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LETTER TO EDITOR
Year : 2015  |  Volume : 59  |  Issue : 4  |  Page : 261-262  

Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients


Department of Minimal Access Surgery, Gem Hospital and Research Centre, Coimbatore, Tamil Nadu, India

Date of Web Publication13-Apr-2015

Correspondence Address:
Dr. Rachel Maria Gomes
C/O Dr. Praveen P Raj, Department of Minimal Access Surgery, Gem Hospital and Research Centre, Coimbatore - 641 045, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.155013

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How to cite this article:
Gomes RM, Raj PP, Kumar SS, Palanivelu C. Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients. Indian J Anaesth 2015;59:261-2

How to cite this URL:
Gomes RM, Raj PP, Kumar SS, Palanivelu C. Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients. Indian J Anaesth [serial online] 2015 [cited 2021 Aug 5];59:261-2. Available from: https://www.ijaweb.org/text.asp?2015/59/4/261/155013

Sir,

During bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple-line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re-insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis.

NGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magill's forceps to advance the tube 1-2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of the oesophagus secondary to the inflated endotracheal bulb. [1] Several techniques to simplify this procedure have been recommended in the literature. [2],[3],[4],[5],[6],[7] Of these a quick and easy way often adopted intra-operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma. [2],[3],[4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length.

We would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra-operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure 1]a and b. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure 2]a and b.
Figure 1: (a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector

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Figure 2: (a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus , (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus

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Portex ® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1-cm wide tape at the proximal end of tube and secure it to the connector or use a one-size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube. [8] Furthermore, the Portex ® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra-operative complication.

 
   References Top

1.
Kamat RD. Use of Magill tube for passing nasogastric tube in anesthetized or comatose patients. Anesth Analg 1975;54:156.  Back to cited text no. 1
[PUBMED]    
2.
Tahir AH, Adriani J. A method of inserting a nasogastric tube in the anesthetized or comatose patient. Anesth Analg 1971;50:179-80.  Back to cited text no. 2
[PUBMED]    
3.
Singh N, Rao PB, Ambesh SP, Gupta D. Letter to editor: Endotracheal tube aided nasogastric tube placement with classic laryngeal mask airway in situ. Anaesth Pain Intensive Care 2013;17:308.  Back to cited text no. 3
    
4.
Yadav G, Das SK, Jain G, Choupoo S. Letter to editor: A modified technique for difficult nasogastric tube insertion. Anaesth Pain Intensive Care 2013;17:304-5.  Back to cited text no. 4
    
5.
Reid S, Falconer R. A novel method of nasogastric tube insertion. Anaesthesia 2005;60:1154-5.  Back to cited text no. 5
    
6.
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68-70.  Back to cited text no. 6
    
7.
Tsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99.  Back to cited text no. 7
    
8.
Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg 2007;104:1313.  Back to cited text no. 8
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