Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Visit old site
Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 2636


 
 Table of Contents  
TECHNICAL ARTICLE
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 68-70

A new technique to insert nasogastric tube in an unconscious intubated patient


Department of Critical Care Medicine, SGPGIMS, Rai Bareilly Road, Lucknow, Uttar Pradesh, India

Date of Web Publication17-Jan-2013

Correspondence Address:
Tanmoy Ghatak
Rammohan Pally, Arambagh Hooghly, West Bengal - 712 601
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.106215

Rights and Permissions
  Abstract 

Background: Insertion of a nasogastric tube in an unconscious intubated patient may be difficult as they cannot follow the swallowing instructions, and therefore has a high first attempt failure rate. Aim and Methods: We describe here a new technique to insert nasogastric tube in an unconscious intubated patient by neck flexion and using angiography catheter as a stylet and manipulating the cricoid ring of trachea for easy passage of nasogastric tube. Results and Conclusions: The technique is easy and helpful for nasogastric insertion in unconscious intubated patients. Additionally, it neither alters vital responses nor increases intracranial pressure like with laryngoscopy.

Keywords: Cricoid cartilage, Nasogastric tube, Samanta and Ghatak′s technique


How to cite this article:
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. North Am J Med Sci 2013;5:68-70

How to cite this URL:
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. North Am J Med Sci [serial online] 2013 [cited 2019 Nov 12];5:68-70. Available from: http://www.najms.org/text.asp?2013/5/1/68/106215


  Introduction Top


With the proven supremacy of enteral nutrition, nasogastric (NG) tube insertion is now a must to deliver nutrition or medication in hospital wards and intensive care. [1] Patient cooperation by swallowing on instruction while inserting an NG tube is important. As unconscious patients cannot follow the swallowing instructions, NG tube insertion in an unconscious intubated patient may be difficult, often having high first attempt failure rates (nearly 50%). [2] After each unsuccessful insertion, incidences of mucosal bleeding and hemodynamic complication increase. [3] We are describing a new technique to insert NG tube in such patients.


  Materials and Methods Top


Emergency critical care help was asked for difficult NG tube insertion in a 48-year-old male patient with intracerebral hemorrhage who had an acute myocardial infarction 4 days back. Six failed attempts were already made by ward residents. They felt that the NG tube was coiling in upper esophagus, but nobody did a laryngoscopic examination in view of raised intracranial pressure. The patient was unconscious, moving limbs to painful stimulus only with bilateral mid dilated pupil. He was hemodynamically stable with normal perfusion parameters, maintaining a mean blood pressure >85 mm Hg. He was intubated with 8.5-mm-internal diameter cuffed endotracheal tube and mechanically ventilated (PaCO 2 < 35 mm Hg) and kept in a head-up neutral position in a calm isolated room. We packed the selected nostril (relatively large-sized right nostril) with a sterile gauge, adding 3 ml lignocaine 2% with adrenaline (1:200,000). His endotracheal tube cuff was checked to prevent over-inflation and was inflated to that extent that obscure visible leak in the ventilator. Then a 6-Fr sterile angiography catheter (Medtronic, Minnesota, USA) (previously used for angiography, but thoroughly washed with saline after 2% glutaraldehyde treatment for 10 min [4] ) was placed in a 12-Fr NG tube [Figure 1]. The NG tube was then lubricated with 2% lignocaine jelly and inserted gently through the selected nostril with mild flexion of the patient's neck. As the tube entered around 20 cm, the internist identified cricoid cartilage and externally pulled it outward and rightward in a controlled way [Figure 2]. With maintaining this pull, the NG tube (with angiography catheter in situ) was pushed with another hand smoothly. After insertion of 50 cm, angiography catheter was removed with a gentle traction after releasing the outward cricoid pull. Successful insertion of the NG tube in our case was confirmed by auscultating a gurgling sound over the epigastrium after injecting 20 ml of air through the nasal end of NG tube. His vitals were stable during the whole procedure. After the whole procedure, the angiographic catheter was kept in 2% glutaraldehyde solution.
Figure 1: Nasogastric tube with angiography catheter placed inside (arrowed)

