Professional Documents
Culture Documents
1. Dorsch JA, Dorsch SE. Understanding anesthesia equipment: construction, care and complications, 3
rd
ed. Baltimore: Williams & Wilkins 1994.
2. Divatia J, Bhowmick K. Complications of endotracheal
intubation and other airway management procedures.
Indian J Anaesth 2005; 49:308-18.
Fig 1(a) Plastic clip applied on the sheet encasing
the tubing of breathing circuit, (b) inset photograph.
874
Indian Journal of Anaesthesia, Dec 2008
paralyzed patients can sometimes be difficult with a
reported success rate of 40- 68% for first pass
insertion
1,2
.This is because nasogastric tubes tend to impinge on the pyriform sinuses or the arytenoid cartilages
and coil in the oropharynx or pass into the trachea, as
has been demonstrated using a fibreoptic bronchoscope
1
.
Various techniques for aiding NGT insertion may be traumatic (split nasotraceal tube as obturator)
3
, involve laryngeal or neck manipulation
2-5
, require skill (digital insertion)
6
, advance preparation (coiling a tube and freezing it)
7
or laryngoscopy or fibreoptic bronchoscopy to
facilitate insertion
8,9
. We wanted to assess a technique
for NGT insertion which was atraumatic, easy to perform in any patient in whom direct insertion failed, without having to manipulate the larynx or neck and involved
the use of a nasopharyngeal airway (NPA) as an obturator, which is easily available.
After ethical committee clearance 106 adult conII patients aged 18-65 years schedsenting ASA I
uled for surgery under general anaesthesia requiring
orotracheal intubation and nasogastric tube insertion
were included in the study. Patients with a nasal, pharyngeal or esophageal pathology, bleeding diathesis or
with head injury were not included. After intubation with
the patient in the sniffing position, direct insertion of
appropriate size -14, 16 or 18 French gauge NGT was
attempted. Insertion was attempted through the right
nostril unless contraindicated and 2-3 cm of the tube
were pushed in at a time instead of pushing longer segments in one go. Confirmation of correct placement
was by aspiration followed by 5-10 ml of air instillation
and auscultation over the epigastrium. In case gastric
contents could not be aspirated or the sound after air
instillation could not be auscultated, the NGT was
slowly withdrawn 3-5 cm at a time and repeated aspiration and air instillation performed to ensure that a
correctly placed NGT was not missed due to coiling in
the esophagus or oropharynx. If the NGT insertion was
unsuccessful, it was withdrawn and a well lubricated
NPA (Romsons Science and Surgicals Industry Pvt.
Ltd. India) of size 7-7.5 mm ID in females or 7, 7.5 or
8mm ID in males was inserted through the nasopharynx. Through this a fresh, lubricated NGT of the same
size was inserted and the position confirmed as before.
Thereafter the NPA was slid off the NGT and inspected
for blood staining. If the above method failed, laryngoscopy and Magill s forceps guided insertion was
performed.
Fifty-one female and 55 male patients, aged
42.4
+13.6 years and weighing 59.9
+12.8 kg were
studied. Direct insertion of the NGT on first attempt
was successful in 59 out of 106 (55.7%) patients but in
44.3% (47out of 106) patients it was unsuccessful.
Amongst these patients, NGT insertion through NPA
was successful in 41out of 47 (87.2%) patients on first
attempt. A 16 F NGT was used in the majority (66.9%).
The most commonly used NPA size was 7.0mm ID in
males (63.6%) and females (56%). Only 14.8% (7out
of 47) required the use of laryngoscope and Magill s
forceps for NGT insertion. Only 12.7% (6 out of 47)
of patients had slight streaking of blood on the NPA
when it was removed. We found this method successful even in 2 patients with double lumen tubes in situ.
Our success rate for first pass direct insertion was
lesser than that reported by Ozer et al (68%) because
we used NGT of sizes 14-18 French whereas they used
only 18F tubes
1
. Bong et al had a 40% first pass success rate with 14 F NGT
2
.
