Nasogastric Tube Insertion Research Articles

Another simple technique for nasogastric tube insertion in anaesthetised, 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 If any resistance was faced, the NGT was withdrawn a little and reinserted with continuous clockwise rotational movements.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.

Capnography for catheter location confirmation in minimally invasive surfactant administration.

Minimally Invasive Surfactant Treatment (MIST) is a common method for administering surfactant as a treatment for respiratory distress syndrome. However, tracheal catheter placement can be difficult to confirm. We assessed the presence of carbon dioxide (CO2) in tracheal and esophageal gas aspirated using CO2 detector. Retrospective arm: 20 infants, MIST catheter placement was assessed with a CO2 detector in two techniques and confirmed with clinical response. Prospective arm-10 infants, aimed to check for CO2 presence in aspirated esophageal gas during routine nasogastric tube insertion. Retrospective arm: All infants had positive capnography. One infant that had no clinical response to MIST was diagnosed with total anomalous pulmonary venous return. All 10 infants of the prospective arm had a Negative capnography (P < 0.001, Fisher's exact test). Readily available CO2 detectors can distinguish between tracheal and esophageal placement of MIST catheters prior to MIST.

Content validity and inter-rater reliability of procedural skill checklists used in the online OSCE scoring management system

Introduction: The use of online Objective Structured Clinical Examination (OSCE) scoring system in medical and nursing education is emerging. To ensure valid student’ score, the OSCE check lists need to be assessed for its validity and reliability. This study aims to test the validity and reliability of several procedural check lists commonly used in nursing profession such as peripheral intravenous insertion, electrocardiogram placement, nasogastric tube insertion, urinary catheter insertion and oxygenation procedure. Methods: The expert consensus was used to generate items, content validity index and inter-rater reliability was used to evaluate the validity and reliability of the check lists. Five experts assessed the content validity of the checklists and five raters used the check list to evaluate performance of 11 students. Data were collected from April to May 2022. The panel experts rated the content relevance of each instrument using a four-point rating scale. Item level and scale level content validity index were calculated. Inter-rater reliability was calculated using Fleiss Kappa. Results: The item validity index for the five check lists reviewed showed relatively high content validity among experts. I-CVI for each tool was very good, ranging from 0.8 to 1. The average content agreement (S-CVI/Ave) and the universal agreement (S-CVI/UA) for each check list were also very good. The inter-rater reliability results indicated that the agreement among raters was ranged from moderate to very good/excellent. The lowest Kappa value was for the nasogastric insertion check list (0.40, 95%CI 0.40 – 0.41) and the highest Kappa value was for the oxygenation check list (1, 95% CI 0.99 – 1). Conclusion: The face validity was reported as easy to understand and presented logically. Nonetheless, re-formatting of some items and addition of details in the checklists are needed to avoid ambiguity, which could lead to confusion for the examiner and examinee.

Iatrogenic Neonatal Esophageal Perforation: A European Multicentre Review on Management and Outcomes.

The aim of this multicenter retrospective study and literature review was to review management and outcomes of neonatal esophageal perforation (NEP). Protocol data were collected from four European Centers on gestational age, factors surrounding feeding tube insertion, management and outcomes. The 5-year study period (2014-2018) identified eight neonates with median gestational age of 26 + 4 weeks (23 + 4-39) and median birth weight 636 g (511-3500). All patients had NEP from enterogastric tube insertions, with the perforation occurring at median 1st day of life (range 0-25). Seven/eight patients were ventilated (two/seven-high frequency oscillation). NEP became apparent on first tube placement (n = 1), first change (n = 5), and after multiple changes (n = 2). Site of perforation was known in six (distal n = 3, proximal n = 2 and middle n = 1). Diagnosis was established by respiratory distress (n = 4), respiratory distress and sepsis (n = 2) and post-insertion chest X-ray (n = 2). Management in all patients included antibiotics and parenteral nutrition with two/eight receiving steroids and ranitidine, one/eight steroids only and one/eight ranitidine only. One neonate had a gastrostomy inserted, while in another an enterogastric tube was orally successfully re-inserted. Two neonates developed pleural effusion and/or mediastinal abscess requiring chest tube. Three neonates had significant morbidities (related to prematurity) and there was one death 10 days post-perforation (related to prematurity complications). NEP during NGT insertion is rare even in premature infants after evaluating data from four tertiary centers and reviewing the literature. In this small cohort, conservative management seems to be safe. A larger sample size will be necessary to answer questions on efficacy of antibiotics, antacids and NGT re-insertion time frame in NEP.

