Intraoperative wide bore nasogastric tube knotting: A rare incidence.

Nasogastric tubes are commonly used in anesthetic practice for gastric decompression in surgical patients intraoperatively. The indications for its use are associated with a number of potential complications. Knotting of small-bore nasogastric tubes is usually common both during insertion and removal as compared to wide bore nasogastric tubes. Knotting of wide bore nasogastric tube is a rare complication and if occurs usually seen in long standing cases. We hereby report a case of incidental knotting of wide bore nasogastric tube that occurred intraoperatively.

INTRODUCTION

Nasogastric tube insertion is a very frequently used procedure in various settings of hospital care including emergency care, operation theaters, Intensive Care Units (ICUs) and wards. This procedure is routinely performed by health care providers including anesthesia personnel. Knotting of the nasogastric tube during insertion and removal is rare, but it may lead to the serious complications including epistaxis, severe laryngeal injury, respiratory distress, and tracheoesophageal fistula.[12] Knotting of wide bore nasogastric tubes is even more uncommon and among the reported cases, knotting of wide bore nasogastric tube intraoperatively during its insertion is rare and not reported yet. This case report highlights the incidental knotting of wide bore nasogastric tube intraoperatively during its insertion with an endotracheal tube in situ.

CASE REPORT

A 40-year-old male patient of American Society of Anesthesiologists grade II with a diagnosis of the pseudopancreatic cyst was scheduled for elective exploratory laparotomy and gastrojejunostomy. After the induction and endotracheal intubation, a lubricated nasogastric tube of size 18 Fr was inserted blindly through the right nostril, but gets coiled in the oral cavity. So a next attempt was made with another 18 Fr nasogastric tube as previous tube get kinked. Resistance was encountered while advancing tube further, so laryngoscope and Magill forceps were used. But after some length it again offered resistance. For confirmation of correct placement of tube aspiration of gastric contents was done but negative and surgeon also couldn't palpate the tube in the stomach. We tried to pull it out, but couldn't as its distal end got stuck in the nasopharynx. We again moved it forward and tried to pull it out gently while rotating but all in vain. Then laryngoscopy was done, and a knot found which was then pulled out with Magill forceps [Figure 1]. It was a true knot at the distal end of the nasogastric tube. Knot was opened up, and the nasogastric tube was withdrawn. There was minimal trauma and bleeding in the nasopharynx. No other complications were seen. Postoperatively, the patient had no complaint and was discharged on the 7th day [Figure 2].

Figure 1

True knot of wide bore nasogastric tube seen at its distal end after it is withdrawn using Magill forcep

Figure 2

True knot at its distal end (lateral view)

DISCUSSION

Nasogastric tubes are frequently used intraoperatively for various surgical procedures and its insertion are associated with several minor and major complications including nasal irritation, epistaxis, sinusitis, pneumothorax, lung aspiration, intravascular penetration, respiratory distress, intracranial entry, enteral complications, and coiling.[34]

Risk factors for knotting of nasogastric tube appears to include small bore tubes, insertion of excess length into the stomach, and interference encountered due to the endotracheal tube in an intubated patient.[56] Once knotted, the traction during an attempt to remove it, tightens the knot.[7] In our case resistance offered by pharyngeal tissue or endotracheal tube and advancement of the long length of the tube may lead to kinking and knotting of a nasogastric tube. Previous case reports on knotting of the nasogastric tube have usually involved tubes that were in situ for a prolonged duration, usually from 1 to 12 days.[89] In our case, knotting of nasogastric tube occurred during the second attempt at insertion intraoperatively. So, we want to highlight the fact that it is not necessary that knotting of a nasogastric tube is always associated with the prolonged duration of intubation, but this can occur during its insertion also. Wide bore nasogastric tubes and avoiding insertion of an excess length of nasogastric tube into the stomach may minimize this complication. In our case, although the tube was a wide bore, but coiling of the tube with further advancement of tube and the presence of endotracheal tube could have been causative factors. Only the required length of the tube should be inserted, and this length should be determined by measuring from the nostril along the side of the face past the tragus of the ear to the xiphoid process. The appropriate length which is required should be marked with a measuring tape or by noting the mark on the tube just beyond this point. So finally, we conclude from this case report that it is not necessary that knotting of nasogastric tube occurs in long-standing cases (ICU's or wards) or with smaller diameter tubes but it can occur intraoperatively during insertion also even with a wide bore tube. So the nasogastric tube should be inserted after measuring the adequate length of the tube. Once the resistance is met during its insertion, it should not be pushed further as it will lead to coiling of nasogastric tube, and thus knotting can occur. Hence, knotting of the nasogastric tube should always be kept in mind when the difficulty is encountered upon the removal and diagnosis can be confirmed by direct laryngoscopy or radiologically by plain X-ray.

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Conflicts of interest

There are no conflicts of interest