The length of NPA of sizes 7, 7.5 and 8 mm ID
are 13.5, 14 and 14.5 cm respectively. Ozer et al have
shown that a nasally inserted gastric tube usually passes
the arytenoids at a length of 16.2
+ 1.2 cm
1
. The NPA
provides a conduit for the NGT to track along the posterior pharyngeal wall and emerge just 2-3 cm proximal to the arytenoids more in the midline resulting in
higher success rates and lesser oropharyngeal coiling
or tracheal insertion especially if shorter segments (2-3
cm) are pushed in at a time.
Shetty et al have used this technique to minimize
trauma during NGT insertion in patients with facial or
cranial trauma
10
.
We conclude that the first pass success of
nasogastric tube insertion through a nasopharyngeal was
875
high without any major bleeding in patients with failed
first pass direct nasogastric tube insertion via the nares.
Anjolie Chhabra, Assistant Professor
Rakesh Garg, Senior Resident
Department of Anesthesiology and Intensive Care, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi-110029,
India.
Email: anjolie5@hotmail.com
References
1. Ozer S, Benumof JL. Oro and nasogastric tube passage
in intubated patients. Anesthesiology 1999; 91:137-43.
2. Bong CL, Macachor JD, Hwang NC. Insertion of the
nasogastric tube made easy. Anesthesiology 2004; 101:
266.
3. Chen YS, Wang SM. A modified method to insert a
nasogastric tube without kinking in the nasal cavity.
Am J Em Med 1992; 10: 614-15.
4. Perel A, Yosef Y, Pizov R. Forward displacement of the
larynx for nasogastric tube insertion in intubated patients. Crit Care Med 1985; 13: 204-5.
5. Mahajan R, Gupta R., Sharma A. Role of neck flexion in
facilitating nasogastric tube insertion. Anesthesiology
2005; 103: 446-47.
6. Mahajan R, Gupta R. Another method to assist nasogastric
tube insertion. Can J Anesth 2005; 52: 652-53.
7. Flegar M, Ball A. Easier nasogastric tube insertion. Anaesthesia 2004; 59: 197.
8. Jones AP, Diddee R, Bonner S. Insertion of a nasogastric
tube under direct vision. Anaesthesia 2006; 61:305.
9. Gombar S, Khanna AK, Gombar KK. Insertion of a
nasogastric tube under direct vision: another atraumatic
approach to an age-old issue. Acta Anaesth Scand 2007;
51: 962 63.
10. Shetty S, Henthorn RW, Ganta R. A method to reduce
nasopharyngeal trauma from nasogastric tube placement. Anesth Analg 1994; 78: 410-11.
Perioperative Antiplatelet Therapy in
Patients with Coronary Stents: Importance
of Patient Education
To,
The Editor, IJA
Madam,
We would like to share our experience of an interesting case of premature discontinuation of
antiplatelet therapy by patient in ignorance, thereby highlighting the immense importance of patient education.
A 59-year-old male with intracoronary drug
eluting stent to LAD placed two months prior to surgery and low ejection fraction presented for stapled
hemorrhoidectomy. He was on dual antiplatelet therapy
with aspirin & clopidogrel after stenting and was advised to continue antiplatelet drugs perioperatively by
the cardiologist. In view of active bleeding, an urgent
surgery was advised. The patient had noticed a direct
correlation between the intensity of bleeding and intake of antiplatelet drugs and had therefore stopped
both antiplatelet drugs two days before surgery.
In the preoperative period, the patient became
unresponsive and ECG showed bradycardia progress-
-blockers.
Isoproterenol has also been used to treat anaphylactic
shock in a beta-blocked child.
5
Further, there are case
reports suggesting role of atropine in the presence of
relative and severe bradycardia.
6
Increasing population presenting for surgery and
anaesthesia is on