Efficacy of Daikenchuto in the prevention of bowel obstruction in patients with colorectal cancer undergoing laparoscopic surgery: An observational study using a Japanese administrative claims database.

Daikenchuto is an herbal medicine widely used in Japan without clear evidence to prevent bowel obstruction after abdominal surgery. We evaluated the efficacy of Daikenchuto in laparoscopic surgery for colorectal cancer (CRC). We included patients from the medical claims databases diagnosed with CRC between January 2012 and December 2019 and treated with laparoscopic surgery. We compared the Daikenchuto and control groups to evaluate early bowel obstruction (EBO) events for 1year. The Daikenchuto group included patients prescribed Daikenchuto on postoperative day (POD) 0 or 1. An EBO event was defined as the use of a nasogastric tube, transnasal ileus tube, endoscopic balloon dilatation, or the requirement of reoperation for bowel obstruction from PODs 1 to 364. In total, 46,458 patients met the eligibility criteria; 2407 and 44,051 patients were included in the Daikenchuto and control groups, respectively. Some of the patient's characteristics were significantly different between the groups. The frequencies of EBO events in the Daikenchuto and control groups were 5.7% (95% confidence interval: 4.8-6.7) and 4.6% (4.4-4.8), respectively. The most frequent events were nasogastric tube (3.1%, 2.9%) and transnasal ileus tube insertions (1.4%, 0.8%) in the Daikenchuto and control groups, respectively. The hospital stay was significantly shorter in the Daikenchuto group than in the control; this trend was confirmed in the sensitivity analysis. Daikenchuto did not demonstrate efficacy for EBO. It might be adequate for shortening patient's hospital stay. Further studies are warranted.

Rectal stimulation with prebiotics and probiotics before ileostomy reversal: a study protocol for a randomized controlled trial

BackgroundIleostomy closure is associated with a high rate of postoperative morbidity, and adynamic ileus is the most common complication, with an incidence of up to 32%. This complication is associated with delayed initiation of oral diet intake, abdominal distention, prolonged hospital stay, and more significant patient discomfort. The present study aims to evaluate the rectal stimulus with prebiotics and probiotics before ileostomy reversal.MethodsThis is a protocol study for an open-label randomized controlled clinical trial. Ethical approval was received (CAAE: 56551722.6.0000.0071). The following criteria will be used for inclusion: adult patients with rectal cancer stages cT3/4Nx or cTxN+ that underwent loop protection ileostomy, patients treated with neoadjuvant chemoradiotherapy, and patients who underwent laparoscopic or robotic total mesorectal excision. Patients will be randomized to one of two groups. The intervention group (with rectal stimulus): the patients will apply 500 ml of saline solution with 6 g of Simbioflora® rectally, once a day, for 15 days before ileostomy closure. The control group (without rectal stimulation): the patients will close the ileostomy with no previous rectal stimulus. The primary outcomes will be the adynamic ileus (need for postoperative nasogastric tube insertion; nausea/vomiting; or intolerance to oral feedings within the first 72 h) and intestinal transit (time to first evacuation/flatus).ResultsThe patient’s enrollment starts in January 2023. We expect to finish in July 2025.DiscussionThe findings of this randomized clinical study may have important implications for managing patients undergoing ileostomy reversal.Trial registrationThis study is registered in the Brazilian Trial Registry (ReBEC) under RBR-366n64w. Registration date: 19/07/2022

Post-Stroke Pneumonia in Real-World Practice: Background, Microbiological Examination, and Treatment.