Click here to view
Figure 2: Outward and rightward pull of trachea externally at cricoid level (Samanta and Ghatak's technique). Thyroid cartilage is arrowed

Click here to view



  Results and Discussion Top


Unconscious intubated patients cannot follow the instructions to swallow, like awake patients, and cannot help in successful insertion of the NG tube. This is a major drawback in intubated patients. Not only this, but also failures during NG tube insertion in unconscious intubated patients are firstly due to softening of tube during placement on exposure to body temperature and secondly due to impaction of NG tube tip.

The modern soft and atraumatic NG tubes are made up of polyurethane which becomes more soft on exposure to patient's body temperature. [5] Additionally, several non-opposing lateral eyes like opening near the tip make the NG tube more prone for kinking. [6] Moreover, a curved NG tube (when it is in the packet) promotes coiling in the mouth than a straight tube. [7] Stiffening of NG tube can be done by various techniques like cooling of the NG tube with iced saline, and by using a guitar wire or ureteral catheter as a stylet. [2] We used a smaller-diameter NG tube (12 Fr) to decrease the incidence of iatrogenic sinusitis and the patient discomfort. [8] So, we used angiography catheter as a stylet in our case to strengthen the small-bore NG tube. To decrease the intraoral coiling of NG tube in an intubated patient, intraoral manipulation of the NG tube is described as a method. [7] We feel this technique will not help much in intensive care setting where we do not prefer to use muscle relaxants.

Piriform sinuses and arytenoid cartilages areas are the most common sites of NG tube impaction. [9] Lateral neck pressure/thyroid cartilage traction anteriorly can allow the successful passage of NG tube. [9] We handled the impaction issue with flexion of the patient's neck (keeping the tube proximal to posterior pharyngeal wall [10] ) and by outward and rightward traction of the trachea at the level of cricoid cartilage. In addition to collapse of the piriform recesses and anterior movement of arytenoid cartilage, by manipulating the cricoid cartilage we can separate trachea from esophagus effectively, making room for NG tube [Figure 3]. Our technique is based on two concepts: Firstly, NG tube is impacted at arytenoid cartilage level [9] and secondly, in intubated patients, inflated balloon of tracheal tube can cause obstruction of the NG tube, especially in a setup where cuff pressure measurement is not common. [11] Additionally, cerebroprotection was an issue in our case, so we did not use the laryngoscope (that could increase intracranial pressure further). Our technique also helps in decreasing the aspiration and ventilator-associated pneumonia chances as we are also in favour of inflating the tracheal tube cuff. [12] However, we feel further studies based on our new technique are needed to prove ease and supremacy of the technique.
Figure 3: Concept behind Samanta and Ghatak's technique. Anterior movement of arytenoid with separation of trachea and esophagus following pull at cricoid level

Click here to view


 
  References Top

1.Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: Review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429-33.  Back to cited text no. 1
[PUBMED]    
2.Appukutty J, Shroff PP. Nasogastric tube insertion using different techniques in anesthetized patients: A Prospective, randomized study. Anesth Analg 2009;109:832-5.  Back to cited text no. 2
[PUBMED]    
3.Chun DH, Kim NY, Shin YS, Kim SH. A randomized, clinical trial of frozen versus standard nasogastric tube placement. World J Surg 2009;33:1789-92.  Back to cited text no. 3
[PUBMED]    
4.Rutala WA, Weber DJ. Healthcare infection control practices advisory committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. (Accessed April 20, 2010, at http://www.cdc.gov/hipac/pdf/guidelines/Disinfection_ Nov_2008.pdf ).  Back to cited text no. 4
    
