- Email: [email protected]
Insertion of a nasogastric tube using a modified ureteric guide wire
Correspondence
387
Rahul Gupta MBBS, MD (Junior Resident) Department of Anesthesia and Intensive Care Unit Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, 160012 India Vinod Kumar Grover MBBS, MD (Professor) Department of Hepatology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India doi:10.1016/j.jclinane.2009.01.004
References [1] Drolet P, Girard M. An aid to correct positioning of the ProSeal laryngeal mask. Can J Anaesth 2001;48:718-9. [2] Martínez-Pons V, Madrid V. Easy placement of LMA ProSeal with a gastric tube inserted. Anesth Analg 2004;98:1816-7. [3] Brimacombe J, Vosoba Judd D, Tortely K, Barron E, Branagan H. Gastric tube-guided reinsertion of the ProSeal laryngeal mask airway. Anesth Analg 2002;94:1670. [4] Mahajan R, Gupta R, Sharma A. Insertion of nasogastric tube using modified ureteric guide wire. J Clin Anesth 2009;21:387-8.
Check for carotid puncture: a simple equation to an old rule To the Editor: It is a common practice to check the placement of the central venous catheter (CVC) in the internal jugular vein
(IJV) by attaching intravenous (IV) fluid tubing to the 14gauge introducer needle and observing for free flow of fluid. However, this practice can be very misleading in certain special situations. In severe hypotension, IV fluids can flow freely into a major artery from a considerable height and can mislead the physician. Remember, one mmHg = 0.53 inches (1.3 cm) water column [1]. Therefore, for a systolic blood pressure (SBP) of approximately 60 mmHg, a height of three feet (90 cm) above the bed level will generate sufficient pressure for the fluid column to flow down from the hanging IV fluid bottle Fig. 1. Thus, we devised a simple formula to determine the height of the IV fluid bottle for checking intraarterial placement. If ‘h’ = height of fluid column in inches, this value should be lower than 0.53 × SBP in mmHg, or approximately half of the SBP reading. This equation will ensure that IV fluid will not flow into a major artery in hypotensive patients. Chakravarty Chandrashish MD (Junior Resident) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India E-mail address: [email protected] Khanna Puneet MD (Junior Resident) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India Dehran Maya MD (Professor) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India doi:10.1016/j.jclinane.2009.01.003
Reference [1] http://www.csgnetwork.com/prestableinfo.html. Accessed july2008.
Insertion of a nasogastric tube using a modified ureteric guide wire
Fig. 1 Line diagram showing the height of the fluid column (h) above the patient with intravenous (IV) fluid tubing connected to the vascular access site in the neck, as a method of checking for inadvertent carotid artery cannulation. (in)=inches, SBP=systolic blood pressure.
To the Editor: Insertion of a nasogastric tube can be a difficult and frustrating experience in patients who are anesthetized [1,2]. Ozer and Benumof have found that the most common sites of impaction of orogastric and nasogastric tubes are the pyriform sinuses and arytenoid cartilage, leading to coiling
388
Correspondence procure and there is the inherent risk of injury by the sharp end of the wire [4]. The ureteric wire is readily available and it can be modified and sterilized easily. We have used this method in 70 patients; it was successful on the first attempt in 67 patients, and on the second attempt in the other three cases. There were no untoward sequelae in any of the cases.
Fig. 1 Photographic view of a modified ureteric guide wire with the tip coated with Teflon (right).
in the oropharynx [3]. The basic design of the tube contributes to tube coiling in the oropharynx. The distal 6 cm of the gastric tube has multiple holes that are less firm [3]. A new technique to facilitate nasogastric tube insertion using a modified ureteric guide wire is presented. A ureteric guide wire is a metallic flexible wire coated with Teflon. It is 0.97 mm in diameter and its length is more than 140 cm. Its one end is straight and blunt while the other end is flexible and soft. We modified the straight, blunt end by coating it with Teflon, thus providing a smooth globular coating over it (Fig. 1). Although this bulbous envelop is thin enough to be advanced through the lumen of the gastric tube, it is too large to pass through the side holes at the distal end of size 14 and size 16-French gastric tubes. This modified ureteric wire thus is lubricated with water-soluble jelly and passed into the gastric tube. The gastric tube is then lubricated and introduced via a nostril and advanced through the nares and oropharynx into the esophagus. The guide wire reinforces the distal part of the gastric tube, thus preventing its impaction and bending. Once the gastric tube seems to be negotiated into the esophagus, the guide wire is withdrawn and correct positioning of the gastric tube is verified. Although the use of guitar wire has been described to facilitate entry of the nasogastric tube, it is difficult to
Rajesh Mahajan MBBS, MD (Consultant) Department of Anesthesia Acharya Shri Chander College of Medical Sciences and Hospital (ASCOMS) Jammu, Jammu & Kashmir, 180001 India E-mail addresses: [email protected] [email protected] Rahul Gupta MBBS, MD (Junior Resident) Department of Hepatology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, 160012 India Anju Sharma MBBS (Junior Resident) Department of Anesthesia Acharya Shri Chander College of Medical Sciences and Hospital (ASCOMS) Jammu, Jammu & Kashmir, 180001 India doi:10.1016/j.jclinane.2009.01.005
References [1] Mahajan R, Gupta R, Sharma A. Role of neck flexion in facilitating nasogastric tube insertion. Anesthesiology 2005;103:446-7. [2] Mahajan R, Gupta R. Another method to assist nasogastric tube insertion. Can J Anaesth 2005;52:652-3. [3] Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43. [4] Matsuki A, Oyama T. Safe and simple method of nasogastric tube insertion during surgery. Masui 1971;20:369-70.