Post-stroke pneumonia (PSP) has an impact on acute ischemic stroke (AIS). Although predictive scores for PSP have been developed, it is occasionally difficult to predict. Clarifying how PSP was treated after its onset in clinical practice is important. Admitted patients with AIS over a 2-year period were retrospectively reviewed. Of 281 patients with AIS, 24 (8.5%) developed PSP. The integer-based pneumonia risk score was higher in patients with PSP. The onset of PSP was frequently seen up to the 4th day of hospitalization. Of patients with PSP, sputum examination yielded Geckler 4 or 5 in only 8.3%. Angiotensin-converting enzyme inhibitor (ACE-I) was more frequently administered to patients with PSP; however, all these cases were started with ACE-I following PSP onset. Nasogastric tubes (NGTs) were inserted in 16 of the patients with PSP, of whom 11 were inserted following PSP onset. Multivariate analysis showed that PSP onset was a poor prognostic factor independent of the female sex, urinary tract infection, and National Institutes of Health Stroke Scale. PSP treatment would benefit from the administration of antimicrobials and ACE-I, as well as NGT insertion. To select effective agents for PSP and evaluate the indications for NGT insertion, further case studies are needed.

Self-Perceived Competence of Primary Healthcare Physicians in Managing Medical Emergencies in Health Centers; Kingdom of Bahrain: A Cross-Sectional Study

Background: Primary care physicians (PCPs) are the first point of contact for individuals when seeking healthcare and the cornerstone for providing a wide variety of preventive and curative services. Family physicians and general practitioners in primary care often encounter medical emergencies and their role in dealing with emergencies is essential to improve the patient’s outcome. Data about self-perceived competence of primary care physicians in dealing with emergencies in primary care in the Kingdom of Bahrain are lacking. This study aims at assessing the self-perceived competence of primary healthcare physicians in dealing with emergencies in primary care settings. Methods: A descriptive questionnaire-based cross-sectional study of primary healthcare family physicians and general practitioners in the Kingdom of Bahrain was conducted in January to February 2022. A total of 375 family physicians and general practitioners working in health centers were identified from Ministry of health database and 7 element anonymous self-administered electronic questionnaires were sent to their email to evaluate their level of competence in managing emergencies. Results: out of 375 PCPs; 184 (45.5%) participated and returned answered questionnaires. Most of the PCPs were females 117 (83.6%) with median age of 35 years. Regarding the level of competency in managing emergencies the majority either agreed feeling competent (37.5%) or were not sure if they feel competent in managing emergencies in primary care(37.5%).The study did not find any statistical significance or correlation between the reported competency among primary care physicians(PCPs) and age (P=0.486), years of practice(P=0.462), specialty(P=0.053), or the attended course; basic life support (BLS)(p=0.334),advanced cardiovascular life support (ACLS) (P=0.156), advanced trauma life support (ATLS)(P=0.691), pediatric advanced life support (PALS) (P=0.920).Study revealed that highest number of participants reported not feeling comfortable in dealing with major and multiple traumas in adults (n= 67, 47.86%) and pediatrics (n= 63, 45%) . The lowest level of competence in performing emergency skills was found in transcutaneous pacing, cardioversion, and nasogastric tube (NGT) insertion at which PCPs reported that they wouldn’t know how to start transcutaneous pacing (n= 67, 47.9%), while (n= 51, 36.4%) would perform cardioversion and nasogastric tube insertion (n= 43, 30.7%) only if no-one else was available. Most PCPs (n= 137, 97.9%) think that they need training in emergencies and the preferred method is practical training in health center by qualified staff (n= 122, 87.1%). Conclusion: Based on study findings, more efforts should be directed towards practical training of healthcare physicians in dealing with emergencies and the barriers should be explored. More practical training sessions should be devoted to pediatric emergencies, transcutaneous pacing, and cardioversion.

