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873
Nasogastric Tube Insertion Through A
Nasopharyngeal Airway in Patients with
Failed Insertion Through the Nares
To,
The Editor, IJA
Madam,
Inserting nasogastric tubes (NGT) in intubated,
Fixation of Paediatric Breathing Circuit
Tubing - A Simple Solution.
To,
The Editor, IJA
Madam,
Maintaining airway in paediatric patients is as important as securing it. Tracheal tube kinking,
dislodgement or accidental extubation should always
be prevented.
1
A common cause of tracheal tube
dislodgement is drag on tracheal tube by the breathing
circuit.
1, 2
To prevent the pull on tracheal tube by breathing circuit, tubing of the circuit is supported on the operation table and held in position by application of towel
clip on the sheet encasing the tubing. However, the use
of towel clip has an inherent disadvantage of accidentally puncturing the tubing of breathing circuit. This can
lead on to inadequate ventilation and operating room
pollution. Sometimes, tapes are used to hold the tubing
in situ but with tapes fixation is not adequate.
1
Correspondence : Letter to Editor
Indian Journal of Anaesthesia 2008; 52 (6):873-884
We, in our clinical practice, are applying a plastic
clip on the operation table sheet that is encasing the
tubing. (Fig 1a & b) This is the same clip that is used to
hold the clothes when they are hanged for drying. This
is a simple, easily available and inexpensive fixation
device to hold the tubing of breathing circuit in situ. It
has no potential of puncturing the tubing and subsequent uselessness of the breathing circuit, wasted ventilation and operating room pollution. This simple
method was initially suggested by our female anaesthesia nurse, as in our part of the country such a clip is
routinely used at homes by the females.
To conclude, application of a plastic clip is an
atraumatic method of holding the paediatric breathing
circuit tubing in situ. Simple but highly useful suggestions can come from any quarter and are at times highly
useful in clinical practice.
Naveen Malhotra, Associate Professor
Prashant Kumar, Assistant Professor
Renu Bala, Assistant Professor
Sushma Salhotra, Staff Nurse
Department of Anaesthesiology & Critical Care, Pt. B. D. S.
Post Graduate Institute of Medical Sciences, Rohtak-124001
(Haryana), INDIA. E-mail: [email protected]
References

1. Dorsch JA, Dorsch SE. Understanding anesthesia equipment: construction, care and complications, 3
rd
ed. Baltimore: Williams & Wilkins 1994.
2. Divatia J, Bhowmick K. Complications of endotracheal
intubation and other airway management procedures.
Indian J Anaesth 2005; 49:308-18.
Fig 1(a) Plastic clip applied on the sheet encasing
the tubing of breathing circuit, (b) inset photograph.
874
Indian Journal of Anaesthesia, Dec 2008
paralyzed patients can sometimes be difficult with a
reported success rate of 40- 68% for first pass
insertion
1,2
.This is because nasogastric tubes tend to impinge on the pyriform sinuses or the arytenoid cartilages
and coil in the oropharynx or pass into the trachea, as
has been demonstrated using a fibreoptic bronchoscope
1
.
Various techniques for aiding NGT insertion may be traumatic (split nasotraceal tube as obturator)
3
, involve laryngeal or neck manipulation
2-5
, require skill (digital insertion)
6
, advance preparation (coiling a tube and freezing it)
7
or laryngoscopy or fibreoptic bronchoscopy to
facilitate insertion
8,9
. We wanted to assess a technique
for NGT insertion which was atraumatic, easy to perform in any patient in whom direct insertion failed, without having to manipulate the larynx or neck and involved
the use of a nasopharyngeal airway (NPA) as an obturator, which is easily available.
After ethical committee clearance 106 adult conII patients aged 18-65 years schedsenting ASA I
uled for surgery under general anaesthesia requiring
orotracheal intubation and nasogastric tube insertion
were included in the study. Patients with a nasal, pharyngeal or esophageal pathology, bleeding diathesis or
with head injury were not included. After intubation with
the patient in the sniffing position, direct insertion of
appropriate size -14, 16 or 18 French gauge NGT was
attempted. Insertion was attempted through the right
nostril unless contraindicated and 2-3 cm of the tube
were pushed in at a time instead of pushing longer segments in one go. Confirmation of correct placement
was by aspiration followed by 5-10 ml of air instillation
and auscultation over the epigastrium. In case gastric
contents could not be aspirated or the sound after air
instillation could not be auscultated, the NGT was

