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   Table of Contents      
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 2  |  Page : 105-107

Entanglement of Nasogastric Tube and Nasopharyngeal Temperature Probe During Surgery


1 Department of Anaesthesiology and Intensive Care, G.B. Pant Institute of Post Graduate Medical Education and Research and Associated Maulana Azad Medical College, New Delhi, India
2 Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India

Date of Web Publication1-Jun-2015

Correspondence Address:
Dr. Kapil Chaudhary
Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.157927

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  Abstract 

Nasogastric tube (NGT) insertion and nasopharyngeal temperature probe (NTP) insertion are routine procedures in patients scheduled for gastric pull or colonic pull surgeries for corrosive esophageal strictures. Although intra-gastric and intra-esophgeal knotting of NGT is described in the literature, there is no report of entanglement of NTP with the NGT in a knot in the nasopharynx. We report entanglement of NGT and NTP in a 17-year-old female scheduled for gastric pull-up surgery and discuss the possible causes and preventive measures. The preventive measures discussed may improve patient safety and quality of care by preventing misplacements of NGT and NTP which can cause such entanglement.

Keywords: Corrosive esophageal stricture, entanglement, nasogastric tube, nasopharyngeal temperature probe


How to cite this article:
Bagharwal P, Chaudhary K, Uppal R, Maheshwari C. Entanglement of Nasogastric Tube and Nasopharyngeal Temperature Probe During Surgery. MAMC J Med Sci 2015;1:105-7

How to cite this URL:
Bagharwal P, Chaudhary K, Uppal R, Maheshwari C. Entanglement of Nasogastric Tube and Nasopharyngeal Temperature Probe During Surgery. MAMC J Med Sci [serial online] 2015 [cited 2019 Aug 19];1:105-7. Available from: http://www.mamcjms.in/text.asp?2015/1/2/105/157927


  Introduction Top


Nasogastric tube (NGT) is inserted during gastric pull-up surgery (GPUS) for corrosive esophageal stricture to help intra-operatively in identifying the esophagus and confirming the stricture site. Temperature monitoring is one of the minimum monitoring standards during anesthesia. It is usually performed using a nasopharyngeal temperature probe (NTP) as nasopharyngeal temperature monitoring correlates well with other centrally monitored sites. [1],[2] We report an unusual entanglement of NTP and NGT which hindered in the intra-operative identification of NGT tip and nasal bleeding in a patient scheduled for GPUS.


  Case Report Top


A 17-year-old female was scheduled to undergo GPUS for an alleged history of corrosive (toilet cleaner) ingestion 3 months back resulting in esophageal injury Type 2B and concentric narrowing at the level of upper esophageal sphincter. Induction of general anesthesia was achieved with intravenous propofol and fentanyl, and tracheal intubation facilitated using rocuronium. An adult thermistor NTP available with anesthesia workstation Drager Infinity XL (Drager Medical AG and Company, Lubeck, Germany) was inserted via a nostril up to a length equal to the distance between the nares and tragus. A 12 F NGT (Alpha Medicare and Devices Pvt Ltd., Narol, Ahmedabad, India) was inserted through other nostril, but it could not be negotiated beyond 20 cm. Both the NTP and NGT were inserted by a junior anesthesiologist.

Intra-operatively, the surgeon could not palpate the NGT tip and attempts were made to push it further in but were met with resistance. Considering the NGT to be coiled up, around 5 cm of the tube was gently withdrawn and another attempt was made to reposition it. However, the NGT tip was still not palpable. It was decided to reinsert the NGT under vision using a laryngoscope. While gently withdrawing the NGT for reinsertion, resistance was felt after withdrawing 2-3 cm and it could not be withdrawn any further. On doing pharyngoscopy, the NGT could not be visualized. At this point, resistance was felt on pushing the NGT further in as well as on its withdrawal. On the application of little more force, the NGT could be retrieved. However, when completely retrieved the NGT and NTP were found to be entangled with each other in a knot [Figure 1]. This resulted in bleeding from the nostril which was controlled on pressing the nostril for 2 min. The NGT was then directed into the esophagus under vision. The further course of surgery was uneventful.
Figure 1: Entanglement of the nasogastric tube (NGT) with a nasopharyngeal probe inserted from other nostril resulting in nasal bleeding when withdrawn (a). Knotting of the NGT (b) resulted in its entanglement with the nasopharyngeal probe (a)

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  Discussion Top


The knotting of NGT has a low incidence and is mainly attributed to excessive length insertion into the stomach, smaller diameter tubes and interference with an endotracheal tube in an intubated patient. [3],[4],[5] Although the phenomenon of intragastric/intra-esophageal knotting of NGT has been reported previously, [3],[4],[5] there is no report of its entanglement with a NTP in nasopharynx. It was suspected that due to upper esophageal stricture the flexible distal end of NGT with a large lumen to wall thickness and lateral openings, coiled back on itself and concatenated on interference with endotracheal tube resulting in a knot, [4] and got entangled with the NTP when attempts were made to reposition the NGT. This entanglement might have further tightened when attempts were made to retrieve the impacted NGT. Although the intra-operative displacement of the NTP could not be ascertained in this case, it might have happened during neck positioning as the junior anesthesiologist later admitted to pushing it in when it got slightly pulled out.