5.Boyes RJ, Kruse JA. Nasogastric and nasoenteric intubation. Crit Care Clin 1992;8:865-78.  Back to cited text no. 5
[PUBMED]    
6.Tsai YF, Luo CF, Illias A, Lin CC, Hu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99.  Back to cited text no. 6
    
7.Kumar P, Girdhar KK, Anand R, Dali JS, Sheshadri TR. Nasogastric tube placement in difficult cases: A novel and simple maneuver. J Anaesth Clin Pharmacol 2005;21:429-34.  Back to cited text no. 7
    
8.Ramkrishnan K, Mold JW. The place of nasogastric tube. J Okla State Med Assoc 2002;95:535-8.  Back to cited text no. 8
    
9.Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: Fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43.  Back to cited text no. 9
[PUBMED]    
10.Mahajan R, Gupta R. Another method to assist nasogastric tube insertion. Can J Anaesth 2005;52:652-3.  Back to cited text no. 10
[PUBMED]    
11.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.  Back to cited text no. 11
    
12.Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Adherence to standard nursing protocols on nasogastric tube feeding in a secondary referral hospital in Ghana: comparing self-ratings by professional and auxiliary nurses
Robert Kaba Alhassan,Richard Tsikata,Richard Naatu Tizaawaw,Prince Asante Tannor,Perpetual Praba Quaw,Cecilia Aba Ata Awortwi,Martin Amogre Ayanore,Agani Afaya,Solomon Mohammed Salia,Japiong Milipaak,Prudence Portia Mwini-Nyaledzigbor
BMC Health Services Research. 2019; 19(1)
[Pubmed] | [DOI]
2 Cervical Subcutaneous Emphysema following Total Laryngectomy: An Unusual Complication of Nasogastric Intubation
Guled M. Jama,Behrad Barmayehvar,Sanjay Vydianath,John Mathews,Catherine Spinou
Case Reports in Otolaryngology. 2019; 2019: 1
[Pubmed] | [DOI]
3 Comparação de diferentes métodos de inserção de sonda nasogástrica em pacientes anestesiados e intubados
Ali Sait Kavakli,Nilgun Kavrut Ozturk,Arzu Karaveli,Asuman Arslan Onuk,Lutfi Ozyurek,Kerem Inanoglu
Brazilian Journal of Anesthesiology. 2017;
[Pubmed] | [DOI]
4 NASOGASTRIC TUBE PLACEMENT- A SIMPLE YET DIFFICULT PROCEDURE- A REVIEW
Mohanchandra Mandal,Dipanjan Bagchi,Susanta Sarkar,Piyali Chakrabarti,Suchitra Pal
Journal of Evolution of Medical and Dental Sciences. 2017; 6(31): 2572
[Pubmed] | [DOI]
5 Reinforcing of the blocker tube of air-Q blocker device
Rajesh Mahajan,Roshini Gupta,Smriti Gulati,Robina Nazir
Journal of Clinical Anesthesia. 2016; 34: 414
[Pubmed] | [DOI]
6 Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients
Ali Sait Kavakli,Nilgun Kavrut Ozturk,Arzu Karaveli,Asuman Arslan Onuk,Lutfi Ozyurek,Kerem Inanoglu
Brazilian Journal of Anesthesiology (English Edition). 2016;
[Pubmed] | [DOI]
7 Measures to facilitate endotracheal tube-assisted orogastric tube insertion
Gao-Pu Liu,Fu-Shan Xue,Rui-Ping Li,Chao Sun,Gui-Zhen Yang
The American Journal of Emergency Medicine. 2014;
[Pubmed] | [DOI]
8 Difficult tracheostomy tube insertion rescued by an angiographic catheter
Rudrashish Haldar,Sukhen Samanta,Prakhar Gyanesh
Journal of Anesthesia. 2013; 27(5): 787
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results and Disc...
References
Article Figures

 Article Access Statistics
    Viewed3072    
    Printed70    
    Emailed0    
    PDF Downloaded484    
    Comments [Add]    
    Cited by others 8    

Recommend this journal