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HAZARDS OF NASOGASTRIC TUBE INSERTION IN THE NEWBORN INFANT
680 Adrenaline is the treatment of choice for severe clinical manifestations of anaphylaxis1 but many clinicians withhold such therapy, fearing the side-effects of this drug. A report of non-fatal myocardial ischaemia induced by intravenous adrenaline2 reinforces these inhibitions despite being based on a single normotensive case. Severe anaphylaxis requires immediate therapy with incremental doses of intravenous adrenaline if the untreatable consequences of global cerebral and myocardial ischaemia are to be prevented. Acute cor pulmonale associated with this condition3 further argues for the early use of adrenaline rather than intravenous fluid loading alone. Anaesthetists, by the nature of their work, will inevitably encounter life-threatening drug-induced hypersensitivity reactions and must at an early stage in their careers be trained to treat them promptly and unequivocally. More than a decade ago I argued against the use of adrenaline for the management of anaesthetic drug-induced anaphylaxis.’’ Subsequent clinical experience has taught me that I was wrong. Perhaps I am imbued with the fervour of a convert, but I do think that an authoritative body such as the Association of Anaesthetists must now issue clear recommendations on the treatment of these reactions, which should centre on adrenaline. Moreover, such a body should organise the reporting of cases which fail to respond to or are adversely affected by these recommendations. Only then will those who still doubt the wisdom of giving adrenaline intravenously for the treatment of severe anaphylaxis be assuaged. Department of Anaesthesia and Intensive Care, Royal Liverpool Hospital, Liverpool L7 8XP
intubation, allowing a false track to be created by the nasogastric tube. Irrespective of the cause of the perforation the insertion of a nasogastric tube resulted in a situation which mimicked oesophageal atresia. Perforation of the pharynx in the newborn infant by either nasogastric or endotracheal tube has been reported in paediatric surgical journals,2,3 although such dangers are not mentioned in any paediatric and neonatal textbooks.l,4 Babies with birth weights of less than 2.5 kg are at greatest risk of pharyngeal perforation and have a mortality of 30%. Early clues to the diagnosis of pharyngeal perforation include a history of difficult nasogastric intubation (especially in a struggling baby) and blood in the nasogastric tube.3 Medical and nursing staff in neonatal units and delivery wards should be aware of this potential hazard of nasogastric tube insertion. Departments of Neonatology and Surgery, Children’s Hospital, Camperdown, Sydney 2050, Australia
T. SANDS M. GLASSON A. BERRY
Jones PG, Woodward AA, eds. Clinical paediatric surgery. 3rd ed. Melbourne: Blackwell Scientific Publications, 1986. 2. Ducharme JC, Bertrand R, Debie J. Perforation of the pharynx in the newborn. a condition mimicking esophageal atresia. Can Med Assoc J 1971; 104: 785-87. 3. Blair GK, Filler RM, Theodorescu D. Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis. J Ped Surg 1987; 22: 770-74. 4. Roberton NRC, ed. Textbook of neonatology. Edinburgh: Churchill Livingstone, 1.
1986.
TRIAZOLAM R. G. WILKES
SIR,-Professor Oswald (Aug 19,
p 451) does not take into all the available data on triazolam. This drug has been evaluated in controlled trials for more than ten years; and it has been the subject of intense clinical research,! detailed epidemiological study,2 and post-marketing surveillance in several countries including the UK.3,4 The triazolam clinical development programme is part of a major psychopharmacology research effort that has defined and refined prescribing recommendations for this product. Regulatory authorities in over seventy countries currently permit its sale. Research continues at academic sleep centres and in other research institutions. As appropriate for any hypnotic, special attention has been paid to starting dose, duration of therapy, daytime effect,5-7 and use in the elderly.8-10 For instance, data specific for older patients were included in the original submission for approval in the UK. A "monitored release" study of 3010 patients providing additional safety data.4 Triazolam is a safe and effective hypnotic and Upjohn supports it for the indications and conditions of use described in its periodically updated data sheet and in other prescribing information. account
1. Patterson R, Valentine M. Anaphylaxis and related allergic emergencies. JAMA 1982; 248: 2579. 2. Horak A, Raine R, Opie L, Lloyd E. Severe myocardial ischaemia induced by intravenous adrenaline. Br Med J 1983; 286: 519. 3. Pavek K. Anaphylactic shock in the monkey: its haemodynamics and mediators. Acta Anaesth Scand 1977; 21: 293-307. 4. Royston P, Wilkes RG. True anaphylaxis to suxamethonium chloride. Br J Anaesth 1978; 50: 611-15.
