A Hit? or A Miss? Learning From Errors: A Misplaced Nasogastric Tube

Innocuous clinical presentation of a SMARCA4-deficient thoracic sarcoma arising in a patient with chronic empyema thoracis

Nasogastric (NG) tube insertion is a common procedure in the clinical setting that causes much discomfort and pain for the patient. Pain control is often suboptimal, as many NG tube insertions are performed without any pain-relieving supplements. The aim of this study was to summarize and critically evaluate the evidence from randomized controlled trials (RCTs) on the effect and adverse effects of lidocaine agents in reducing pain and discomfort associated with NG tube insertion. Databases from the Cochrane Library, MEDLINE, EMBASE, Airiti Library, PerioPath Index to Taiwan Periodical Literature, and Cumulative Index of Nursing and Allied Health (CINAHL) were searched from inception to April 2017. RCTs focusing on lidocaine before NG tube insertion were appraised. The primary outcome was the visual analog scale (VAS) score. The modified Jadad scale was used for quality assessment. Mean difference (MD) with 95% confidence intervals (95% CIs) and odds ratio (OR) for binary outcomes were assessed by a random effects model. Heterogeneity was determined by using the Cochran Q test and I statistics. Publication bias was analyzed by using a funnel plot analysis. Ten RCTs enrolling 734 patients were included in the meta-analysis. Eight of the 10 RCTs reporting VAS scores had sufficient quantitative data to be pooled through meta-analysis. Results revealed a significant reduction in VAS score, with a MD of -26.05 and a CI of -28.21 to -23.89 with moderate heterogeneity (P < .001, I = 56%). There were no significant changes in difficulty of NG tube insertions (MD = -0.30, 95% CI, -1.30 to 0.70, P = .55), number of NG tube insertion attempts (MD = -0.22, 95% CI, -0.98 to 0.53, P = .56), nasal bleeding (OR = 0.62, 95% CI, 0.11-3.41, P = .59), and vomiting (OR = 0.30, 95% CI, 0.07-1.27, P = .10). This meta-analysis suggests that applying lidocaine before NG tube insertion can alleviate pain and discomfort by 26% without increasing nasal bleeding or vomiting.

Clostridium difficile infection (CDI) is a major concern for public health worldwide. Interestingly, the risk of poor clinical outcomes of CDI in patients with nasogastric tube (NGT) insertion is still controversial. The aim of this study was to assess the outcomes of CDI in patients with NGT insertion. A literature search was performed using MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews from inception through November 2017. Studies that reported relative risks, odds ratios, or hazard ratios comparing the clinical outcome of CDI in patients with NGT versus those who did not were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Eight observational studies were included in our analysis to assess the association between NGT insertion and risk of poor outcome of CDI. The pooled RR of severe or complicated clinical outcomes of CDI in patients with NGT insertion was 1.81 (95% CI: 1.17 to 2.81). This study demonstrated a statistically significant association between NGT insertion and risk of poor outcomes of CDI. This finding may impact clinical management and primary prevention of CDI. Avoidance of unnecessary NGT uses would improve the clinical outcomes of CDI.

