A Novel and Innovative Way of Nasogastric Tube Insertion in Anesthetized Intubated Patient.

Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate.

INTRODUCTION

Nasogastric tube (NGT) is usually required for various diagnostic and therapeutic procedures. During surgery, NGT is put to as guide during various gastro–surgery procedures, decompression, and drainage of the stomach or for postoperative feeding/medications. It is easy to put NGT in awake and cooperative patient. NGT insertion in an anesthetized intubated patient is difficult and cumbersome with more than 50% failure rates after the first attempt.[1] It is also associated with each episode of unsuccessful insertion, increase incidences of mucosal bleeding and hemodynamic complication, coiling, kinking, and knotting, etc.[23]

CASE REPORT

NGT placement failure in the first time is quite higher it may delay in the start of surgical procedure in anesthetized patients. We had tried almost all the previously described methods to improve the performance during NGT placement, but none is proved to be full proof. Now we are using Sahu's three in one technique of NGT placement that seems to be an evidenced-based full proof method.

In this technique, a new guide wire of endoscopic jejunal feeding tube (EJFT) (Devon Innovation Pvt. Ltd., Bangalore, India, Figure 1a) that is 1 mm wide, 150 cm length, semi-rigid, plastic coated, was placed in 12–16 Fr NGT (each size of NGT used to check the efficacy of technique). The NGT with preloaded EJFT wire [Figure 1b] was lubricated with 2% lidocaine jelly and was gently inserted throw selected nostril with mid flexion of the neck. The NGT was entered 20 cm than GlideScope video laryngoscope (Verathan, USA) was introduced in intubated patient. At this instance, one assistant do an external laryngeal maneuver to upward and forward displace the glottis at cricoid level [Figure 1c]. These both maneuver of the GlideScope movement and external laryngeal maneuver leads to opening and increased the esophageal opening under direct visualization [Figure 1d]. Now under the vision of GlideScope, the EJFT strengthen NGT is further advanced to the opened esophageal opening. The EJFT guide wire gives strength and C-shape to NGT and facilitates the targeted downward movement in esophagus during above maneuver. These three modifications help in downward, straight movement of NGT under direct vision in esophagus. After insertion around 50 cm, the EJFT guide wire was removed with gentle traction. After confirmation, the NGT was secured.

Figure 1

Sahu's three in one method of nasogastric tube insertion. (a) Endoscopic jejunal feeding tube guide wire. (b) Nasogastric tube loaded with endoscopic jejunal feeding tube guide wire. (c) External view of Intubated patient with GlideScope, endoscopic jejunal feeding tube strengthen nasogastric tube and external laryngeal maneuver in situ. (d) GlideScope view showing Glottis with in situ endotracheal tube and wide oesophageal opening having NGT after Sahu's 3 in 1 method.

DISCUSSION

The possible causes of failure of NGT placement are anatomical, NGT itself, or the performer related. The piriform sinuses and the arytenoid cartilages areas are the usual sites of NGT impaction.[4] This impaction can be dealt with head flexion, forward displacement of the larynx or thyroid cartilage or by lateral neck pressure increasing successful passage of NGT.[4] Some had tried insufflations of air in the oropharynx to open the upper esophageal sphincter to overcome anatomical problems.[5]

The modern NGTs are soft and atraumatic, made of polyurethane are flexible, which may become softer on exposure to patient body temperature. It had several nonopposing eyes at tip making it more prone to kink at tip as compared rest of tube. Also, it comes in a packing with several folds and curves that promotes coiling while placing it.[6] Various methods had been used like to make NGT straight and hard. Hung and Lee used a water-fill method to facilitate NGT insertion.[7] Other described methods are use of the nasopharyngeal airway as an obturator, use of a slit endotracheal (ET) tube as conduit or by hardening of NGT by keeping it in ice before use, the use of various laryngoscope and forceps, and the use of a gloved finger to steer the NGT after impaction.[78] We had used the EJFT guide wire as our stylet and to strengthen and guiding the NGT. The use of a rush intubation stylet,[6] ureteral guidewire or guitar wire as a stylet, esophageal guide wire with success 99.2% in the first attempt and use of angiographic catheter.[9] All these had been used to strengthen the tube while manipulation. However, none had proven to be sound proof to manage this problem.

The performer usually places it blindly with own expertise using anatomical landmarks techniques. Esophageal perforation a complication associated with blind NGT insertion so visualization by bronchoscope or GlideScope during attempted NGT insertion may be more beneficial with a success rate in the first attempt up to 85% under direct vision.[10] Endoscopic placement or the use of various endoscopic forceps for lifting the thyroid cartilage had been used. Some have suggested that deflating the ET cuff will decrease the esophageal compression, and facilitate the insertion.

We handled above issues by keeping the tube proximal to posterior pharyngeal wall by flexion of the neck at the initiation of procedure.[8] This is further helped by upward and rightward lifting of glottis with ET tube by GlideScope under vision at vallecula and the trachea at the cricoid cartilage externally. This combined maneuver helped to separate trachea upward from esophagus and visualization of esophageal opening with creation of more space for tip of NGT. Furthermore, under GlideScope vision, one can manipulate and direct the downward placement of NGT in esophagus. This will also prevent NGT to go in trachea, that may gone if it done blindly and can cause pneumonitis. The third problem is performer related the experienced faces less problem as compared to beginners but sometimes it is problematic to both. Multiple attempts can increase chances of trauma, bleeding, and aspiration. Ours three-in-one technique is not only solving the above two problems but also giving under vision guidance for manipulation and proceed to increase the chance of success. We named our new and novel techniques as Sahu's technique. Previously study says to deflate cuff that may be problematic in emergency settings, where patients are usually full stomach.[11] However, in our technique, we do not deflate cuff while entering esophageal opening our two maneuvers and strengthen NGT is sufficient enough to facilitate downward placement of NGT. However, we are in the process of further clinical study based on this novel technique to prove its efficacy and supremacy.

Concept of Sahu's technique of nasogastric tube placement

GlideScope anterior and the forward pull at cricoid level lead to anterior and forward movement of larynx leading separation of trachea and esophagus. Under direct vision desired and targeted movement of EJFT guide wire strengthen NGT give it a C-shape, keep it to lateral or near posterior pharyngeal wall during insertion, so it directly goes in esophagus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.