Challenging removal of a knotted nasogastric tube following insertion under general anaesthetic

Abstract

A 74-year-old man presented with acute small bowel obstruction secondary to recurrence of a caecal tumour. The patient underwent laparotomy and formation of loop ileostomy and had a nasogastric tube (NGT) inserted in the theatre. A decision was made to remove the patient’s NGT postoperatively, which was found to be stuck. High-quality imaging demonstrated a knot in the tube within the nasopharynx; so, subsequent removal via the oral route necessitated sedation. This case highlights the importance of considering rare or unusual complications of NGT insertion when a patient describes more pain or discomfort than would otherwise be expected. The clarity of imaging highlights clearly the underlying findings when compared with the few other documented cases. We offer a number of learning points specific to this complication.

Knot the Best Scenario: A Case of a Knotted Nasogastric Tube

“…As knotting can cause significant trauma upon nasogastric tube removal,8 safe removal practices should be followed. Removal should be stopped immediately if the clinician encounters resistance,14 at which point X-rays or endoscopic procedures can be used to ascertain the cause 4, 6. If a knot is identified, clinicians should decide on the best removal method by estimating the extent and size of the knot.…”

“…15 Conroy and colleagues reported a similar method in which the portion of the nasogastric tube external to the nostril was cut before the remaining portion was removed via the patient's mouth. 4 Other methods involved untangling the knotted tube using an esophagogastroduodenoscopy 6 ; removing the knot using bedside manipulation after application of an anesthetic spray 8 or while the patient is under sedation 7 ; or inserting a nasopharyngeal tube into the nostril with the nasogastric tube, tugging at the nasogastric tube until the knot is secured inside the nasopharyngeal tube, and then removing the entire complex. 12 Such safe removal methods should be given equal emphasis to nasogastric tube insertion techniques in practitioner trainings to provide nurses with a broader sense of the possible complications of nasogastric tube removal.…”

“…By Peijin Esther Monica Fan, BSc, RN, Kai Yunn Teo, BNurs, RN, Min Yi Tan, BNurs, RN, and Shin Yuh Ang, MBA, BSc, RN covered-as it was in our case-when clinicians encountered resistance in attempting to remove the tube. [4][5][6][7][8][9] In a few cases, clinicians reported discovering knotting during nasogastric tube removal due to tube blockage 10,11 or because tube placement could not be confirmed via air insufflation and aspiration. 12 These findings corroborate more recent claims that knotting occurs during nasogastric tube insertion and that the traction caused by its removal tightens the knot.…”

“…8 Researchers have identified several risk factors for nasogastric tube knotting, including repeated tube manipulation, use of highly malleable tubes with narrow lumens, excessive tube length, and patients with altered anatomy (after gastric weight-loss surgery, for example). 4,6,12 The risk of knotting further increases when the patient is under general anesthesia owing to factors related to supine positioning, the presence of an endotracheal tube, and the anesthetized patient's inability to provide feedback regarding their breathing or discomfort. 12 In cases when these risk factors are unavoidable, clinicians should recognize the increased knotting risk-particularly during insertion-and develop response plans in advance.…”

“…Removal should be stopped immediately if the clinician encounters resistance, 14 at which point X-rays or endoscopic procedures can be used to ascertain the cause. 4,6 If a knot is identified, clinicians should decide on the best removal method by estimating the extent and size of the knot. For instance, if the X-ray reveals a knot too big to pass through the patient's nostril, removal via the nostrils should not be attempted as the knot could become lodged in the patient's midnasal cavity.…”