To the Editor, Nasogastric tube (NGT) insertion is a procedure performed routinely in critical care settings. However, NGT placement often proves to be a daunting task, especially in the setting of anesthetized/uncooperative patients with anatomic distortion (i.e., patients with cervical spine instability and/or restricted neck movement) and an endotracheal tube (ETT) already in situ for airway protection and support of the respiratory system. In fact, serious complications secondary to NGT placement appear often in the literature. Therefore, NGT insertion may be a complex procedure that requires skill, experience, and the ability to improvise if it does not proceed smoothly. A 63-year-old male patient, who was sedated and mechanically ventilated in our intensive care unit, had a hard cervical collar in place after sustaining severe traumatic brain injury, cervical spine fracture, and multiple long bone fractures in a motor vehicle accident. The NGT was unintentionally removed during routine patient care, and despite many gentle and prolonged attempts, the on-call physicians’ efforts to re-insert the NGT were unsuccessful. The presence of the cervical collar created poor laryngoscopic views, even with the left molar approach, and the patient’s cervical spine injury did not allow maneuvres that could facilitate NGT insertion, such as neck flexion, turning the head laterally, lateral neck pressure, and forward displacement of the larynx. To this end, a number of techniques to advance the NGT were attempted without success, including blind insertion plus a combination of direct laryngoscopy and use of Magill forceps, placement of fingers in the posterior pharynx to guide the NGT tip downward, deflation of the ETT cuff, and use of a frozen NGT. Finally, a 9.5-mm internal diameter ETT (‘‘conduit’’ ETT) was placed in the oropharynx and—under direct laryngoscopy—was continually kept in contact with the posterior pharyngeal wall and behind the ETT already in place while simultaneously being advanced gently and as far as possible into the esophagus. A well-lubricated 14-Fr NGT was threaded into the ‘‘conduit’’ ETT and was advanced into the full length of the stomach without difficulty during the first attempt. Afterward, the ‘‘conduit’’ ETT was withdrawn and the NGT was pulled back, positioned at the appropriate length, and fastened in the usual way. It is worth noting that no change of head or neck position, no ETT cuff deflation, and no involvement of an assistant were necessary during this alternative mode of NGT insertion. The only technical requirement was to ensure that the ‘‘conduit’’ ETT diameter could accommodate the NGT, including its funnel-shaped proximal end. We did not determine fibreoptically the point where the NGT met resistance and was successfully bypassed by the ‘‘conduit’’ ETT. However, it has been previously shown that the most common sites of resistance at the laryngeal level are the piriform sinuses and the arytenoid cartilages. In conclusion, the use of an ETT as an introducer can facilitate NGT insertion in difficult settings. This alternative mode of NGT insertion is easy, inexpensive, and widely available in the operating room and the intensive care unit. In our view, it is worth considering this blind approach before the physician resorts to other techniques (i.e., videolaryngoscopy) that are either more expensive or that necessitate the involvement of additional equipment. P. Kopterides, MD (&) C. Papageorgiou, MD G. Dimopoulos, MD A. Armaganidis, MD 2nd Critical Care Department, ‘‘Attiko’’ University Hospital, 1 Rimini Str., Haidari, Athens, Greece e-mail: petkop@ath.forthnet.gr

BACKGROUND Finger method is a new simple technique of nasogastric tube (NGT) insertion for intubated patients which only requires the practitioner’s own fingers. This study was aimed to compare the feasibility of finger method and the standard reverse Sellick maneuver in NGT insertion for intubated patients.&#x0D; METHODS This was a single-blinded, randomized clinical trial that included 210 patients aged 18–65 years old who were intubated under general anesthesia and needed NGT insertion. Initially, subjects were randomly allocated by the third party into two groups: subjects who had NGT insertion with finger method and those with reverse Sellick maneuver. Success rate of NGT insertion at the first attempt, duration of the procedure, and complication rate of blood spots were all recorded. Chi-square test and Mann–Whitney analysis were used to analyze the data.&#x0D; RESULTS Success rate of NGT insertion at the first attempt in finger method group was higher in comparison with reverse Sellick maneuver group (81.6% versus 60%, respectively, p = 0.002). Likewise, the median of NGT insertion duration was longer in finger group compared to reverse Sellick maneuver group (13 sec versus 12 sec, respectively, p &lt; 0.001) but it was not clinically significant. Moreover, the complication rate of blood spots found during the procedure was lower in subjects with finger method than with reverse Sellick maneuver (10.7% versus 28%, respectively, p = 0.003).&#x0D; CONCLUSIONS Using finger method was more feasible than reverse Sellick maneuvers in NGT insertion.