387
Rahul Gupta MBBS, MD (Junior Resident) Department of Anesthesia and Intensive Care Unit Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, 160012 India Vinod Kumar Grover MBBS, MD (Professor) Department of Hepatology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India doi:10.1016/j.jclinane.2009.01.004
References [1] Drolet P, Girard M. An aid to correct positioning of the ProSeal laryngeal mask. Can J Anaesth 2001;48:718-9. [2] Martínez-Pons V, Madrid V. Easy placement of LMA ProSeal with a gastric tube inserted. Anesth Analg 2004;98:1816-7. [3] Brimacombe J, Vosoba Judd D, Tortely K, Barron E, Branagan H. Gastric tube-guided reinsertion of the ProSeal laryngeal mask airway. Anesth Analg 2002;94:1670. [4] Mahajan R, Gupta R, Sharma A. Insertion of nasogastric tube using modified ureteric guide wire. J Clin Anesth 2009;21:387-8.
Check for carotid puncture: a simple equation to an old rule To the Editor: It is a common practice to check the placement of the central venous catheter (CVC) in the internal jugular vein
(IJV) by attaching intravenous (IV) fluid tubing to the 14gauge introducer needle and observing for free flow of fluid. However, this practice can be very misleading in certain special situations. In severe hypotension, IV fluids can flow freely into a major artery from a considerable height and can mislead the physician. Remember, one mmHg = 0.53 inches (1.3 cm) water column [1]. Therefore, for a systolic blood pressure (SBP) of approximately 60 mmHg, a height of three feet (90 cm) above the bed level will generate sufficient pressure for the fluid column to flow down from the hanging IV fluid bottle Fig. 1. Thus, we devised a simple formula to determine the height of the IV fluid bottle for checking intraarterial placement. If ‘h’ = height of fluid column in inches, this value should be lower than 0.53 × SBP in mmHg, or approximately half of the SBP reading. This equation will ensure that IV fluid will not flow into a major artery in hypotensive patients. Chakravarty Chandrashish MD (Junior Resident) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India E-mail address: [email protected] Khanna Puneet MD (Junior Resident) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India Dehran Maya MD (Professor) Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences New Delhi, 110029 India doi:10.1016/j.jclinane.2009.01.003
Reference [1] http://www.csgnetwork.com/prestableinfo.html. Accessed july2008.
Insertion of a nasogastric tube using a modified ureteric guide wire
Fig. 1 Line diagram showing the height of the fluid column (h) above the patient with intravenous (IV) fluid tubing connected to the vascular access site in the neck, as a method of checking for inadvertent carotid artery cannulation. (in)=inches, SBP=systolic blood pressure.
To the Editor: Insertion of a nasogastric tube can be a difficult and frustrating experience in patients who are anesthetized [1,2]. Ozer and Benumof have found that the most common sites of impaction of orogastric and nasogastric tubes are the pyriform sinuses and arytenoid cartilage, leading to coiling
388
Correspondence procure and there is the inherent risk of injury by the sharp end of the wire [4]. The ureteric wire is readily available and it can be modified and sterilized easily. We have used this method in 70 patients; it was successful on the first attempt in 67 patients, and on the second attempt in the other three cases. There were no untoward sequelae in any of the cases.
Fig. 1 Photographic view of a modified ureteric guide wire with the tip coated with Teflon (right).
in the oropharynx [3]. The basic design of the tube contributes to tube coiling in the oropharynx. The distal 6 cm of the gastric tube has multiple holes that are less firm [3]. A new technique to facilitate nasogastric tube insertion using a modified ureteric guide wire is presented. A ureteric guide wire is a metallic flexible wire coated with Teflon. It is 0.97 mm in diameter and its length is more than 140 cm. Its one end is straight and blunt while the other end is flexible and soft. We modified the straight, blunt end by coating it with Teflon, thus providing a smooth globular coating over it (Fig. 1). Although this bulbous envelop is thin enough to be advanced through the lumen of the gastric tube, it is too large to pass through the side holes at the distal end of size 14 and size 16-French gastric tubes. This modified ureteric wire thus is lubricated with water-soluble jelly and passed into the gastric tube. The gastric tube is then lubricated and introduced via a nostril and advanced through the nares and oropharynx into the esophagus. The guide wire reinforces the distal part of the gastric tube, thus preventing its impaction and bending. Once the gastric tube seems to be negotiated into the esophagus, the guide wire is withdrawn and correct positioning of the gastric tube is verified. Although the use of guitar wire has been described to facilitate entry of the nasogastric tube, it is difficult to
Rajesh Mahajan MBBS, MD (Consultant) Department of Anesthesia Acharya Shri Chander College of Medical Sciences and Hospital (ASCOMS) Jammu, Jammu & Kashmir, 180001 India E-mail addresses: [email protected] [email protected] Rahul Gupta MBBS, MD (Junior Resident) Department of Hepatology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, 160012 India Anju Sharma MBBS (Junior Resident) Department of Anesthesia Acharya Shri Chander College of Medical Sciences and Hospital (ASCOMS) Jammu, Jammu & Kashmir, 180001 India doi:10.1016/j.jclinane.2009.01.005
References [1] Mahajan R, Gupta R, Sharma A. Role of neck flexion in facilitating nasogastric tube insertion. Anesthesiology 2005;103:446-7. [2] Mahajan R, Gupta R. Another method to assist nasogastric tube insertion. Can J Anaesth 2005;52:652-3. [3] Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43. [4] Matsuki A, Oyama T. Safe and simple method of nasogastric tube insertion during surgery. Masui 1971;20:369-70.