LMA Protector ve Baska Maskın Retrograd Üreteroskopik Cerrahide Karşılaştırılması: Prospektif Randomize Klinik Çalışma

Objective: The Baska and the Protector Laryngeal masks are single-use second-generation supraglottic airway devices with a dual gastric channel. Material and Methods: 64 American Society of Anesthesiologists physical status 1-2 patients between the ages of 18-70 undergoing retrograde ureteroscopic surgery enrolled in this prospective randomized study. Results: Demographic airway variables and airway characteristics were similar between the groups. Insertion time was shorter in the Baska mask group [14 (11-20) versus 20 (13-27) seconds, p=0.035]. The need for optimization maneuvers during insertion was higher for the Baska mask group (p=0.009). The laryngeal mask airway (LMA) insertion was easier in the LMA Protector group (p=0.023). The first insertion success rate was 75% for the LMA Protector and 84% in the Baska mask. The total success rate of both devices was 91%. Nasogastric tube insertion was faster in the Baska mask group [14 (12-15) versus 17 (13-25) seconds; p=0.003]. Fiberoptic views were similar between the groups. Minute volume after insertion of the device was higher in the LMA Protector group [8 (6.5-10) L/min versus 6 (5-7) L/min; p<0.001]. Expiratory tidal volume was higher in the LMA Protector group after insertion of the device, 15 minutes, 30 minutes, and 45 minutes after insertion (p<0.001, p=0.032, p=0.001, p=0.027 respectively). The end-tidal sevoflurane concentration (ETsevo) 30 minutes after device insertion was higher in the Baska mask group (1.49±0.38 vs 1.75±0.36; p=0.014). Conclusion: The LMA Protector is superior to the Baska mask in providing higher tidal volumes and decreased need for optimization maneuvers in retrograde ureteroscopic surgery.

Treatment of delayed cervical oesophageal perforation with T-tube

Cervical oesophageal perforation is a potentially life-threatening situation associated with pooled mortality of 5.9%. Early detection and referral to the thoracic surgery is important. We present a case of an obese lady admitted for foreign body ingestion and had an endoscopic removal of foreign body. Her general condition deteriorated two days later and the diagnosis of delayed cervical oesophageal perforation was made. She was managed surgically by placement of T-tube as controlled-fistula, nasogastric tube insertion and drain at superior mediastinum to control sepsis and contamination. Patient was discharged well despite prolonged hospital stay. T-tube drainage is established as safe and effective to manage delayed cervical oesophageal perforation.

Evaluation of the Effect of Nasogastric Intubation on Olfactory Function

Aim: To evaluate the olfactory functions in patients having had nasogastric intubation.&#x0D; Material and Methods: The study included 40 adult patients who underwent general anesthesia&#x0D; between January 2021 and June 2021 for elective abdominal surgery requiring a nasogastric tube&#x0D; (NGT) insertion. Olfactory function [Brief Smell Identification Test (B-SIT)] was evaluated prior to surgery&#x0D; and four weeks post-surgery in all the patients. The demographic characteristics of the patients, duration&#x0D; of NGT application, and B-SIT scores before and after NGT application were recorded. B-SIT scores&#x0D; were recorded separately for the NGT-applied and non-NGT-applied nasal side.&#x0D; Results: The mean NGT application time was 3.4 ± 1.5 (3-7) days. The mean preoperative and&#x0D; postoperative B-SIT scores of the NGT-applied side were 5.20 ± 2.06 and 5.01 ± 2.02, respectively.&#x0D; There was no statistically significant difference between the mean preoperative and postoperative B-SIT&#x0D; scores of the NGT-applied side (p = 0.421). The mean pre- and postoperative B-SIT scores of the&#x0D; patients in the non-NGT-applied nasal side group were 5.28 ± 2.16 and 5.11 ± 2.07, respectively. No&#x0D; statistically significant difference was found in the mean preoperative and postoperative B-SIT scores in&#x0D; the non-NGT-applied nasal side (p = 0.370). No statistically significant difference was found in the mean&#x0D; preoperative and postoperative B-SIT scores between the NGT-applied and non-NGT-applied nasal&#x0D; sides, respectively (p = 0.890, p = 0.654).&#x0D; Conclusion: The result of our study showed that there was no change in the olfactory function of&#x0D; patients after nasogastric intubation.