<h3>Introduction</h3> Nasogastric tube (NGT) insertion for enteral feeding is common practise, but is associated with the risk of tube misplacement or malposition in both the immediate and subsequent time points.¹ Between 2005 to 2010, 21 deaths and 79 other cases of harm have been reported on the updated National Patient Safety Agency (NPSA) Alert (2011), “Reducing harm caused by nasogastric feeding tubes”. In 45% of cases, misinterpretation of the chest X-ray was directly responsible for the harm inflicted. The General Medical Council’s (GMC) guidance for undergraduate education, “Tomorrow’s Doctors (2009)” does not specify NGT placement as a core competency for a graduate or Foundation Trainee.² The purpose of this survey was to ascertain the number of medical schools in the United Kingdom (UK) which provide specific teaching on NGT placement and correct identification of tube position (using either pH method or clinical interpretation of a plain chest X-ray film). Furthermore, the authors sought to identify whether these medical schools included formative or summative assessment of the respective methods. <h3>Methods</h3> All 30 GMC recognised Medical Schools within the UK were invited to participate by means of a standardised survey proforma. This proforma was emailed to relevant staff members who were either responsible for course development or were personnel within the clinical skills faculty. <h3>Results</h3> To date, there has been a 57% (17/30) response rate (<i>Table 1</i>). Of the 10 medical schools that provide formal teaching on NGT insertion, 8 of them required formative assessment for both the practical technique and the interpretation of correct tube position. Of the 7 medical schools that do not to provide formal teaching of NGT insertion, 6 of them stated that this was due to the GMC’s “Tomorrow’s Doctors” guidance not including NGT placement as a mandatory proficiency for a graduate. <h3>Conclusion</h3> This survey found that 59% (10/17) of the participating UK medical schools provide formal teaching on NGT placement and correct identification of tube position. There is variable emphasis on NGT procedure proficiency in undergraduate medical education. Given the risks highlighted by the 2011 NPSA report, we would suggest that NGT placement instruction and training should be facilitated at the undergraduate level. <h3>Disclosure of Interest</h3> None Declared <h3>References</h3> National Patient Safety Alert (PSA 002): Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants; Mar 2011. URL: http://www.nrls.npsa.nhs.uk/alerts/?entryid45 = 129640 General Medical Council (GMC) Tomorrow’s Doctors 2009; URL: http://www .gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf

Background:Nasogastric tube (NGT) insertion is an easy procedure that can be routinely performed under general anesthesia. However, for difficult cases, there are limited insertion techniques available in routine clinical practice, considering the flexibility of NGTs. The SUZY curved forceps are designed for the removal of pharyngolaryngeal foreign bodies under guidance of the McGRATH MAC (McG) videolaryngoscope. Because McG enables clear visualization of the esophageal inlet, we hypothesized that the SUZY forceps can facilitate easier NGT insertion compared with the conventional Magill forceps under McG guidance and designed a randomized, crossover manikin study to test this hypothesis.Materials and Methods:Ten anesthesiologists participated in this study. Each participant was instructed to insert an NGT using either the SUZY or the Magill forceps under McG guidance. Both types of forceps were used by each participant in a computer-generated random order. The primary outcome measure was the number of “strokes” (1 stroke was defined by a specific sequence of participant actions) required to advance the NGT 30 cm from the starting point. Data are expressed as medians (interquartile ranges [ranges]).Results:The number of strokes required for NGT insertion was fewer in the SUZY group than in the Magill group {7 [7.0–12.5 (5–14)] vs 16.5 [13.5–20.3 (7–22)]; P <.05}. The time required for NGT insertion was also lesser in the SUZY group than in the Magill group {15.4 [13.7–20.0 (7.0–38.3)] seconds vs 30.3 [22.0–42.3 (12.8–47.5) seconds]; P <.05}.Conclusions:The SUZY curved forceps facilitated NGT insertion more effectively than the Magill straight forceps under McG guidance. Our results suggest that NGT insertion using the SUZY forceps under McG guidance is a secure and easy procedure.

Objective:Due to the presence of pain during nasogastric tube (NGT) insertion and related complications and lack of positive clinical response of nasopharyngeal anesthesia with lidocaine and the related side effects and limitations in ketamine and intravenous midazolam, this study aims to determine the efficacy of oral midazolam in relieving pain in the patients requiring NGT insertion.Methods:A randomized, triple-blind clinical trial was performed on the patients in the Emergency Department of Zanjan Valiasr and Mousavi Hospitals in Iran, who were nominated for NGT. In each group, 100 patients were examined. Two milligram syrups of midazolam and placebo were administered 20 min before the procedure. In two groups, the pain based on the Visual Analog Scale and satisfaction rate of patients during the NGT insertion were compared. The data were analyzed through the SPSS software version 16.0.Findings:There was no statistically significant difference in the demographic characteristics of two groups. Despite the effects of potential confounding variables, the cause of the referral and indication of NGT, as well as the use of midazolam syrup, had a significant relationship with the outcome, so that midazolam group experienced less pain. The mean and standard deviation of the examined outcomes (feeling of pain and satisfaction with NGT insertion) was statistically significantly different in the midazolam group as compared to the placebo group (P = 0.001).Conclusion:Midazolam was effective in decreasing pain and increasing the satisfaction of patients after NGT insertion. This manuscript is registered in Irct. com with code IRCT20110629006922N4.

