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COMMENTARY
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 103-104  

Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: Better safe than sorry


1 Department of Anesthesiology, Pain Medicine and Intensive Care, AIIMS, New Delhi, India
2 Department of Onco.Anaesthesia and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India

Date of Submission01-Mar-2020
Date of Decision11-Sep-2020
Date of Acceptance30-Sep-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Nishkarsh Gupta
437 Pocket A, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_72_20

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How to cite this article:
Gupta A, Gupta N. Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: Better safe than sorry. Med J DY Patil Vidyapeeth 2021;14:103-4

How to cite this URL:
Gupta A, Gupta N. Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: Better safe than sorry. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Mar 9];14:103-4. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/103/307690



Minimally invasive surgeries have become the standard of care and are increasingly been performed for various surgical procedures across the globe. In the majority of these cases, insertion of a Ryle's tube (RT) is a prerequisite for gastric decompression, and hence, the need for RT insertion during surgical procedures is ever-increasing. It is generally done following of induction of anesthesia and intubation. With an endotracheal tube (ETT) in situ and following muscle relaxation, the conditions for insertion are worsened.

Insertion of an orogastric/nasogastric tube (NGT) can be a herculin task and be very time consuming. An average failure rate of nearly 50%–66% was reported on the first attempt made by conventional technique with the patient's head in sniffing position[1] and the most common sites of RT impaction being the pyriform sinus, the arytenoids cartilage, and the esophagus at the site of compression by the inflated cuff of an ETT.[2] In addition, complications in the form of nasopharyngeal mucosa and hoarseness have been reported.[1]

Various aids and techniques have been described to are often used to ease the insertion of these naso/orogastric tubes (OGTs). For NGT, the use of nasopharyngeal airway as a conduit has been found to increase the success rate of the procedure. Siddhartha et al. documented an improved success rate of the technique of reverse Sellick's and the use of neck flexion with lateral pressure for NGT insertion as compared to the conventional one.[1]

Other successful methods described in the literature are tools such as forceps, the use of a Guidewire within the lumen of RT, use of oral guides (ETT gastric guide tube, Peel Away split tracheal tube etc.,), the use of intubation stylet, endoscopic technique, the use of frozen NGT, angiography catheter-guided technique, and so on.[1]

The present case report has illustrated the complication that occurred from the esophageal migration of an oral guiding tube (an un-cuffed ETT of 6.0 mm (Rusch) internal diameter [ID]) that was used to ease OGT insertion. During its insertion, the universal connector of the guide ETT got dislodged and lost. It was finally retrieved by esophagogastroduodenoscopy under monitored anesthesia care.[3] The use of maneuvers such as “reverse Sellick's manoeuvre” was found to have a high success rate of 95.2% in a study by Mandal et al.[4] Although the patient did not suffer from any sequel due to the complication, added morbidity in the form of an invasive procedure and sedation could easily have been averted by proper precautions.

Kwon et al. had similarly reported the use of an 8.5 mm ID cuffed ETT (with its cuffed end removed by cutting) as an oral tube guide.[5] Specialized guides for nasotracheal intubation have been described for placement of orogastric tube.[6] As mentioned by the authors of the present article also, there was a 16% incidence of mucosal trauma, which is unacceptably high. Although the authors of the present report have used a smaller (6 mm ID) uncuffed ETT, there is an ever-present risk of trauma with the blind insertion of another ETT in a narrowed oropharynx in an intubated patient. The same has not been reported (presence of blood on the ETT used as a guide) or studied by a detailed follow-up of the patients, where the technique was employed. The incidence of the sore throat has also not been documented in the 530 patients, where the authors describe to have used the technique. In these patients, any trauma or postoperative sore throat could be attributed to intubation and lead to legal implications and added patient morbidity due to a potentially avoidable procedure.

A 12Fr RT was to be inserted for intraoperative gastric decompression, while in our experience, the thicker NGT would provide for better success rates even without the ETT guide. The authors mention the use of C-MAC videolaryngosocpe to assist in the retrieval of the ETT guide. The same could have been used to aid in placement of the RT as visualized placement would avoid the potential trauma of the blind procedure. The use of GlideScope to assist the placement of RT has been described previously.[7]

Another solution to the difficult placement of RT is the use of second-generation supraglottic airway (SGA) as a primary airway device in laparoscopic surgeries. These devices have a gastric channel which serves as a direct conduit for gastric placement of RT and reduces the possibility of RT malposition. In a study by Liew et al., the respective success rates of gastric tube insertion on the first attempt with the i-gel, Supreme, and ProSeal SGAs were 94%, 100%, and 94%, respectively.[8]

In conclusion, there are several simpler and less invasive methods which have been successfully employed to improve the success rate of RT insertion and the use of an oral tube guide may be employed as a rescue technique rather than used as a primary technique in all patients. Whenever an oral tube guide is used, checklists should be in place to prevent the occurrence of such a grave event.



 
  References Top

1.
Siddhartha BS, Sharma NG, Kamble S, Shankaranarayana P. Nasogastric tube insertion in anesthetized intubated patients undergoing laparoscopic hysterectomies: A comparative study of three techniques. Anesth Essays Res 2017;11:550-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
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. 2
    
3.
Gangakhedkar GR, Buddhi M, Toal S, Soitkar R, Patel RD, Sundaram S. Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: An unfortunate complication in an intubated patient. Med J DY Patil Vidyapeeth 2021;14:100-2.  Back to cited text no. 3
  [Full text]  
4.
Mandal M, Karmakar A, Basu SR. Nasogastric tube insertion in anaesthetised, intubated adult patients: A comparison between three techniques. Indian J Anaesth 2018;62:609-15.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kwon OS, Cho GC, Jo CH, Cho YS. Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED. Am J Emerg Med 2015;33:177-80.  Back to cited text no. 5
    
6.
Alflen C, Kriege M, Schmidtmann I, Noppens RR, Piepho T. Orogastric tube insertion using the new gastric tube guide: First experiences from a manikin study. BMC Anesthesiol 2017;17:54.  Back to cited text no. 6
    
7.
Sahu S, Kishore K, Sachan V, Chatterjee A. A novel and innovative way of nasogastric tube insertion in anesthetized intubated patient. Anesth Essays Res 2017;11:248-50.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Liew GH, Yu ED, Shah SS, Kothandan H. Comparison of the clinical performance of i-gel, LMA supreme and LMA ProSeal in elective surgery. Singapore Med J 2016;57:432-7.  Back to cited text no. 8
    




 

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