The GlideScope with modified Magill forceps facilitates nasogastric tube insertion in anesthetized patients: A randomized clinical study

Experimental Analysis of the Efficiency and Usability of Tylke Versus Magill Forceps

INTRODUCTION

The procedure of nasotracheal intubation (NI) has long been performed utilizing the Magill forceps as developed by Sir Ivan Magill in the 1920s. While used for nearly a century, several serious patient safety concerns remain including torn tube cuffs, vocal cord trauma, and inefficient tube placement. The Tylke forceps have been developed as a modification to the largely unchanged form of Magill forceps.

METHODS

In the present investigation we compared the efficacy, number of clasps, and muscle activation involved in NI using the Tylke forceps versus the Magill forceps in previously untrained individuals.

RESULTS

Tylke forceps showed faster successful NI over the standard Magill forceps at an average intubation time of 6.54s vs. 13.73s, respectively. Tylke forceps also had fewer clasps per intubation over the Magill. The trapezius, deltoid, and brachioradialis muscle activation was also compared in Tylke vs Magill forceps intubation trials. Tylke forceps required less lower muscle activation in the brachioradialis and trapezius over the Magill forceps with Tylke forceps resulting in higher deltoid muscle activation.

CONCLUSION

Tylke forceps were more efficacious and reduced the number of clasps over the Magill forceps when used in successful NI with different muscle activation patterns.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

Role of Endotracheal Tube Cuff Deflation in Facilitating Passage of Nasogastric Tube

Background

Nasogastric tube insertion is a routinely performed technique in anesthetized and intubated patients. However, failure leads to repeated insertion attempts causing injury, which makes the situation cumbersome. Therefore, we introduce a simple technique of deflating endotracheal tube cuff for nasogastric tube insertion in such patients.

Methods

Eighty adult patients scheduled for elective abdominal surgeries were randomly allocated into two groups, Group A (nasogastric tube insertion without endotracheal cuff deflation) and Group B (nasogastric tube insertion with endotracheal tube cuff deflation) along with lateral pressure application at cricoid in both groups. The number of attempts required, overall success rate, the time taken, rescue maneuvers, and incidence of complications were compared between the groups.

Results

In Group B, the total success rate for nasogastric tube placement was significantly higher than in Group A (80% vs 55%, p=0.016). Group B had a 55% first attempt success rate, but only 25% of patients in Group A had a first attempt success rate (p=0.014). The overall time for successful nasogastric tube placement was longer in Group A than in Group B (65.4 ± 28.72 seconds vs 43.5 ± 25.37 seconds, p=0.0005). The differences in nasogastric tube kinking and coiling between Group B and Group A were not statistically significant (20% vs 22.5%, 10% vs 27.5%, p = 0.78 and 0.08, respectively). Mucosal bleeding was substantially higher in Group A than in Group B (30% vs 10%, p=0.025, respectively).

Conclusions

This study showed that endotracheal tube deflation significantly increased the first-attempt success rate, overall successful placement of the nasogastric tube in intubated patients, and incidence of complications like mucosal bleeding decreased.

Placement of Nasogastric Feeding Tube and Postinsertion Care Review

Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients: A meta-analysis

BACKGROUND

Several techniques of nasogastric tube (NGT) insertion have been described in the literature with different success rates.

AIM

To systematically search the literature and conduct a meta-analysis comparing the success rates, insertion time and complications associated with different techniques of NGT insertion in anesthetized and intubated patients.

METHODS

An electronic search of the PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google Scholar databases were performed up to October 31, 2019. We included 17 randomized controlled trials with 2500 participants in the meta-analysis.