Reducing patient harm following inadvertent endobronchial placecement of nasogastric tubes in patients with SARS-COV-2

BACKGROUND AND OBJECTIVESSeveral techniques are available to facilitate nasogastric (NG) tube insertion with or without using other instruments to guide the NG tube to the stomach. This study aimed to determine the success rate and time required for inserting NG tube by 2 non-instrumental methods of NG tube insertion and compare the findings with the common method of NG tube insertion.DESIGN AND SETTINGSA prospective randomized, controlled clinical trial carried out at Chang Gung Memorial Hospital in Taiwan.SUBJECTS AND METHODSA total of 150 patients were randomized into 3 groups: control group, neck flexion with lateral pressure group, and lifting of the larynx group. The number of attempted insertions, success rate, duration of insertion, and various complications were recorded.RESULTSBoth neck flexion with lateral pressure and lifting of the thyroid cartilage techniques had high success rates; however, the time required to insert the NG tube was shortest in the thyroid cartilage lifting group.CONCLUSIONNeck flexion with lateral pressure and lifting of the thyroid cartilage are convenient and reliable techniques for NG tube insertion without using any other instruments. Lifting of the thyroid cartilage had the highest success rate and was less time consuming than the other NG tube insertion techniques. Familiarization with the procedure influenced the success rate and the time required for insertion.

The risk of Clostridium difficile associated diarrhea in nasogastric tube insertion: A systematic review and meta-analysis

Objective: This study aimed to compare gastric babble sound with chest X-ray for positioning in nasogastric tube insertion on general anesthesia for oral and maxillofacial patients. Methods: Fifty-six oral and maxillofacial patients with nasogastric tube on general anesthesia were included in this study. Length of nasogastric tube using gastric babble sound for positioning in nasogastric tube insertion on general anesthesia were compared with those using chest X-ray after general anesthesia. Furthermore, we evaluated the relationship between height, weight, Body Mass Index (BMI) and length of nasogastric tube using Pearson’s correlation test. A P value lower than 0.05 was considered as statistically significant. Results: The incidences of adjustment after chest X-ray were 39.3 % (22/56 cases). Regarding cases of the adjustment after chest X-ray, over tube length cases was 90.9 % (20/22 cases, over length: 5.3 ± 1.8 cm) and under tube length cases was 9.1 % (2/22 cases, under length: -10 ± 0.0 cm). Furthermore, Height correlated with length of nasogastric tube using gastric babble sound for positioning in nasogastric tube insertion on general anesthesia (R = 0.505; p = 0.000) and length after adjustment using chest X-ray (R = 0.494; p = 0.000). Conclusions: The chest X-ray seems to be useful for positioning in nasogastric tube insertion on general anesthesia for oral and maxillofacial patients.

Objective:Our study aimed to evaluate two modified nasogastric tube (NGT) insertion techniques in intubated patients compared to the conventional method in respect of first attempt success rate, time taken for insertion, and complications.Methods:In this prospective interventional study, patients with orotracheal intubation requiring NGT insertion were randomly allocated into three groups by SNOS Group A (control group- standard sniffing position, n = 40), Group B (additional flexion of the neck, n = 40), Group C (standard sniffing position with lateral neck pressure, n = 40). The number of attempts for successful NGT insertion, time for insertion, and complications were compared.Results:Modified positions showed a high first-attempt success rate in Group B (55%) and Group C (85%) as compared to conventional Group A (32.50%) (P < 0.001). On intergroup analysis of modified groups (B and C), Group C was superior to Group B in 1st attempt success rate with a significant P value of 0.003.Conclusion:In intubated patients, NGT insertion in standard sniffing position with lateral neck pressure has the highest first attempt success rate followed by additional flexion of neck position. Both the modified positions are better positions for NGT insertion in intubated patients.