The incident initiated several changes in our anesthetic practices to prevent such recurrence. We would suggest such few measures in routine clinical practice to have a positive influence on patient care and when implemented may help in continuous quality improvement for such surgical patient population. First, the fixation of NTP which is often considered least important should be given due importance. The fixation should preferentially be done with an adhesive bandage on a dry skin area and the probe should be marked/flagged after measuring the distance to be inserted. Markings at regular intervals on the NTP by manufacturers can help provide an idea of the distance at which the probe is fixed, and identify its intra-operative displacement. Displacement of NTP may also be identified by a change in temperature readings on the monitor. Alternatively, in patients with an indwelling urinary catheter, monitoring of the core temperature should be done using a bladder probe [6] if available. Second, due emphasis should be given to NTP stabilization during positioning for surgery. NTP stabilization is often neglected during positioning and can be misplaced easily. Furthermore, blind pushing to an unestimated length is common when such misplacement occurs. Third, NGT insertion should be performed under direct vision preferably using videolaryngoscopes in patients with corrosive esophageal strictures as the correct positioning cannot be confirmed by air inflation and epigastric auscultation test as the air does not reach the stomach. Furthermore, insertion under vision using a videolaryngoscope can identify any interference with endotracheal tube resulting in coiling and knotting. Fourth, equal importance should be given to withdrawal of NGT under direct vision, as its insertion. Withdrawal of NGT under direct vision using a videolaryngoscope in a slow and controlled manner allows early identification of any knotting/entanglement. This is especially important in cases where resistance is encountered and there is suspicion of coiling while removal. [3] Identification of coiling of NGT or its entanglement could possibly have been identified in this case and necessary measures taken, had the NGT been withdrawn under direct vision. Fifth, if the site of stricture can be identified preoperatively, the NGT should not be pushed more than 2-3 cm beyond that estimated distance. This usually corresponds to around 20 cm in case of upper esophageal sphincter level stricture, [7] which is a common site of stricture needing surgical intervention. Sixth, smaller diameter NGT should be avoided and appropriate sized NGT should be inserted. Seventh, NGT and NTP insertion should either be performed by an experienced team member or under his close supervision; especially in cases where coiling of NGT and its entanglement are a possibility. These blind techniques are not simple procedures as is the general belief, [4] and should not be left to the inexperienced team members without supervision because of the attendant unexpected complications of these seemingly innocuous devices as highlighted by our report and of other authors. [3],[4],[7]


  Summary Top


We report an unusual case of NTP entanglement with NGT during GPUS for corrosive esophageal injury. We suggest the above changes in routine clinical practice to have a positive influence on patient care and when implemented may help in continuous quality improvement for such surgical patient population.

 
  References Top

1.
Sato H, Yamakage M, Okuyama K, Imai Y, Iwashita H, Masamune T, et al. Influence of thermistor probe depth from the anterior nares on measurement of nasopharyngeal temperature. Med Equip Insights 2008;1:9-13.  Back to cited text no. 1
    
2.
Chatburn J, Sandberg WS, Levine WC. Monitoring. In: Clinical Anesthesia Procedures of the Massachusetts General Hospital. 8 th ed. Philadelphia, USA: Lippincott Williams and Wilkins; 2012. p. 130.  Back to cited text no. 2
    
3.
Dinsmore RC, Benson JF. Endoscopic removal of a knotted nasogastric tube lodged in the posterior nasopharynx. South Med J 1999;92:1005-7.  Back to cited text no. 3
    
4.
Mohsin M, Saleem Mir I, Hanief Beg M, Nazir Shah N, Arjumand Farooq S, Altaf Bachh A, et al. Nasogastric tube knotting with tracheoesophageal fistula - A rare association. Interact Cardiovasc Thorac Surg 2007;6:508-10.  Back to cited text no. 4
    
5.
Santhanam V, Margarson M. Removal of self-knotted nasogastric tube: Technical note. Int J Oral Maxillofac Surg 2008;37:384-5.  Back to cited text no. 5
    
6.
Wass CT, Long TR, Deschamps C. Entrapment of a nasopharyngeal temperature probe: An unusual complication during an apparently uneventful elective revision laparoscopic Nissen fundoplication. Dis Esophagus 2010;23:33-5.  Back to cited text no. 6
    
7.
Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: Review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429-33.  Back to cited text no. 7
    


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