HAZARDS OF NASOGASTRIC TUBE INSERTION IN THE NEWBORN INFANT
SIR,-Dr Loubser and colleagues (June 24, p 1444) point out the potential hazards of routine endotracheal suction in neonatal units. We present a patient in whom insertion of a nasogastric tube resulted in substantial morbidity. A baby girl weighing 1100 g was delivered by caesarean section at 28 weeks. She needed bag and mask ventilation at birth and had Apgar scores of 3 at 1 minute and 7 at 5 minutes. On the first day of life she was intubated and mechanically ventilated because of recurrent apnoea and bradycardia. The initial Cole-pattern shouldered tube was replaced with a ’Portex’ tube. As a routine a nasogastric tube was inserted but its progress was arrested at 10 cm. Repeated attempts at insertion by other staff members yielded the same result. Radiography supported a presumptive diagnosis of oesophageal atresia and she was referred to the Children’s Hospital in Sydney for further management. The existing gastric tube was left in situ. At age two days she had a right thoracotomy. At operation the gastric tube proved to have perforated the posterior pharynx and its tip was in the posterior mediastinum. The pharyngeal anatomy was otherwise normal. A drain was inserted in the neck at the site of the pharyngeal perforation and intravenous antibiotics
begun. The next day fever and metabolic acidosis Mediastinitis was provisionally diagnosed and cefotaxime was added to the flucloxacillin and gentamicin. Swabs of the site subsequently grew clostridia. She was treated with antibiotics for two weeks and was extubated shortly afterwards. Unlike endotracheal suction the insertion of a nasogastric tube is commonplace in the care of the newborn, especially if they are preterm and unwell. It has even been recommended that every newborn infant should have a size 10 nasogastric tube inserted shortly after birth to exclude oesophageal atresia.In our patient the posterior pharynx could have been trauniatised by tracheal
developed.
were
Upjohn Co, Kalamazoo, Michigan, USA
R. F. DRUCKER
Upjohn Ltd, Crawley, Sussex RH10 2NJ
N. MACLEOD
1. Pakes
GE, Brogden RN, Heel RC, et al. Triazolam: a review of its pharmacological properties and therapeutic efficacy in patients with insomnia. Drugs 1981; 22: 81-110. 2. Baker MI, Oleen MA. The use of benzodiazepine hypnotics in the elderly. Pharmacotherapy 1988; 8: 241-47. 3. Schou JS. Triazolam: Adverse effects m relation to dosage. Pharmacol Toxicol 1989; 64: 6-8. 4. MacLeod N. Triazolam: monitored release in the United Kingdom. Br J Clin Pharmacol 1981; 11: 51S-53S. 5. Mitler MM, Seidel WF, VanDenHoed J, et al. Comparative hypnotic effects of flurazepam, triazolam and placebo: a long term simultaneous nighttime and daytime study. Clin Psychopharmacol 1984; 4: 2-13. J 6. Seidel WF, Roth T, Roehrs T, et al. Treatment of a 12-hour shift of sleep schedule with benzodiazepines. Science 1984; 224: 1262-64. 7. Bliwise DL, Seidel WF, Cohen SA, et al. Profile of mood state changes during and after 5 weeks of nightly triazolam administration. J Clin Psychiatry 1988; 49: 349-55. 8. Dahl LE, Dencker SJ, Lundin L, et al. Comparison of nitrazepam with triazolam in insomniac outpatients. Acta Psychiatr Scand 1982; 65: 86-92 9. Dehlin O, Bjornson G. Triazolam as a hypnotic for genatric patients. Acta Psychiatr Scand 1983; 67: 290-96. 10. Goetzke E, Findeisen P, Welbers IB. Comparative study on the efficacy of and the tolerance to the triazolodiazepines, triazolam and brotizolam. Br J Clin Pharmacol
1983; 16: 407S-12S.
intubation, allowing a false track to be created by the nasogastric tube. Irrespective of the cause of the perforation the insertion of a nasogastric tube resulted in a situation which mimicked oesophageal atresia. Perforation of the pharynx in the newborn infant by either nasogastric or endotracheal tube has been reported in paediatric surgical journals,2,3 although such dangers are not mentioned in any paediatric and neonatal textbooks.l,4 Babies with birth weights of less than 2.5 kg are at greatest risk of pharyngeal perforation and have a mortality of 30%. Early clues to the diagnosis of pharyngeal perforation include a history of difficult nasogastric intubation (especially in a struggling baby) and blood in the nasogastric tube.3 Medical and nursing staff in neonatal units and delivery wards should be aware of this potential hazard of nasogastric tube insertion. Departments of Neonatology and Surgery, Children’s Hospital, Camperdown, Sydney 2050, Australia
T. SANDS M. GLASSON A. BERRY
Jones PG, Woodward AA, eds. Clinical paediatric surgery. 3rd ed. Melbourne: Blackwell Scientific Publications, 1986. 2. Ducharme JC, Bertrand R, Debie J. Perforation of the pharynx in the newborn. a condition mimicking esophageal atresia. Can Med Assoc J 1971; 104: 785-87. 3. Blair GK, Filler RM, Theodorescu D. Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis. J Ped Surg 1987; 22: 770-74. 4. Roberton NRC, ed. Textbook of neonatology. Edinburgh: Churchill Livingstone, 1.
1986.