Dear Editor, Insertion of a nasogastric tube (NGT) in an anaesthetised, intubated patient can become challenging. The conventional method of blind NGT insertion has a success rate of approximately 40–58%.[1] After obtaining patients' consent and ethical clearance, we selected 20 anaesthetised, intubated patients posted for surgery (1st to 31st January 2022). Patients who needed general anesthesia with intubation and NGT placement (laparoscopic surgery, gastrointestinal surgery, etc.) were included in our study. Patients with skull base fracture, coagulopathy, nasopharyngeal and oesophageal pathology, and head and neck radiotherapy were excluded. Size 16 French, 105 cm NGT was used. NGT insertion was performed by a single anaesthesiologist. After intubation, the head was kept in a neutral position using an intubation pillow (8–10 cm height soft pad placed under the occiput). NGT length was estimated by measuring the distance from the xiphoid process to the nostril via the earlobe. The proximal end of the NGT was lubricated with water-based jelly and inserted through the larger nostril. Once NGT entered the nasopharynx, it was gently inserted further and simultaneously rotated in a clockwise direction continuously using the right hand. The remaining length of the NGT was straightened with its distal end held with the left hand and rotated continuously in the same direction so that the NGT rotates in toto. If any resistance was faced, the NGT was withdrawn a little and reinserted with continuous clockwise rotational movements. Correct placement of NGT was confirmed with epigastric auscultation. Time taken for NGT insertion was noted. A laryngoscopy was done to look for kinking of NGT or bleeding in the oral cavity. If the first attempt failed, NGT was cleaned and reinserted by a similar technique. Time taken for the second attempt of NGT insertion was noted. It was considered as failed, after the failed second attempt. NGT insertion was then guided by laryngoscope and Magill forceps. Demographic characteristics and procedural parameters are summarized in Table 1. Eleven patients were of normal weight, six were overweight and three were obese. NGT insertion was successful in the first attempt in 19/20 patients and in the second attempt in 1/20 patients. In one patient where the first attempt of NGT insertion was unsuccessful, both bleeding and full coiling were noted. The shortest and longest time taken for the procedure was 14 and 55 seconds respectively. Fourteen patients (70%) NGT was inserted in ≤30 seconds and six patients (30%) in >30 seconds. Two patients had right nasal intubation because of carcinoma tongue. In both these patients, NGT was inserted through the left nostril successfully in the first attempt. Three patients had developed a single coil of NGT in the oropharynx because of over-insertion. Common sites of NGT misplacement are piriform sinus, arytenoid cartilage, oesophagus, and lungs.[2] Several techniques like neck flexion, lateral neck pressure, and reverse sellick maneuver had been tried with different success rates (85% vs 85% vs 80%, respectively).[3] Strengthening the distal portion of NGT by freezing (85% success)[4] or threading guide wire (96% success)[3] improves the ease of insertion. Despite GlideScope or Macintosh laryngoscope-guided NGT insertion being successful, it can limit the space for manipulation of Magill forceps. NGT insertion by SORT (Sniffing position, orientation of NGT, contralateral Rotation, Twisting) technique has also shown good results (97%).[2] However, with rotational movement alone, we had successful NGT insertion in all the patients. Thus, we hypothesize that if the NGT tip faces any resistance during insertion, the continuous rotational movement will deflect the tip from resistance. The tip will then find the path of least resistance to the oesophagus. This is a very simple technique that nurses can perform easily. As the neck position is not altered, this technique can be helpful in anesthetized cervical spine fracture patients. Also, this technique may be convenient in anesthetized patients with facial bone fractures or intra-oral lesions, as there is no necessity for devices like laryngoscope or Magill forceps.Table 1: Patient demographics and procedural parametersFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Background: Nasogastric tube (NGT) insertion is an essential procedure in the operating room for which the anesthesiologists often take the responsibility. This simple procedure often becomes difficult in anesthetized patients. Literature reveals the flooding of studies and novel techniques are in the pipeline, indicating that quest for the best is still on. Aims and Objectives: The aim of the study was to determine the proportion of patients in whom successful NGT insertion would be possible in the first attempt using either the “Reverse Sellick’s maneuver (RSM) with throat pack in situ” technique or RSM alone; and to compare the proportions between the two groups. Materials and Methods: This interventional study was performed on 222 adult patients (≥18 years), undergoing abdominal surgeries requiring intraoperative NGT insertion. Patients received NGT insertion using the combined RSM with “throat pack in situ” technique (Group A, n=111) or RSM alone (Group B, n=111). The proportion of patients in whom successful NGT insertion was possible in the first attempt using either of the techniques and the time taken for correct placement of NGT in both the groups. In addition, the incidence of adverse events was noted. Results: Although, NGT placement was possible in higher proportions of patients in Group A in first attempt compared with Group B (91% vs. 83.8%), it was not significant on analysis (P=0.106). The procedure time in both the groups was comparable (30.0±4.0 vs. 29.9±4.3, P=0.859). Coiling was found to be significantly more in the RSM alone technique as compared to the combined method. (P=0.04). Conclusion: With comparable success rate and lesser incidence of adverse events, it can be commented that the RSM with throat pack in situ technique appears to be a better alternative to RSM alone.