PEG tubes, and feeding Cassius. Warning - Wall of Text to follow...

As some of you may know, my early generation boy Cassius has a condition called Megaesophagus (This is covered in another thread, so I won’t go over it all again here, but here’s the link if you’re interested… viewtopic.php?f=2&t=15238).

He has recently had issues with his throat, and is currently unable to eat normally, so he has had a PEG tube (Percutaneous Endoscopic Gastrostomy tube) fitted to assist with feeding.

I spent a fair amount of time on the internet looking for information on these tubes, and the lack of informative posts regarding this type of tube feeding for cats really frustrated me. Many people seem to think a feeding tube is the end of the line for a cat, but it's really not. This method of feeding has proved far easier than the upright feeding we were struggling with previously. So I thought I would go through Cass’ new feeding process with you all, and hopefully this might help someone in the future.

So, here goes… Spoiler alert – some of the photos are a wee bit gross.


FEEDING:
Cassius currently gets 70ml of liquidised EN food, four times a day. It seems a lot, but at just on 3kg right now, he needs to put on some weight! I prepare the food each morning by liquidising 1 ½ tins of Purina EN with 50mls of warm water until it is a thick soupy consistency. The food can be kept in the fridge between feeds.

Assemble all of the necessary equipment. This includes:


Syringes of liquid food – warmed to body temperature
Syringe of warm water – again, body temperature
Empty syringe
Any medications
Towel
Small empty tub
Paper towels
Hungry cat

Procedure:
1. I wear an old shirt. It gets messy. Ask someone to help. Put an old towel down on the table – it is easier to feed him at that height.

2. Start by drawing up the liquidised food into two large (60ml) syringes. 35ml in each makes them easier to handle.

3. I also draw up 30ml water into another syringe. Tap water is fine.

4. Place all syringes into a jug of warm water and warm to body temperature.

5. Find Cassius. He is usually on the table by now waiting for food. Sometimes he's patient. Usually he's howling...


6. I pull the netting bandage forward and unravel the tubing from under the netting. Check that the plug was secure in the port.


7. Always remember to kink the tube to prevent air entering the tube when removing or replacing the plug or a syringe. A small amount of air entering the tube is ok, but large amounts should be avoided.

8. Remove the plug. ALWAYS PUT THIS PLUG SOMEWHERE SAFE! THIS IS VITAL! If I drop this plug there will be chaos when it comes time to replace it. I use a small Tupperware container beside the food just for the plug.


9. I start by attaching an empty syringe to the port, and then I draw back on the syringe to see if there is any fluid left in his stomach. There should not be more than 10 – 15mls fluid left in the stomach. If I get a large volume of fluid from his stomach at this point, I do not feed this meal. Dispose of this fluid.

10. Flush the tube with a small amount of the warmed water (10 – 15mls) to ensure that it is not blocked.

11. Attach the first food syringe. I administer this slowly over the next 15 – 20 minutes (approx 4ml per minute). The food drips and makes a mess. Note to self: consider investing in a paper towel company.


12. If the feeding tube becomes blocked, I flush with a few mls of warmed water. Try manipulating the tube to see if the blockage can be squidged away. If this does not clear it, I try flushing with cola. The acid and the bubbles in the fizzy drink should dissolve the blockage.

13. Hubby is now bribing Cassius to stay still by allowing him to lick at the end of the other food syringe. Or, we’re chasing him around the kitchen, trailing the tube and splattering liquid food up the walls.


14. Any medications can be given through the feeding tube too. The plug has a smaller port at the end for smaller syringes. Remember to kink the tube and flush with a few mls of warmed water after the meds have been given.

15. When all of the food has been given, I flush the tube again with 15mls of warm water, given at a rate of approx 5ml per minute.

16. When finished, I wrap the plug in a cotton swab and coil up the tubing, tucking it under the netting. Ensure the swab remains around the end of the tube and the plug – this will let me know if the ports are leaking, as the swab will become wet. We re-dress Cassius in his netting bandage, and make a fuss of him.


17. I then write up the feed. How much Cass was given, what drugs he had, any residual fluid and any other info that might be useful for the vet.