RESULTS

As compared to the conventional method, successful insertion of the NGT on first attempt was higher with modified techniques such as the reverse Sellick’s maneuver [relative risk (RR) 1.94; 95% confidence interval (CI): 1.62-2.31], use of a frozen NGT (RR 1.55; 95%CI: 1.13-2.13), inserting the NGT with neck flexion and lateral neck pressure (RR 1.64; 95%CI: 1.10-2.45), endotracheal tube-assisted (RR 1.88; 95%CI: 1.52-2.32) and video-assisted placements (RR 1.60; 95%CI: 1.31-1.95). All the modified techniques also led to comparatively higher insertion success rates than the conventional technique.

CONCLUSION

The use of modified techniques of NGT insertion such as the reverse Sellick’s maneuver, neck flexion with lateral neck pressure, frozen NGT, endotracheal tube-guided or video-assisted methods result in a significantly better chance of successful tube insertion at first attempt as compared to the conventional technique. All modified techniques also significantly improve the overall chance of successful NGT placement as compared to the conventional method.

SUZYTM forceps facilitate nasogastric tube insertion under McGRATHTM MAC videolaryngoscopic guidance: A randomized, controlled trial

BACKGROUND

Nasogastric tubes can be easily inserted in patients under general anesthesia. However, for difficult cases, insertion techniques that can be used in routine clinical practice are limited. SUZY forceps are designed for the removal of pharyngolaryngeal foreign bodies under guidance of a McGrath videolaryngoscope. We hypothesized that using SUZY forceps under McGrath videolaryngoscopic guidance may facilitate nasogastric tube insertion and tested this in a randomized controlled trial.

METHODS

Adult patients who underwent gastrointestinal or hepato-pancreato-biliary surgery were randomly allocated to 2 groups; the SUZY group and the Magill group. Patients, nurses, and all clinical staff except for the attending anesthesiologist were blinded to group assignment throughout the study. After anesthesia induction, insertion of the nasogastric tube was performed by skilled anesthesiologists with either SUZY or Magill forceps according to group allocation under McGrath videolaryngoscopic guidance. The primary endpoint was insertion time which was defined as the time required to advance the nasogastric tube by 55 cm from the nostril. Secondary endpoints were the success rates of the nasogastric tube insertion, which were defined as a 55-cm advancement from the nostril at the 1st, 2nd, and 3rd attempt, proper insertion rate, the severity of pharyngolaryngeal complications, and hemodynamic parameters during nasogastric tube insertion.

RESULTS

Sixty patients were randomized and none of these patients were excluded from the final analysis. The median [interquartile range] insertion time was 25 [18-33] seconds in the SUZY group, and 33 [21-54] seconds in the Magill group (P = .02). Success rates were not different between the groups (97% and 80% in the SUZY and Magill group at 1st attempt, respectively, P = .10). Both, the severity score of the mucosal injury and the severity of sore throat were higher in the Magill than in the SUZY group, whereas the degree of hoarseness did not differ between the 2 groups. Hemodynamic parameters were not significantly different between the groups.

CONCLUSION

Using SUZY forceps under McGrath videolaryngoscopic guidance reduced the time required to insert a nasogastric tube and the severity of pharyngolaryngeal complications, when compared to using Magill forceps.

Tracheopulmonary Complications of a Malpositioned Nasogastric Tube

Tracheopulmonary complications following placement of a nasogastric (NG) feeding tube are uncommon but can cause significant morbidity and mortality. In this case report, an 83-year-old woman of American Society of Anesthesiologists class IV with underlying pulmonary disease required placement of an NG feeding tube after surgical treatment of primary squamous cell carcinoma of the tongue. Malpositioning of the NG feeding tube into the right pleural space was confirmed by computed tomography. Removal of the NG feeding tube resulted in a tension pneumothorax that necessitated chest tube placement. Because of the difficulty of blind NG feeding tube placement in this patient, the subsequently placed NG feeding tube was successfully positioned with the aid of a video laryngoscope. This case report illustrates the risk of NG feeding tube malpositioning in a nasally intubated patient undergoing head and neck surgery and discusses improvements in techniques for proper NG feeding tube placement.