1153: BLIND NG TUBE INSERTION WITHIN 1 MINUTE OR 3 ATTEMPTS MINIMIZES MUCOSAL INJURY DURING RESUSCITATION

Introduction: Patients under resuscitation are at high risk for aspiration of gastric contents which causes ventilator-associated pneumonia. Therefore, blind nasogastric (NG) insertion is performed for decompression, however minimal trauma to the laryngopharynx can sometimes lead to severe bleeding in patients with a bleeding diathesis. Recently, the usefulness of NG tube placement under the assistance of a Video-laryngoscope (VLS) has reported. However, NG tube insertion is still performed blind, and insertion techniques to minimize mucosal injury during resuscitation are not well understood. We investigated laryngopharyngeal mucosal injury associated with blind NG tube insertion during resuscitation and considered practical blind NG tube insertion guidelines to minimize mucosal injury. Methods: We included patients (n = 84) with cardio pulmonary arrest on arrival in whom blind nasogastric tube insertion was possible within 120 s in the Blind group and those in whom it was not possible in the Difficult (Dif) group. In the Dif group, VLS-assisted nasogastric tube insertion was performed. The laryngopharyngeal mucosal condition was recorded after NG tube insertion using VLS. Patient background, success rates, insertion time, the number of insertions, and injury scores were evaluated. A single regression analysis was performed, and practical blind NG tube parameters for insertion during resuscitation were assessed. Results: Success rates in the Blind and Dif groups were 98.5% and 76.5%, respectively, and insertion times were 48.8 ± 4.0 and 54.8 ± 3.0 s, respectively. The number of insertions (2.1 ± 0.2 vs. 8.1 ± 0.8) and injury scores (1.04 ± 0.21 vs. 6.40 ± 0.64) in the Blind group were significantly lower than those in the Dif group, respectively. Mucosal injuries were most severe in the retropharyngeal wall in both groups. The number of insertions and insertion time both showed strong positive correlations with injury scores. Conclusions: The severity of laryngopharyngeal mucosal injury increased with increased insertion time and the number of insertions. Blind nasogastric tube insertion performed within 1 min or for a maximum of two or three attempts may minimize laryngopharyngeal mucosal injury, and VLS-assisted insertion should be considered if these limits are exceeded.

Large variations between NICU nurses in predicting nasogastric tube insertion length in a mannequin study.

To evaluate the inter- and intraindividual variation of predicted nasogastric tube insertion lengths by nurses working in two neonatal intensive care units in the Netherlands, using a mannequin model. A total of 110 nurses (55 nurses from Center A and 55 from Center B) were asked to predict the nasogastric tube insertion length on a neonatal mannequin. We evaluated the length and prediction method used by the nurses. We also estimated the number of tubes that would have correctly been placed in the stomach of a neonate according to the seize of the mannequin. The mean predicted insertion length of the nasogastric tube was 30.0cm with an interindividual variation of 12cm (range 24-36cm). The mean intraindividual variation was 0.75cm. The two centers used two different prediction methods in their local guidelines, but overall at least 6 different methods were used by the nurses. We estimated that 77% (85/110) of the tubes would have ended in the body of the mannequins stomach, while 10% (11/110) would have ended in the esophagus and 13% (14/110) would have ended against the stomach lining or in the duodenum. Nurses in two neonatal intensive care units used many different methods which lead to a large interindividual variation in predicted insertion lengths of the nasogastric tubes. Regular evaluations using this mannequin model could lead to more uniformity and reduce the risk of tube misplacement in neonates.