And that’s the feed. We will repeat the above in four hours. This can be done by yourself, but it is SO much easier with two people. My husband distracts Cass while I take care of the feeding.



But we’re not done yet… We need to check the incision site daily for redness, inflammation, excess discharge (a small amount of discharge is expected) or smelly discharge. If the wound is looking ok, or only a little bit nasty, we need to clean it and replace the dressing. If the wound is oozing pus or bleeding, we need to contact the vet for further advice.

CLEANING:
The cleaning can be done directly after the feed, or more likely, an hour or so after a feed once Cassius has calmed down and is snoozing with a full belly.

(Look at that fat wee bald belly... Just look at it! Don't you just want to blow raspberries on it? I'm holding the netting away from his tummy so he can have a nice groom, and also protecting the tube site from him licking it...)

Gather the necessary materials. They include:
Gloves
Several gauze swabs soaked in a diluted disinfectant solution
Gauze swab soaked with warm water
Scissors
One Allevyn Adhesive Dressing. Make a small Y-shaped cut half-way into the pad for the tube
Clean muscle vest if necessary

Procedure:
1. Wear gloves.

2. Roll up the muscle vest to expose the tube site. If the netting is grubby and needs changing, I remove it completely at this point.

3. Unravel the tube and ensure that the plug is not loose in the port.

4. Gently remove the old dressing. I snip through the dressing rather than pull it off, being VERY careful not to snip through the stitches holding the tube in place. This would be bad.


5. Using the soaked swabs, I gently wipe away any dried discharge around the incision site.

(This is looking good - just a wee bit of dried gunk, and no redness.)

6. We wipe the disinfectant away with the water soaked swab. I do not leave disinfectant on the skin, as this can cause a reaction.

7. Carefully place the clean dressing around the feeding tube, and gently press onto the skin with the white shiny side facing the skin, matt pink side up.


8. I pull the vest down into place over the tube. Or, I replace the muscle vest with a clean one, if I removed it.

9. Replace the swab around the plug, coil up the tube and tuck it under the netting.

10. Make a fuss of Cass. We’re done. Now I can put a cute jumper over the whole lot to stop him licking at it.


Or, he gets the silly cushion collar.


I don't have many photos yet of the cleaning procedure, as it's difficult to wipe and take pictures at the same time! I'll get more images over the next few weeks as we get better at it...


And that's that. We're hoping that in a couple of weeks Cassius will be fitted with a special low profile port, that will mean he won't need the sexy muscle vest and the long piece of tube trailing after him all the time. I'll continue to update this thread as we go on, and I hope that this information helps anyone else struggling to find information on this type of feeding.

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Not exactly the same thing but I'm very used to pegs and other direct feeding methods with babies as I was a neonatal nurse.... The tube Cas has got now we would call a gastronomy tube, the low profile we would call a PEG... But they're basically the same. I assume the low profile one will be very similar, if not the same as the ones used on babies.....

One thing we did have was a clamp thing on the tube so you didn't have to kink it. Sometimes easier as you can quickly clamp it if the feeding tube becomes unconnected.... I'll see if I can find out the official name for it in case you can attach one to make life easier....

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Lollo

Amazing, thanks for sharing this.

Just goes to show we will do anything to help our babies. I've given insulin injections and subq fluids for renal failure to a kitty (she was 17 years old when we had to put her to sleep). It wasn't easy as I hate needles--just the sight of them makes ne nauseous. But, it was either learn this myself or take the cat to the vet twice a day for them to do it and pay them to do it. The needle for the subq fluids was gigantic. But Kitty was a trouper over it all and we got through it. This was so informative, and thank you for sharing the process with us.

Hi again...

The saga continues.

The stricture in Cass' throat is continuing to cause problems. We have had his throat ballooned open three times now, and each time the stricture comes back within a few weeks. So we're trying a new, slightly experimental process...

Cassius has had an esophageal feeding tube placed in his throat, to act as a kind of stent, to hopefully allow the scar tissue to form about the tube. We're not feeding him through this tube, it is simply there to stop his throat closing over completely.


This is Cass with the two tubes - curled in a ball ignoring the world.