slowly withdrawn 3-5 cm at a time and repeated aspiration and air instillation performed to ensure that a
correctly placed NGT was not missed due to coiling in
the esophagus or oropharynx. If the NGT insertion was
unsuccessful, it was withdrawn and a well lubricated
NPA (Romsons Science and Surgicals Industry Pvt.
Ltd. India) of size 7-7.5 mm ID in females or 7, 7.5 or
8mm ID in males was inserted through the nasopharynx. Through this a fresh, lubricated NGT of the same
size was inserted and the position confirmed as before.
Thereafter the NPA was slid off the NGT and inspected
for blood staining. If the above method failed, laryngoscopy and Magill s forceps guided insertion was
performed.
Fifty-one female and 55 male patients, aged
42.4
+13.6 years and weighing 59.9
+12.8 kg were
studied. Direct insertion of the NGT on first attempt
was successful in 59 out of 106 (55.7%) patients but in
44.3% (47out of 106) patients it was unsuccessful.
Amongst these patients, NGT insertion through NPA
was successful in 41out of 47 (87.2%) patients on first
attempt. A 16 F NGT was used in the majority (66.9%).
The most commonly used NPA size was 7.0mm ID in
males (63.6%) and females (56%). Only 14.8% (7out
of 47) required the use of laryngoscope and Magill s
forceps for NGT insertion. Only 12.7% (6 out of 47)
of patients had slight streaking of blood on the NPA
when it was removed. We found this method successful even in 2 patients with double lumen tubes in situ.
Our success rate for first pass direct insertion was
lesser than that reported by Ozer et al (68%) because
we used NGT of sizes 14-18 French whereas they used
only 18F tubes
1
. Bong et al had a 40% first pass success rate with 14 F NGT
2
.
The length of NPA of sizes 7, 7.5 and 8 mm ID
are 13.5, 14 and 14.5 cm respectively. Ozer et al have
shown that a nasally inserted gastric tube usually passes
the arytenoids at a length of 16.2
+ 1.2 cm
1
. The NPA
provides a conduit for the NGT to track along the posterior pharyngeal wall and emerge just 2-3 cm proximal to the arytenoids more in the midline resulting in
higher success rates and lesser oropharyngeal coiling
or tracheal insertion especially if shorter segments (2-3
cm) are pushed in at a time.
Shetty et al have used this technique to minimize
trauma during NGT insertion in patients with facial or
cranial trauma
10
.
We conclude that the first pass success of
nasogastric tube insertion through a nasopharyngeal was

875
high without any major bleeding in patients with failed
first pass direct nasogastric tube insertion via the nares.
Anjolie Chhabra, Assistant Professor
Rakesh Garg, Senior Resident
Department of Anesthesiology and Intensive Care, All India
Institute of Medical Sciences, Ansari Nagar, New Delhi-110029,
India.
Email: [email protected]
References
1. Ozer S, Benumof JL. Oro and nasogastric tube passage
in intubated patients. Anesthesiology 1999; 91:137-43.
2. Bong CL, Macachor JD, Hwang NC. Insertion of the
nasogastric tube made easy. Anesthesiology 2004; 101:
266.
3. Chen YS, Wang SM. A modified method to insert a
nasogastric tube without kinking in the nasal cavity.
Am J Em Med 1992; 10: 614-15.
4. Perel A, Yosef Y, Pizov R. Forward displacement of the
larynx for nasogastric tube insertion in intubated patients. Crit Care Med 1985; 13: 204-5.
5. Mahajan R, Gupta R., Sharma A. Role of neck flexion in
facilitating nasogastric tube insertion. Anesthesiology
2005; 103: 446-47.
6. Mahajan R, Gupta R. Another method to assist nasogastric
tube insertion. Can J Anesth 2005; 52: 652-53.
7. Flegar M, Ball A. Easier nasogastric tube insertion. Anaesthesia 2004; 59: 197.
8. Jones AP, Diddee R, Bonner S. Insertion of a nasogastric
tube under direct vision. Anaesthesia 2006; 61:305.
9. Gombar S, Khanna AK, Gombar KK. Insertion of a
nasogastric tube under direct vision: another atraumatic
approach to an age-old issue. Acta Anaesth Scand 2007;
51: 962 63.
10. Shetty S, Henthorn RW, Ganta R. A method to reduce
nasopharyngeal trauma from nasogastric tube placement. Anesth Analg 1994; 78: 410-11.
Perioperative Antiplatelet Therapy in
Patients with Coronary Stents: Importance
of Patient Education
To,
The Editor, IJA
Madam,
We would like to share our experience of an interesting case of premature discontinuation of
antiplatelet therapy by patient in ignorance, thereby highlighting the immense importance of patient education.
A 59-year-old male with intracoronary drug
eluting stent to LAD placed two months prior to surgery and low ejection fraction presented for stapled
hemorrhoidectomy. He was on dual antiplatelet therapy
with aspirin & clopidogrel after stenting and was advised to continue antiplatelet drugs perioperatively by
the cardiologist. In view of active bleeding, an urgent
surgery was advised. The patient had noticed a direct
correlation between the intensity of bleeding and intake of antiplatelet drugs and had therefore stopped
both antiplatelet drugs two days before surgery.
In the preoperative period, the patient became
unresponsive and ECG showed bradycardia progress-

