Intraoperative Nasogastric Tube Insertion with Non-ProSeal Laryngeal Mask Airway in Place

Abstract

To the Editor: It is difficult to place a nasogastric tube (NGT) behind a properly positioned laryngeal mask airway (LMA). We describe a simple technique of NGT insertion in two patients who had an LMA in place. The first patient was a non-fasted primigravida scheduled for emergency cesarean section for fetal bradycardia. Following several failed intubation attempts, a #3.0-LMA-Classic™ was used to secure the airway. After safe delivery of the baby, the surgeon requested placement of an NGT for stomach evacuation. A well-lubricated 6.0-mm inner diameter cuffed red rubber endotracheal tube (ETT) (Rusch, Munchen, Germany) was passed through right nostril into the nasopharynx and further into hypopharynx, where the cuff was inflated to maximum. The NGT (Romsons Sci & Surg Ltd., Agra, India) was introduced through the nasal ETT into the stomach without difficulty (Fig. 1). Residual fluid (50 mL) and gases were suctioned.Figure 1.: Side view of the patient showing nasogastric tube placed through nasal cuffed red rubber tube behind laryngeal mask airway cuff.The second case was a 55-yr-old woman scheduled for laparoscopic abdominal hysterectomy. Again, after several failed intubation attempts, a #3.0 intubating LMA (ILMA-Fastrach™) was inserted to secure the airway. A fiberoptic bronchoscope (FOB)-assisted ILMA endotracheal tube was then guided into the trachea. We could not remove the LMA because the stabilizing rod was unavailable. The surgeon requested for evacuation of gases before institution of carboperitoneum and trocar insertion. A well-lubricated NGT with a soft angiographic guide wire was passed into the nasopharynx. An orally introduced FOB was advanced behind the ILMA cuff and used to guide the NGT behind the partially inflated ILMA cuff. Both were advanced concurrently (cm by cm; NGT first, then FOB, and so on). Once the NGT was advanced beyond the hypopharynx (the tip of LMA), the NGT alone was advanced into the esophagus and subsequently into the stomach (Fig. 2).Figure 2.: Lateral fluoroscopic image depicting intubating laryngeal mask airway (ILMA) and ILMA - tracheal tube in place. Nasogastric tube is passed behind the ILMA.Meta-analysis has shown that gastric tube insertion is less successful behind the LMA cuff as compared with via the drain tube (1). Ozer et al. delineated the utility of FOB imaging to avoid failure of NGT insertion in intubated patients (2). Our first method used an inflated red rubber ETT cuff to displace the LMA cuff forward whereas the second technique used FOB-guided NGT insertion. These techniques may be helpful for nasogastric tube insertion in patients with an LMA in place. Amitabh Dutta, MD Neelam Ganguly, MD Jayashree Sood, MD, FFARCS, PGDHHM V.P. Kumra, MD, DA, DAC Department of Anaesthesiology, Pain & Perioperative Medicine Sir Ganga Ram Hospital New Delhi, India [email protected]