However, we now have the more permanent low-profile port in place, and we've been able to remove the sexy vest, which has been a big relief to the poor wee boy - he's been just dying to have a proper groom and it's very difficult to allow that when there's a tube dangling all over the place...


Here's the new port - I've just woken him up and he looks grumpy, he's not really...


Close-up of the new port.

Feeding him is still a two person job, but it's slightly easier than before. The tube just clicks and disconnects from the port, and as long as I can get the plug back in to the port Cass can jump off the table as soon as we're done feeding; there's no more mucking about re-dressing him.

The new feeding process:


Get everything ready as before; food in two syringes, warm water, empty syringe, and the new addition of the removable tube.


Plug 'im in and fill 'im up. (There's one of those clamps that Lollo was talking about.)


Close-up of the food going in...


Once all the food, water and medications have been given through the tube, unplug him and that's that.


Cass then crashes in a heap with a full belly and goes to sleep. Bless...


If we're out, Cassius wears his new Neck Hug from Wag Tail Farms. ( http://www.wagtailfarms.com/index.html )
This is a wonderful alternative to a standard cone of shame, and much better for Cass as it supports his head in an up-right position when he's asleep, preventing him from regurging. With the new tube in place, preventing regurging is more important than ever...

And that's where we're at now. Fingers crossed, this new tube will work, and in a month or so we can have it removed and the scar tissue will be solid enough to stay open. That's the plan anyway. Please cross fingers and paws for us!

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Wow - just wow.
I have no words but total admiration for what you are doing for Cass!

Your dedication is to be applauded.
Bless Cass and his donut collar, he's just so adorable even after all he's been through.

I have so much respect for you, your partner.... and of course for Cas too (just for putting up with it all!). You're doing such an amazing job and your hard work and dedication is utterly fantastic. You've kept going where others probably would have simply given up.

Loved the photos of the muscle shirt. ;)

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Katrina

Owned by:

You and your cat are definitely troopers! Thanks for sharing this.

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The little monsters 3

So, here's where we are at.


Cassius with his fancy dressing/collar holding the throat tube in place... (http://www.kittykollar.com/ - awesome product BTW!)

The throat tube seemed to be doing it's job. However...

After three weeks with the tube in place in Cass' throat, a week ago the wee sod managed to rip the stitches holding this tube in place. Blast. Off to the vets at midnight, to get the stitches replaced... Unfortunately, this damage didn't heal quite as well as it should have, and so the throat tube was removed a few days ago to allow the infection to heal up.


Bonus pic with Ember...

So we're back to just the one tube; the low profile one in his belly. We're hoping that three weeks with the tube in his throat acting as a stent will have been enough to allow the scar tissue to form.


The throat wound has closed up and healed very nicely.

Cass is very cooperative when it comes to cleaning the port on his belly - as long as he gets a belly rub with it he'll lie there for ever... Wee hussy.


'belly scritch, please!'

The Neck Hug ( http://www.wagtailfarms.com/ ) does a wonderful job of keeping him from getting at the port, and also keeps his head up. I can't recommend these collars highly enough as an alternative to the cone of shame, and Jamie at Wagtail Farms has been amazing. I ordered a second Hug so I could wash the first one, and the service was fast and friendly. If your furkid hates the cone (and let's face it, don't they all?), then go for a Neck Hug.


Posing in his Hug.

The stoma on his belly is forming very well. There's a tiny bit of 'leakage' when we feed him, as this low profile tube is ever so slightly smaller in diameter that the first tube, so we're cleaning and re-dressing it every day till it closes up a wee bit more.


Cleaning the port.


The next two or three weeks will be crucial. If, in two weeks Cass begins to wheeze after feeds again, we will know that the experiment hasn't worked, and it'll be back to the drawing board. As it is the saliva build-up in his throat that causes the main problem, the vets at the RDV have mentioned the possibility of removing his saliva glands. That's another big surgery though, and we want to avoid it if possible. Please keep fingers and paws crossed for us!

Some good news though - Cass has put on a fair chunk of weight since the tummy tube went in! He had dropped to 3.02kg at his lightest, when the port was first placed. He weighed in on Wednesday at a fairly robust 3.58kg - that's a gain of over 1/2 a kilo in a little under six weeks!


