Intraoperative Gastric Tube Intubation: A Summary of Case Studies and Review of the Literature

Abstract

Study Objective Establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature. Measurements An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus, and Google Scholar was performed applying the search terms “gastric tube”, “complications”, “decompression”, “blind insertion”, “perioperative”, “intraoperative” in various order sequences. A five-year limit was applied to limit the number and timeliness of articles selected. Main Results Patients are exposed to potentially serious morbidity and mortality from blindly inserted gastric tubes. Risk factors associated with malposition include blind insertion, the presence of endotracheal tubes, altered sensorium, and previous tube misplacements. Pulmonary aspiration risk prevention remains the only indication for anesthesia-related intraoperative use. There are no singularly effective tools that predict or verify the proper placement of blindly inserted gastric tubes. Current placement facilitation techniques are perpetuated through anecdotal experience and technique variability warrants further study. Conclusion In the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of gastric tubes.

Case Series: Nasogastric (NG) Feeding Tube Misplacement in Critically Ill Tracheostomized Patients

“…NGT misplacement or malposition occurs in 1.2% -2.4% of NGT placements where up to 60% of these incidents are in mechanically ventilated patients, and various studies demonstrating an increased risk for NGT malposition and associated complication in ventilated patients [1] NGT placement in specific and enteral feeding in the ICU setting is crucial and mandatory to all patients. It is a fundamental and routine maneuver in the ICU setting, usually performed by the nursing staff [14].…”

“…Despite an intuitive expectation for a protective effect by mechanically ventilated apparatuses (because of the presence of a tube which theoretically obstructs the trachea and therefore may prevent NGT misplacement to occur in that location) the literature demonstrates mechanically ventilation as the most substantial risk factor for NGT misplacement [1] A 2011 critical review of 9931 nasogastric tube placements including 5 large scale studies, reported that all 5 studies report an increased risk of pulmonary misplacement among ventilated patients. The incidence reported was 30% -93% [5].…”

“…Nasogastric feeding tube insertion is a very common procedure with over a mil-*Mr.Comay and Dr. Quint contributed equally to the paper. lion nasogastric placements performed in 2013 in the US [1]. Nasogastric tube (NGT) is used in intensive care units (ICU), emergency departments and hospital wards routinely.…”

Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors

“…Furthermore, in gastroenterological procedures, endoscopy is inherently associated with higher aspiration risk due to compromised airway reflexes following local anaesthetic application and stenting of the upper oesophageal sphincter by the endoscope . Carefully considering whether an RSI and/or NGT is indicated in these case types is critical, though NGT placement is associated with its own risks including endobronchial placement; trauma to the nasopharyngeal and hypopharyngeal mucosa, including the piriform sinus and arytenoid cartilage; pneumothorax; and oesophageal perforation …”

Sounds Impossible, but It’s Knot

“…Rarely, serious complications occur, including tracheal or bronchial placement and pneumothorax, esophageal perforation, intravascular placement and hemorrhage, and entanglement with other equipment including endotracheal tubes. 1 Anesthesia providers need to be cognizant of these complications in order to ensure rapid detection and correction of incorrectly placed or entangled orogastric tubes. The orogastric tube shown was blindly inserted after anesthetic induction and endotracheal intubation, and gastric fluid was suctioned.…”