hear Liz’s thoughts on this one.
My own cat was sadly diagnosed with HCM this week.
I hope all is OK with you.
Scott 🙂
Replying to Christina Frigast 28/04/2025 - 10:16
Hi Christina,
Great questions.
For aggressive enteral nutrition, I usually aim to introduce a complete and balanced recovery diet as early as possible. Hill’s a/d, Royal Canin Recovery, or Clinicare are all good options depending on tolerance. If a feeding tube is in place, I really like the Royal Canin GI High Energy Liquid as it is specifically formulated for tube feeding, energy dense, and generally very well tolerated. In patients without a tube, Oralade is a useful starting point to support hydration and provide glutamate, but it is not nutritionally complete, so I try to transition to a more complete diet quickly. Placing a nasogastric tube allows for gentle, consistent nutritional support and can help avoid the stress of syringe feeding. It also enables trickle feeding, which is often better tolerated in fragile patients and may reduce the risk of reflux or vomiting. In some cases, a syringe driver can be used to provide a constant rate infusion of liquid diet over several hours, which works especially well for patients with poor appetite or gastrointestinal sensitivity.
Here’s the full link to the Royal Canin GI High Energy Liquid for dogs in case it’s helpful:
https://www.royalcanin.com/uk/dogs/products/vet-products/gi-high-energy-liquid-dog-4913
For fluid support, I usually start at 1 to 2 mL/kg/hr in stable hypoalbuminemic patients. That provides volume support without risking overload. I adjust based on perfusion parameters, urine output, respiratory rate, and any evidence of effusions or peripheral oedema. If there are signs of third spacing, I tend to reduce the rate further and reassess frequently.
Hope that helps.
Scott 🙂
Replying to Neus E. 28/04/2025 - 10:22
Hi Neus,
Thank you so much for your comments. I really appreciate your insights, especially around total protein and the nuances of POCUS in these cases. I’ll definitely keep those TXA tips in mind too. Looking forward to the upcoming lectures.
Thanks again.
Scott 🙂
Replying to Christina Frigast 28/04/2025 - 10:07
Hi Christina,
Thanks for your follow-up. You are absolutely right that TXA isn’t widely documented for feline use in the BSAVA formulary, which makes the decision tricky. The data in cats is definitely more limited, but we will be sharing a lot more on this topic later in the course, including the evolving evidence base.
One helpful reference is a retrospective study from J Vet Emerg Crit Care (2022) that looked at 266 dogs and 28 cats who received tranexamic acid in a critical care setting. In that group, the most common indications in cats were idiopathic hemoabdomen, neoplasia, and trauma, including high-rise injuries. The median IV dose was around 10 mg/kg for both species. Adverse effects were rare, with only one cat showing hypersalivation, and another reportedly tolerating a 10 times overdose without issue. So, while it is still off-label and used cautiously, this study does offer some reassurance about its safety profile in cats, particularly when used as a one-off dose.
I think your instinct to weigh the risks of xenotransfusion against potential benefit was sound. While it can be life-saving in select emergencies, your concerns were well justified, especially given the context of the FIP case. It is always such a difficult balance between acting early and not overreaching in uncertain clinical terrain.
Looking forward to exploring this further with everyone as the course progresses.
All the best,
Scott
I am listening to it now! It is amazing!
One of my favourite moments:
“My point is simple: Adults will have negative opinions about you and everything you do. Let Them judge. Let Them react. Let Them doubt you. Let Them question the decisions you are making. Let Them be wrong about you. Let Them roll their eyes when you start posting videos online or you want to rewrite the manuscript for the 12th time. Instead of wasting your time worrying about them, start living your life in a way that makes you proud of yourself. Let Me do what I want to do with my one wild and precious life.”
― Mel Robbins, The Let Them TheoryOur one precious life… that is what we need to remember!
Scott 🙂
Replying to Christina Frigast 28/04/2025 - 09:55
Hi Christina,
Thank you for the detailed reply. I really appreciate you taking the time to share these cases, and I’m so glad to hear the first patient is still hospitalised but doing well. Fingers crossed for a smooth recovery.
