Another simple technique for nasogastric tube insertion in anaesthetised, intubated patients.

Abstract

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 If any resistance was faced, the NGT was withdrawn a little and reinserted with continuous clockwise rotational movements.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.