He's still stupid as a stump though. He just can't figure out why he can't get into the garage anymore...


'I'm sure I used to fit...' 'Nope; definitely not...'

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So glad to have found this post. My sweet kitty, Oscar has just gotten a PEG tube and we are struggling with making him comfortable with it. So much good info here that I'm going to copy. Especially Cassius's sexy muscle shirt!

The mesh thing Oscar's vet outfitted him with is just a tube that's around his upper torso and it keeps rolling up and the tube hangs on both sides - not ideal for him. Where did you get Cassius's shirt? Did you fashion it yourself or did your vet provide? I'm thinking of cutting holes in Oscar's mesh tube to make it more of a shirt but worried it's not long enough and don't want to cut holes wrong and mess it up as it's the only one we have.

Oscar is actually not bengal - he's a beautiful british shorthair who was diagnosed with lymphoma a few days ago. :(

Thanks so much!
Linsey

Hi Linsey,

This. This is why I wrote this post...

I'm so sorry to hear about your Oscar, but try not to stress too much - a PEG isn't as bad as it seems.

The mesh vest is just a length of tubular gauze stockinette - our vet provided it, and the stuff we were given is called Netelast Stockinette. We had the same problem with the tube rolling down, so yes, I just cut a couple of holes in it to make it into a vest. Be aware that you only need to chop teeny-tiny holes, as the gauze stretches a lot. Start small and adjust bigger if you need to. Your vet should be able to give you a supply of it if you ask.

Or, you could buy a puppy t-shirt and sew the stockinette to it to hold it in place. I use this one - http://cgi.ebay.co.uk/ws/eBayISAPI.dll? ... 619862003- make sure you get one without sleeves, as they just seemed too long and generally annoyed the h*ll out of Cass...

To be honest, any sort of tubular gauze bandage or dressing retainer will work just fine. Make sure that you get the correct size to go around Oscar, and chop away! (I first went with the "small adult limb" size, and it was a bit too loose on Cass, but he's a skinny wee sod. The "bulky fingers" size works for him, if there was a size in-between the two it would be perfect...) You can get this type of bandage at most large chemists or online.

If the PEG is going to be a long term thing for Oscar, definitely ask your vet about a low profile port for the tube. Also, I've just received these reusable dressings - http://www.patchworkpeddler.com/reusabl ... ted-sizes/ - which hopefully will make redressing the stoma easier.

Feel free to ask as many questions as you like! I hope I can help. Give Oscar a (gentle) hug from me...
Tina

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Just because it's adorable, here's a clip of Cassius being fed...

https://www.youtube.com/watch?v=X_2e0JGb_gA

(I couldn't get the Youtube link thingy to work...)

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Soooo. Today has not been a good day...

Cassius went back in to the Dick Vet this morning to have his throat tube replaced, as the stricture was getting worse again. He has spent the last two days wheezing and bringing up frothy saliva, so we knew that his stricture was beginning to affect his ability to swallow the saliva produced during the normal course of the day.

The procedure was simply to re-open his stricture a small amount, and re-insert the throat tube on a more permanent basis. When he had the throat tube in place we had no issues at all, so the vets decided to use a more permanent version.

Unfortunately, Cassius went into respiratory arrest during the procedure, and had to be resuscitated. His lungs flooded with saliva, and his blood oxygen level dropped to a dangerously low level. I got the call about 4pm asking permission to PTS if he didn't begin breathing by himself.

Professor Danielle Gunn-Moore did the procedure herself, and refused to give up on him. He started breathing again by himself at about 5pm, and sat up unaided at about 5.30.

The main concern now is the possibility of brain damage after being deprived of oxygen for as long as it was. We are going in tomorrow to assess him and make a decision then. It's not an easy thing to consider. In fact, this looks likely to be the hardest decision we have ever had to make... But we will need to do what's best for Cassius.

Please can I ask everyone to think positive thoughts for our boy? I will update this thread tomorrow, no matter what the outcome...

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Oh Cass!

So sorry to hear this, but it sounds like he's a fighter.
Big hugs to you all and I am keeping you all in my thoughts, sending positive vibes your way xx