ing to left bundle branch block followed by complete
heart block. He was immediately resuscitated and
shifted to Interventional Cardiology Suite. The coronary angiogram revealed stent thrombosis and emergency revascularization in form of balloon angioplasty
was performed.
Percutaneous coronary intervention (PCI) involving placement of intracoronary stents requires long term
treatment with antiplatelet agents, which are mandatory for coronary stents
1
. We strongly agree with the
recommendations of AHA/ACC Science Advisory
which highlight the importance of patient and healthcare
provider education, clear instructions, drug cost and
regular follow-up by treating cardiologist for better
patient compliance and optimal outcome
2.
The patient
education is of paramount importance, more so in context of developing countries with relatively lower literacy rates for better patient compliance. The option
of Bare Metal Stent or surgical coronary revascularization with less stringent requirement of antiplatelet
agents should also be considered and offered to such
patient subgroup.
Correspondence
876
Indian Journal of Anaesthesia, Dec 2008
Neetu Jain, Consultant
Rashmi Jain, Consultant
Jayashree Sood, Senior Consultant and Chairperson
Department of Anaesthesia, Pain and Perioperative Medicine,
Sir Ganga Ram Hospital, New Delhi.
Email: [email protected]
References
1. Chassot PG, Delabays A, Spahn DR. Perioperative
antiplatelet therapy: the case for continuing therapy in
patients at risk of myocardial infarction. Br J Anaesth
2007 ; 99:316-28.
2. Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart
PB, Moliterno DJ, O Gara P, Whitlow P; American Heart
Association; American College of Cardiology; Society
for Cardiovascular Angiography and Interventions;
American college of Surgeons; American Dental Association; with representation from the American College
of Physicians. Prevention of premature discontinuation
of dual antiplatelet therapy in patients with coronary
artery stents: a science advisory from the American Heart
Association, American College of Cardiology, Society
for Cardiovascular Angiography and Interventions,
American College of Surgeons, and American Dental
Association, with representation from the American
College of Physicians. Circulation 2007;115:813-8.
Severe Anaphylaxis in Beta-Blocked
Patients
To,
The Editor, IJA
Madam,
We read with interest the case report entitled In-

traoperative Anaphylaxis to Inj Ceftriaxone: Here we
go again....... .
1
Patients with pre-existing cardiovascular disease, asthma, atopy, those on beta-blockers
and receiving neuraxial anaesthesia are reported to have
increased severity of anaphylaxis.
1-3
Beta-blockers increase the release of mediators via modulation of adenyl cyclase, and decrease the cardiovascular compensatory changes to anaphylactic shock. Epinephrine can
paradoxically worsen anaphylaxis in beta-blocked patients through facilitating unopposed
a
-adrenergic and
reflex vagotonic effects which probably was the case
in this patient. Beta-blocked patients have increased
propensity not only for bronchospasm but also decreased cardiac contractility with perpetuation of hypotension and bradycardia. The recent guidelines for
treatment of refractory anaphylaxis in beta-blocked
patients include glucagon infusion and inhaled
ipratropium bromide.
4
Glucagon can potentially reverse
refractory bronchospasm and hypotension during anaphylaxis in patients receiving beta-blockers by activating adenyl cyclase directly and bypassing the beta-adrenergic receptor. Glucagon dosage is 20-30mcg/kg
administered intravenously over 5 minutes followed by
an infusion 5-15mcg/min titrated to clinical response.
Inhaled ipratropium may be especially useful for treatment of bronchospasm in patients receiving
ß
-blockers.
Isoproterenol has also been used to treat anaphylactic
shock in a beta-blocked child.
5
Further, there are case
reports suggesting role of atropine in the presence of
relative and severe bradycardia.
6
Increasing population presenting for surgery and
anaesthesia is on
ß
-blockers therapy. Awareness of the
fact that beta-blocked status might make the patient more
resistant to the effect of epinephrine should make the
anaesthesiologist resort to early usage of drugs like glucagon, ipratropium and isoproterenol. Resuscitation attempts to manage perianaesthetic anaphylaxis have to
be more vigorous and aggressive in beta-blocked patients and those receiving neuraxial anaesthesia. In the
present case, the patient had loss of consciousness and
was hypotensive with low SpO
2
, unrecordable EtCO
2
for 5 minutes before the administration of salbutamol and

ipratropium bromide. Early external cardiac massage
might have helped the patient.
History of previous allergies or anaphylactic reactions is not always forthcoming. Intradermal testing
prior to surgery is not always feasible and is fraught
with fallacies. Inspite of caution, anaphylactic reactions will still occur. Every anaesthetist should know
the anaphylaxis drill. We also wish to highlight the need
for a national reporting system in our country as in
France and Denmark to report cases of perianaesthetic
anaphylaxis to investigate and promote research in this
field.

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