ISSN : 0259-1162
Anesthesia: Essays and Researches • Volume 5 • Issue 1 • January - June 2011 • Pages 1-****
Vol 5 / Issue 1 / January-June 2011
www.aeronline.org Official publication of Pan Arab Federation of Societies of Anesthesiologists
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Editor-in-Chief : Mohamad Said Maani Takrouri (KSA)
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For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Letters to Editor
A knotted nasogastric tube Sir, Nasogastric tubes are widely used in the practice of anesthesiology and can cause considerable morbidity and, also, mortality.[1] Previous case reports on nasogastric tube knotting have usually involved nasogastric tubes that were in situ for a prolonged duration, ranging from 1[2] to 12 days.[3] We report a knotted nasogastric tube causing difficulty in removal of the tube during a surgical procedure that lasted 40 min and wish to highlight the fact that nasogastric tube knotting is not essentially associated with prolonged duration of intubation. A 45-year-old, obese (body mass index, 31.1 kg/m2) lady, ASA physical status 1, was posted for laparoscopic cholecystectomy. Intraoperatively, after tracheal intubation, a 16 F nasogastric tube (Romsons TM, Nunhai, Agra, India) was inserted through the right nostril. It was fixed at an approximately 55 cm mark at the nostril after confirmation of correct placement by aspiration of gastric contents. After creation of pneumoperitoneum, the surgeon pointed out that the stomach was still distended. The anesthesia trainee then performed direct laryngoscopy and reinserted the nasogastric tube with the aid of a Magill’s forceps. Postoperatively, attempts to withdraw the nasogastric beyond the 60 cm mark were met with resistance. After two such failed attempts, direct laryngoscopy was performed, which, to our surprise, revealed the presence of a knot at the distal end of the nasogastric tube, which was now lying in the nasopharynx [Figure 1]. The knotted end of the tube was withdrawn from the mouth with the aid of a Magill’s forceps to an approximate length of 10 cm and cut, while the remaining length of the tube was removed easily through the nose. The tracheal extubation was uneventful and the patient was discharged from the hospital on the second postoperative day in a satisfactory condition. Nasogastric tube coiling and knotting is more common with small bore tubes or in patients with small stomachs.[4] Insertions of an extra length of the nasogastric tube, endotracheal intubation and repetitive advancement of the tube are the other risk factors associated with knotting of the tube. Agarwal et al. state that pushing or pulling of the nasogastric tube after it has
Figure 1: Knotted nasogastric tube
been placed, either by an operator or due to coughing or neck movement, may lead to the formation of a loop.[5] Hence, repositioning of the nasogastric tube should be avoided, especially in patients who are anesthetized or have an obtunded cough reflex. It is imperative to measure the correct length of insertion of the nasogastric tube prior to its placement and mark this length with a marker or tape so that only the necessary length of the tube is inserted and any unrecognized tube movement can be detected. A lateral radiograph of the head and neck may aid in the diagnosis of a coiled and knotted nasogastric tube. There should be a low threshold for aborting attempts of nasogastric tube withdrawal if such attempts are met with resistance to avoid serious complications, including respiratory distress,[5] or laryngeal injury and epistaxis.[6]
Aparna Williams, Dootika Liddle, Alok K. Singh Department of Anesthesiology and Critical Care, Christian Medical College, Ludhiana, Punjab, India Corresponding author: Dr. Aparna Williams, C/O Department of Anesthesiology and Critical Care, Christian Medical College, Ludhiana - 141 008, Punjab, India. E-mail:
[email protected]
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Anesthesia: Essays and Researches; 5(1); Jan-Jun 2011
REFERENCES 1. 2. 3. 4. 5.
Dyer C. Junior doctor is cleared of manslaughter after feeding tube error. BMJ 2003;326:414. Trujillo MH, Fragachan CF, Tortoledo F, Ceballos F. “Lariat loop” knotting of a nasogastric tube: An ounce of prevention. Am J Crit Care 2006; 15:413-4. Mohsin M, Mir IS, Beg MH, Shah NN, Farooq SA, Bachh AA, et al. Nasogastric tube knotting with tracheoesophageal fistula-a rare association. Interact Cardiovasc Thorac Surg 2007;6:508-10. Mandal NG, Foxell R. Knotting of a nasogastric tube. Anaesthesia 2000; 55:99. Agarwal A, Gaur A, Sahu D, Singh PK, Pandey CK. Nasogastric tube knotting over the epiglottis: A cause of respiratory distress. Anesth Analg 2002;94:1659-60.
Letters
6.
Malik NW, Timon CI, Russel J. A unique complication of primary tracheoesophageal puncture: Knotting of the Nasogastric tube. Otolaryngol Head Neck Surg 1999;120:528-9. Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.84175
Quick Response Code
A newborn with pedunculated teratoma of oral cavity: Possible role of modified nasopharyngeal airway in yet another situation of impossible mask ventilation Sir, We read with interest the well-written letter to the editor, “Anesthestic management of a newborn for pedunculated teratoma of oral cavity” by Mishra et al.[1] It appears that the authors’ remained fortunate enough to intubate the trachea of the newborn with pedunculated teratoma of oral cavity. However, a closer look reveals noncompliance to the difficult airway guidelines and thereby, the authors could have landed in the “can’t ventilate and can’t intubate” scenario. First, pedunculated teratoma of oral cavity has created a situation of difficult or almost impossible mask ventilation. As adequate seal with facemask seemed to be impossible the proper preoxygenation is rather difficult to expect. Second, performing a check laryngoscopy (DL scopy) in an awake patient without proper preparation of the airway with local anesthetics could have resulted in laryngospasm or bronchospam, a risky situation that could not have been managed immediately by the alternative airway techniques (cricothyroidectomy and jet ventilation/traceostomy) arranged as standby procedures. Third, induction of anesthesia even when the Cormack Lehan grade 4 view of glottis was revealed on DL scopy was a dreaded step, especially when the mask ventilation was almost impossible. We suggest that after preparation of the nasal passage with topical lignocaine, an appropriate size modified nasopharyngeal airway (MNPA) or warmed endotracheal tube could have been inserted. Adequate lubrication with lignocaine jelly could facilitate easy and safe placement of MNPA in an awake patient.[2,3] Such an airway could be used as a primary tool for induction of inhalational anesthesia and also as a “dedicated 110
airway” in patients with impossible mask ventilation.[3] Further, the technique of delivering positive pressure ventilation via MNPA with mouth and opposite nostrils closed using one hand has been described;[2] it could be further modified according to the need of the case.[3] The DL scopy could be considered following inhalational induction through the MNPA. The MNPA could also be used to facilitate fiberoptic-guided nasal as well as oral tracheal intubation in small children with difficult airway.[4] In similar fashion, the binasopharyngeal airway system could be used to eliminate the need for the facemask early during inductioin.[5] Although the MNPA or the binasopharyngeal airway system has yet not been included in the current difficult airway algorithm, these could prove to be useful while managing the problems of expected or unexpected difficult mask ventilation. We believe that familiarity with these devices is highly desirable and should be considered while managing expected difficult or impossible mask ventilation as encountered in the present pediatric patient with pedunculated teratoma of oral cavity.
Amit Jain, Sohan Lal Solanki1
Department of Anaesthesia & Intensive Care, Alchemist Hospitals Ltd, Panchkula, Haryana, 1 Department of Anaesthesia & Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Corresponding author: Dr. Amit Jain, Department of Anaesthesia & Intensive Care, Alchemist Hospitals Ltd, Panchkula, Haryana, India. E-mail:
[email protected]