Interventions Employed By Licensed Nurses in Nursing Homes: Refinement and Validation of an Existing Omaha System Nursing Intervention Set.

Background and Purpose: Demands on long-term services and supports for older adults are growing, although geriatric workforce shortages have persisted for decades. Methods to define and quantify practice of licensed nurses in nursing homes are needed for work optimization within limited nurse resources available in nursing homes. This study aimed to refine and validate observable nursing interventions for nursing homes, using the Omaha System. Methods: Based on the existing corpus of Omaha System interventions for acute care nursing, this multi-phase, multi-method study included a mapping procedure of interviews from licensed nurses in nursing homes, the evaluation of content validity and coding of the interventions using a survey, and inter-observer reliability assessment using TimeCaT. Results: This study validated 57 observable interventions for nursing homes. Of the previously identified acute care nursing interventions, eight interventions were deemed out of scope. One additional intervention was identified. Refined intervention definitions were related to procedures common in acute care settings such as tracheal intubations/extubations and nasogastric tube insertion that were not performed in nursing homes. Expert agreement for content validity and coding of the interventions was high (S-CVI = 0.97), and inter-observer reliability levels (Cohen's κ value >0.4; proportion agreement >60%) were acceptable for all case studies. Implications for Practice: The validated observable Omaha System nursing interventions for nursing home practice have potential for use in future studies of nursing home practice to understand evidence-based practice, and gaps in care provided. The methodology may be extended to define observable interventions for other roles and settings.

Efficacy and Safety of Percutaneous Radiological Gastrostomy (PRG) as a Rescue Measure for Enteral Feeding in Patients with Advanced Head, Neck, and Upper Digestive Malignancies.

Background Percutaneous radiologic gastrostomy is an established mode of enteral feeding for nutritional support for patients with dysphagia from upper digestive tract malignancy. Its role as a rescue measure in patients with advanced malignancy, presenting with absolute dysphagia and failure of nasogastric tube insertion has not been well established. Purpose This study was performed to assess technical success and long-term outcomes of percutaneous radiologic gastrostomy (push type) for nutritional support for patients with absolute dysphagia as a last ditch nonsurgical rescue effort for enteral access. Materials and Methods This was a prospective observational study of 31 patients who underwent push-type percutaneous radiologic gastrostomy over a period of 2 years (March 2017-March 2019). The study was a part of a larger trial approved by the institutional ethics committee. Patients were followed till the removal of tube, death, or 1 year, whichever was earlier. Gastrostomy tube-related problems and complications were documented. Descriptive summary statistics were employed to analyze the success rate and complications. Results Thirty-one patients with mean age 56 years (26-78 years) including 18 males and 13 females with head and neck squamous cell cancer and esophageal cancer presenting with absolute dysphagia or significant dysphagia with failed nasogastric or endoscopic enteral access were included. Overall technical success was 93.5% (29/31), achieved in 26/31 patients with just fluoroscopy guidance and 3/5 patients with computed tomography guidance. One major (3.3%) and two minor (6.5%) complications were encountered. Five out of 29 gastrostomy tubes had to be exchanged, after a mean of 44 days (1-128 days) after insertion. Conclusion Percutaneous radiologic gastrostomy is a safe and effective intervention even as a rescue measure in patients with absolute dysphagia from advanced upper digestive tract malignancies.

Swallowing function after acute ischemic stroke: Development and validation of a novel clinical prognostic model.