TRIAZOLAM R. G. WILKES
SIR,-Professor Oswald (Aug 19,
p 451) does not take into all the available data on triazolam. This drug has been evaluated in controlled trials for more than ten years; and it has been the subject of intense clinical research,! detailed epidemiological study,2 and post-marketing surveillance in several countries including the UK.3,4 The triazolam clinical development programme is part of a major psychopharmacology research effort that has defined and refined prescribing recommendations for this product. Regulatory authorities in over seventy countries currently permit its sale. Research continues at academic sleep centres and in other research institutions. As appropriate for any hypnotic, special attention has been paid to starting dose, duration of therapy, daytime effect,5-7 and use in the elderly.8-10 For instance, data specific for older patients were included in the original submission for approval in the UK. A "monitored release" study of 3010 patients providing additional safety data.4 Triazolam is a safe and effective hypnotic and Upjohn supports it for the indications and conditions of use described in its periodically updated data sheet and in other prescribing information. account
1. Patterson R, Valentine M. Anaphylaxis and related allergic emergencies. JAMA 1982; 248: 2579. 2. Horak A, Raine R, Opie L, Lloyd E. Severe myocardial ischaemia induced by intravenous adrenaline. Br Med J 1983; 286: 519. 3. Pavek K. Anaphylactic shock in the monkey: its haemodynamics and mediators. Acta Anaesth Scand 1977; 21: 293-307. 4. Royston P, Wilkes RG. True anaphylaxis to suxamethonium chloride. Br J Anaesth 1978; 50: 611-15.
HAZARDS OF NASOGASTRIC TUBE INSERTION IN THE NEWBORN INFANT
SIR,-Dr Loubser and colleagues (June 24, p 1444) point out the potential hazards of routine endotracheal suction in neonatal units. We present a patient in whom insertion of a nasogastric tube resulted in substantial morbidity. A baby girl weighing 1100 g was delivered by caesarean section at 28 weeks. She needed bag and mask ventilation at birth and had Apgar scores of 3 at 1 minute and 7 at 5 minutes. On the first day of life she was intubated and mechanically ventilated because of recurrent apnoea and bradycardia. The initial Cole-pattern shouldered tube was replaced with a ’Portex’ tube. As a routine a nasogastric tube was inserted but its progress was arrested at 10 cm. Repeated attempts at insertion by other staff members yielded the same result. Radiography supported a presumptive diagnosis of oesophageal atresia and she was referred to the Children’s Hospital in Sydney for further management. The existing gastric tube was left in situ. At age two days she had a right thoracotomy. At operation the gastric tube proved to have perforated the posterior pharynx and its tip was in the posterior mediastinum. The pharyngeal anatomy was otherwise normal. A drain was inserted in the neck at the site of the pharyngeal perforation and intravenous antibiotics
begun. The next day fever and metabolic acidosis Mediastinitis was provisionally diagnosed and cefotaxime was added to the flucloxacillin and gentamicin. Swabs of the site subsequently grew clostridia. She was treated with antibiotics for two weeks and was extubated shortly afterwards. Unlike endotracheal suction the insertion of a nasogastric tube is commonplace in the care of the newborn, especially if they are preterm and unwell. It has even been recommended that every newborn infant should have a size 10 nasogastric tube inserted shortly after birth to exclude oesophageal atresia.In our patient the posterior pharynx could have been trauniatised by tracheal
developed.
were
Upjohn Co, Kalamazoo, Michigan, USA
R. F. DRUCKER
Upjohn Ltd, Crawley, Sussex RH10 2NJ
N. MACLEOD
1. Pakes
GE, Brogden RN, Heel RC, et al. Triazolam: a review of its pharmacological properties and therapeutic efficacy in patients with insomnia. Drugs 1981; 22: 81-110. 2. Baker MI, Oleen MA. The use of benzodiazepine hypnotics in the elderly. Pharmacotherapy 1988; 8: 241-47. 3. Schou JS. Triazolam: Adverse effects m relation to dosage. Pharmacol Toxicol 1989; 64: 6-8. 4. MacLeod N. Triazolam: monitored release in the United Kingdom. Br J Clin Pharmacol 1981; 11: 51S-53S. 5. Mitler MM, Seidel WF, VanDenHoed J, et al. Comparative hypnotic effects of flurazepam, triazolam and placebo: a long term simultaneous nighttime and daytime study. Clin Psychopharmacol 1984; 4: 2-13. J 6. Seidel WF, Roth T, Roehrs T, et al. Treatment of a 12-hour shift of sleep schedule with benzodiazepines. Science 1984; 224: 1262-64. 7. Bliwise DL, Seidel WF, Cohen SA, et al. Profile of mood state changes during and after 5 weeks of nightly triazolam administration. J Clin Psychiatry 1988; 49: 349-55. 8. Dahl LE, Dencker SJ, Lundin L, et al. Comparison of nitrazepam with triazolam in insomniac outpatients. Acta Psychiatr Scand 1982; 65: 86-92 9. Dehlin O, Bjornson G. Triazolam as a hypnotic for genatric patients. Acta Psychiatr Scand 1983; 67: 290-96. 10. Goetzke E, Findeisen P, Welbers IB. Comparative study on the efficacy of and the tolerance to the triazolodiazepines, triazolam and brotizolam. Br J Clin Pharmacol
1983; 16: 407S-12S.