Another method to assist nasogastric tube insertion

Abstract

In light of the results of most recent studies showing better survival of surgical patients with tight glycemic control the preservation of intraoperative normoglycemia gains clinical relevance.1 Epidural anesthesia in the absence of general anesthesia has long been recognized to suppress the hyperglycemic and endocrine responses to pelvic surgery. 2 The failure of epidural anesthesia combined with inhalation anesthesia to maintain glucose homeostasis during major abdominal surgery was traditionally ascribed to incomplete inhibition of the counterregulatory endocrine response. 3Studies demonstrating that inhaled agents per se, in contrast to iv anesthetics such as propofol, 4 provoke hyperglycemia, however, indicate that the use of inhaled anesthesia may be, at least in part, responsible. 5 We thus speculated that combining epidural anesthesia with iv propofol anesthesia would prevent the hyperglycemic response to colorectal surgery.After obtaining patient consent we studied six consecutive ASA II patients (three male, three female, mean age 69 ± 12 yr) who underwent resection of colorectal cancer (three hemicolectomies, three sigmoid resections) by the same surgeon (S.M.). An epidural catheter was inserted immediately before the operation between T10 and T12. Afferent neural blockade was established with bupivacaine 0.5% to achieve a bilateral sensory block from T4 to L2, and epidural anesthesia was maintained during the operation by boluses of bupivacaine 0.25%. General anesthesia was induced with propofol administered at a dose to abolish the eye reflex. Tracheal intubation was facilitated by rocuronium 0.6 mg·kg -1 iv and the lungs were ventilated to normocapnia with oxygenenriched air. General anesthesia was maintained by continuous infusion of propofol at 6 to 10 mg·kg . Blood losses were replaced by normal saline in a ratio of 3:1. Phenylephrine boluses (100 µg iv) were given to maintain a mean arterial pressure above 60 mmHg. Arterial blood glucose concentrations were measured before anesthesia, 80 min and 120 min after surgical skin incision using the Accu-Chek™ glucose monitor (Roche Diagnostics, Basel, Switzerland).Differences in blood glucose concentrations were determined using analysis of variance for repeated measures.The blood glucose concentration increased from 5.5 ± 0.6 mmol·L -1 prior to surgery to 6.7 ± 1.2 mmol·L -1 at 80 min (P < 0.05) and 7.1 ± 1.3 mmol·L -1 at 120 min of surgery (P < 0.05). The intraoperative values were numerically greater than values previously obtained in patients undergoing colorectal surgery under combined epidural and inhalation anesthesia. Our data suggest that a clinically modest hyperglycemic response to colorectal surgery occurs in patients receiving epidural anesthesia during propofol anesthesia.

Nasogastric tube insertion in anaesthetized patients: a comprehensive review

“…org/nasogastric-tube-insertion-the-simple-yet-impossible/ accessed 11 Nov 2016). Table 2 shows different RCTs concering NGT insertion methods [62][63][64][65][66][67][68][69][70][71][72][73][74][75].…”

“…Mahajan et al [70] 2005 After introduction into the oropharynx, the orogastric tube or Murphy's eye of tube is directed into the esophagus along the lateral pharyngeal wall using a gloved left index finger Cohen et al [75] 1963 NGT is inserted through the nose and mouth where its tip is grasped with a Magill forceps under laryngoscopic visualization. The NGT is retracted from the mouth until approximately 3 inches remain from the nares.…”

A case of tracheal tube cuff failure

“…Insertion of a gastric tube can be a difficult and frustrating experience, especially in patients who are anesthetised, paralysed and sedated [1][2][3][4][5][6][7]. Ozer and Benumof [8] have found that the most common sites of impaction of orogastric and nasogastric tubes are the pyriform sinuses and arytenoids cartilages, leading to coiling in the oropharynx.…”

“…In our experience, in addition to the impaction of the tube against these structures, the basic design of the tube contributes to tube coiling in the oropharynx. The distal 6 cm of the gastric tube has multiple holes that are weak points [2]. Once the tube is impacted against the pyriform sinuses or arytenoids cartilage, bending of the tube occurs at these points, thereby promoting coiling and retarding its entry into the oesophagus [2,8].…”

“…Literature review revealed cases of pilot balloon malfunction on other makes of tube [1][2][3] and a case in a Portex type tracheal tube due to an elliptical defect in the wall of the ETT, that was at the level of the notch cut for the insertion of the pilot tube [4]. These other cases also had the pilot balloon dysfunction at the junction of the pilot tube to the tracheal tube, but there was no mention of the pressure at which the leak appeared.…”