BackgroundPredicting the duration of dysphagia after acute ischemic stroke (AIS) is important for clinical treatment decisions.ObjectiveThe purpose of this study is to assess the swallowing function of AIS patients and to develop and validate a prognostic model for the need for nasogastric tube (NGT) in these patients.Materials and methodsWe included 554 AIS patients during 2018–2019 as the development group and had 186 AIS patients as the external validation group. The primary end point of the study was the retention of NGT in patients 1 week after admission (Functional Oral Intake Scale ≤ 4). Swallowing function and stroke-associated pneumonia (SAP) at 1 month post-onset were also the objectives of this study. The volume-viscosity swallow test (V-VST) was used to assess the patient’s impaired swallowing function. The Predictive model was built by logistic regression.ResultsOverall, a total of 104 patients required indwelling NGT at 1 week of AIS onset in development group. The final prognostic model includes 5 variables: age (OR: 1.085, 95%CI: 1.049–1.123), neutrophil-to-lymphocyte ratio (NLR) (OR: 1.332, 95%CI: 1.090–1.626), NIHSS (OR: 1.092, 95%CI: 1.025–1.164), history of drinking (OR: 2.532, 95%CI: 1.452–4.417) and stroke location (Subtentorial vs. Supratentorial, OR: 1.954, 95%CI: 1.088–3.509). The prediction model had an AUC of 0.810, while the external validation group was 0.794.ConclusionIn stroke patients, it is very important to decide early whether to indwell a NGT. The nomogram will support decision making for NGT insertion and help these patients recover from their condition.

Gastric volvulus in the mediastinum through a hiatal hernia

Hiatal hernia (HH) is gastric herniation through the oesophageal hiatus into posterior mediastinum. We present an uncommon case of congenital sliding HH in healthy child, with organo-axial gastric-volvulus and normal mid-gut rotation. A 3-month-old female, presented with worsening coffee-ground vomiting for the last 6 weeks. Medical history was unremarkable. She was severely dehydrated with a soft abdomen and no obvious abdominal masses. Initial blood tests revealed elevated White Cell Count (WCC) mainly neutrophils, C-Reactive Protein (CRP) and lactate levels with normal electrolytes. CXR reported discontinuity of left hemi-diaphragm with the stomach shadow occupying the left lower hemi-thorax. The upper GI contrast study and chest CT-scan revealed stomach, pylorus and liver lobe wholly located in the chest, occupying the posterior mediastinum. Both sides of the hemi-thorax were clear, with no evidence of mid-gut malrotation. Radiological images confirmed presence of a large defect in posterior diaphragm around the midline, with stomach and liver herniating into the chest. Following resuscitation, nasogastric tube insertion and consent, a laparotomy revealed organo-axial volvulus of stomach and incarceration, along with the presence of a complete sliding HH through a large defect. Complete reduction of herniated contents, fundoplication and primary closure of defect undertaken. Uneventful post-operative recovery and discharged from hospital after 10 days. We present an infant with complete sliding HH complicated with organo-axial gastric volvulus. Such cases although rare, require high suspicion and prompt management in view of gastric volvulus, as mortality is considerable. With prompt evaluation and adequate resuscitation, we were able to provide immediate optimal surgical treatment and avoid unnecessary complications.

Assessment of risk factors for delayed gastric emptying after distal gastrectomy for gastric cancer

The risk factors for delayed gastric emptying (DGE) following gastrectomy are unclear. This study aimed to investigate the risk factors for DGE and the severity of DGE. We retrospectively evaluated 412 patients who underwent gastrectomy for gastric cancer between 2011 and 2019. The cases were classified into the DGE (n = 27) and non-DGE (n = 385) groups; the DGE group was further classified into two subgroups based on nasogastric tube insertion as an indicator of severity. For determining the relationship between resected stomach volume and DGE, we calculated the area of each surgical specimen using the ImageJ software. Female sex (odds ratio [OR] 2.55; 95% confidence interval [CI] 1.09–5.93; P = 0.03), diabetes (OR 2.38; 95% CI 1.02–5.57; P = 0.03), and distal gastric tumors (OR 2.61; 95% CI 1.10–6.19; P = 0.02) were identified as independent risk factors by multivariate analysis. The duration of hospital stay was longer in the DGE group than in the non-DGE group (29 vs. 15 days, P < 0.01). Overall, 24 cases of DGE (89%) were found in more than 1 week following surgery. No correlation was observed between clinical features and the severity of DGE. The resected area in the DGE group was significantly larger than that in the non-DGE group (198.0 vs. 173.9 cm2, P = 0.03). In conclusion, DGE was frequently observed in females and in patients with diabetes and distal gastric tumors. Most of the DGE cases occurred after 7–14 days of surgery, patients who are discharged early should be informed to seek hospitalization if they have symptoms caused by DGE.