That is a really frustrating situation with the Clamoxyl LA. I completely understand your hesitation. Once that long-acting formulation is on board, it can definitely limit flexibility, especially when you’re trying to escalate or tailor therapy. In terms of whether I would have added IV antibiotics, I probably would have considered it if I felt clinical suspicion for sepsis was increasing, particularly if the LA injection had been given hours earlier and there was ongoing concern for deterioration. Co-amoxiclav IV would have been reasonable in that case.
Your second case is also really interesting. That drop in HR and temperature definitely raises concern, and it sounds like you picked up on those changes quickly. With the findings at surgery and bacteria in the abdominal fluid, I think your antibiotic choices were well justified. Starting with co-amox and metronidazole, and then layering in marbofloxacin to cover potential uropathogens or a renal source was very reasonable, particularly in the context of that asymmetric kidney. I don’t think you were late. You were watching the clinical signs closely and adjusted as soon as there were indicators of decompensation. It’s always easy in retrospect to wish we had acted sooner, but you responded quickly to evolving signs and got her to surgery in time.
Both cases really highlight how dynamic these patients can be and how early subtle signs can be easy to miss. I think your decision-making was sound throughout, and both cases raise great discussion points around antibiotic selection, timing, and the challenge of identifying sepsis early.
I’ll pass both of these on to Kerry and Neus. I think they’ll have some excellent insights, especially around empirical antibiotic strategies and escalation decisions.
Just to support that further discussion, here’s a useful framework on life threatening infections and empirical antibiotic guidance based on consensus and current practice:
LIFE THREATENING INFECTIONS (BSAVA)
Use of antibiotics other than those listed should be based on susceptibility testing.
There is no universally accepted veterinary definition of sepsis, but it may be suspected in dogs and cats who are systemically unstable due to a presumptive or diagnosed bacterial burden. Clinically, this may manifest as:
Refractory hypotension (systolic <90 mmHg) despite appropriate volume resuscitation
Hypoglycaemia requiring supplementation
Neutropenia
Bacteraemia / Sepsis
Amoxicillin/clavulanate 20 mg/kg IV q8h
If recent (<3 months) beta-lactam administration:
Fluoroquinolone (enrofloxacin 10 mg/kg IV q24h [dogs] or marbofloxacin 5 mg/kg IV q24h [cats])
AND clindamycin 11 mg/kg IV q12h or metronidazole 10 mg/kg IV q12h
Investigate and obtain samples from likely sources (urine, bile, effusions, airway washes)
Transition to oral antibiotics once clinically stable
Base treatment duration on resolution of signs (demeanour, pyrexia, CRP if applicable)
Septic Peritonitis
Amoxicillin/clavulanate 20 mg/kg IV q8h
ADD fluoroquinolone if recent beta-lactam use
If amoxicillin/clavulanate is unavailable:
Cefuroxime 20 mg/kg IV q8h AND clindamycin or metronidazole as above
If colonic perforation: always include metronidazole
Early surgical source control is essential
Oral transition and course duration as above (as short as 4 days in human protocols)
Neutropenia
Mild (>1000/μL) and well: no antibiotics
Moderate (<1000/μL) and well: cefalexin, amoxicillin/clavulanate, or TMS orally
Severe (<500/μL) OR any neutropenic patient unwell (hypotension, hypoglycaemia, severe GI signs or pyrexia):
Amoxicillin/clavulanate or cefuroxime IV
Stop antibiotics when neutrophil count >1000/μL
Really brilliant cases to learn from.
Scott 🙂
Replying to Jon H. 28/04/2025 - 18:02
Welcome Jon!
Thank you so much for joining us! We really appreciate your amazing contribution!
Scott x
Replying to Hayley O. 29/04/2025 - 14:40
Hi Hayley,
Thank you so much for sharing your experience, that’s really interesting and completely resonates with what the paper and others have observed too. It’s amazing how much difference a calmer environment and quicker discharge can make for these patients. Even with all our efforts to keep them cool and quiet, sometimes the hospital setting itself just isn’t ideal for them.
How are you finding the course so far? I’d love to hear how you’re getting on!
Best
Scott
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