Role of Endotracheal Tube Cuff Deflation in Facilitating Passage of Nasogastric Tube.

BackgroundNasogastric tube insertion is a routinely performed technique in anesthetized and intubated patients. However, failure leads to repeated insertion attempts causing injury, which makes the situation cumbersome. Therefore, we introduce a simple technique of deflating endotracheal tube cuff for nasogastric tube insertion in such patients.MethodsEighty adult patients scheduled for elective abdominal surgeries were randomly allocated into two groups, Group A (nasogastric tube insertion without endotracheal cuff deflation) and Group B (nasogastric tube insertion with endotracheal tube cuff deflation) along with lateral pressure application at cricoid in both groups. The number of attempts required, overall success rate, the time taken, rescue maneuvers, and incidence of complications were compared between the groups.ResultsIn Group B, the total success rate for nasogastric tube placement was significantly higher than in Group A (80% vs 55%, p=0.016). Group B had a 55% first attempt success rate, but only 25% of patients in Group A had a first attempt success rate (p=0.014). The overall time for successful nasogastric tube placement was longer in Group A than in Group B (65.4 ± 28.72 seconds vs 43.5 ± 25.37 seconds, p=0.0005). The differences in nasogastric tube kinking and coiling between Group B and Group A were not statistically significant (20% vs 22.5%, 10% vs 27.5%, p = 0.78 and 0.08, respectively). Mucosal bleeding was substantially higher in Group A than in Group B (30% vs 10%, p=0.025, respectively).ConclusionsThis study showed that endotracheal tube deflation significantly increased the first-attempt success rate, overall successful placement of the nasogastric tube in intubated patients, and incidence of complications like mucosal bleeding decreased.

The accuracy of methods for determining the internal length of a nasogastric tube in adult patients: a systematic review

Blind insertion of nasogastric (NG) tubes is performed for several reasons: nutrition and medication administration, gastric aspiration/decompression, and other, diagnostic reasons. Accidental intraesophageal and intestinal placement is common, and increases the risk of serious complications. Therefore, accurate determination of the internal length of the NG tube before placement is considered a prerequisite for achieving correct gastric positioning. We aimed to identify, assess, and summarize the evidence on the accuracy of methods for determining the internal length of an NG tube in adults. Cochrane Library, Excerpta Medica database (EMBASE), PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science were searched up to 31 January, 2022. Studies were eligible when reporting data on the accuracy of methods for determining internal NG tube length in adults. Study selection, risk-of-bias assessment, and data extraction were performed independently by 2 investigators. Risk-of-bias was assessed using the Cochrane Risk-of-Bias Tool and the Joanna Briggs Institute Critical Appraisal Checklist for Cross Sectional Studies. A narrative synthesis of the results was then conducted. Twelve articles were included in this review. All studies were observational, cross-sectional in nature, except for 1 randomized controlled trial. Ten methods for determining the internal length of an NG tube were described. Correctly positioned NG tubes ranged from 13% to 99%. Results showed that the tip of the nose-earlobe-xiphoid distance (NEX) + 10cm (mean: 59.9-60.7cm) and (NEX × 0.38696) + 30.37 + 6cm (mean: 56.6-56.7cm) could potentially result in accuracy as high as 97.4% and 99.0%, respectively. Current data do not provide conclusive evidence of 100% accuracy in finding a correctly placed NG tube when using a method for determining the internal length. Blind placement, using any of the documented methods, cannot be considered safe without additional verification of tube tip positioning. Furthermore, using any of these 10 methods does not reduce the risk of pulmonary intubation.This systematic review was registered at https://www.crd.york.ac.uk/PROSPERO/ as CRD42021243180.