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Bathobakae L, Elshaarawy S, Bashir R, Phuu P, Melki G, Hajjar B. Orogastric Tube Fracture and Ingestion in a Patient With Hyperacute Delirium: A Unique and Potentially Catastrophic Complication. J Med Cases 2024; 15:283-286. [PMID: 39328804 PMCID: PMC11424104 DOI: 10.14740/jmc4295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
Orogastric tubes (OGTs) are frequently used to administer feeds and medications to critically ill patients. They are inserted blindly, with a low first-pass success rate and frequent benign complications. OGT fractures and ingestion are exceedingly rare, with only two cases reported to date. Herein, we describe a rare case of OGT transection and ingestion in a male patient admitted for hyperacute delirium and complicated pneumonia. The OGT remnant was retrieved using an endoscope without any complications. Clinicians must be aware of this rare but potentially catastrophic complication of OGT use. OGTs must be inspected in the same manner as endotracheal tubes to ensure patient safety.
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Affiliation(s)
- Lefika Bathobakae
- Internal Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Shaimaa Elshaarawy
- Internal Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Rammy Bashir
- Internal Medicine, Norwalk Hospital/Yale University, Norwalk, CT, USA
| | - Phenyo Phuu
- Internal Medicine, St. Vincent’s Medical Center, Bridgeport, CT, USA
| | - Gabriel Melki
- Gastroenterology and Hepatology, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Bassam Hajjar
- Gastroenterology and Hepatology, St. Joseph’s University Medical Center, Paterson, NJ, USA
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O'Connor GD, Taplin R, Murphy C. Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland. Ir J Med Sci 2024; 193:2461-2468. [PMID: 38850352 PMCID: PMC11450058 DOI: 10.1007/s11845-024-03731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice. METHODS A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively. RESULTS In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin. CONCLUSION UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.
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Affiliation(s)
- Gavin David O'Connor
- University Hospital Limerick, Limerick, Ireland.
- University College Cork, Cork, Ireland.
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Maxwell A. Comment on Miyamoto et al. Laryngopharyngeal Mucosal Injury Due to Nasogastric Tube Insertion during Cardiopulmonary Resuscitation: A Retrospective Cohort Study. J. Clin. Med. 2024, 13, 261. J Clin Med 2024; 13:3447. [PMID: 38929975 PMCID: PMC11204407 DOI: 10.3390/jcm13123447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/18/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
I read with great interest the study from Miyamoto et al [...].
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Affiliation(s)
- Andrew Maxwell
- Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
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Jong HS, Lim TW, Jung KT. Optimal Insertion Depth of Gastric Decompression Tube with a Thermistor for Patients Undergoing Laparoscopic Surgery in Trendelenburg Position. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14708. [PMID: 36429426 PMCID: PMC9690127 DOI: 10.3390/ijerph192214708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
Monitoring core temperature is crucial for maintaining normothermia during general anesthesia. Insertion of a gastric decompression tube (GDT) may be required during laparoscopic surgery. Recently, a newly designed GDT with a thermistor for monitoring esophageal temperature has been introduced. The purpose of the present study was to evaluate the optimal insertion depth of a GDT with a thermistor. Forty-eight patients undergoing elective laparoscopic surgery in the Trendelenburg position were included in the study. The GDT was inserted to a depth of nose-earlobe-xiphoid distance (NEX) + 12 cm and withdrawn sequentially, 2 cm at a time, at 5-min intervals. Temperatures of the GDT thermistor were compared with the core temperature of the tympanic membrane (TM) using Bland and Altman analysis. The correlation between optimal insertion depth of the GDT and anatomical distance (cricoid cartilage to the carina, CCD; carina to the left hemidiaphragm, CLHD) was evaluated, and a mathematical model to predict the optimal insertion depth of the GDT with a thermistor was calculated. Temperatures of TM and GDT thermistor at NEX + 4 cm showed good agreement and strong correlation, but better agreement and stronger correlation were seen at the actual location with the most minor temperature differences. The optimal insertion depth of the GDT was estimated as -15.524 + 0.414 × CCD - 0.145 × CLHD and showed a strong correlation with the actual GDT insertion depth (correlation coefficient 0.797, adjusted R2 = 0.636). The mathematical formula using CCD and CLHD would be helpful in determining the optimal insertion depth of a GDT with a thermistor.
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Affiliation(s)
- Hwa Song Jong
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, Korea
| | - Tae Won Lim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine and Medical School, Chosun University, Gwangju 61452, Korea
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Okada Y, Ohke H, Yoshimoto H, Kobashi M, Saitoh M, Terumitsu M. Nasogastric Tube Knotted Around a Nasal Endotracheal Tube in the Nasopharynx: Possible Cause. Anesth Prog 2021; 68:90-93. [PMID: 34185863 DOI: 10.2344/anpr-67-04-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/12/2020] [Indexed: 11/11/2022] Open
Abstract
A nasogastric tube is often used along with a nasal endotracheal tube during oral surgery or dental treatment under general anesthesia. Although the insertion of a nasogastric tube is a simple procedure, it can be associated with complications that lead to potentially serious consequences. The knotting of a nasogastric tube around an endotracheal tube is rare. Here, we report a case in which the nasogastric tube became knotted around the nasal endotracheal tube in the nasopharynx. We compare this case with 4 previous similar cases and provide a theory of how the nasogastric tube might have become knotted.
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Affiliation(s)
- Yunosuke Okada
- Division of Pediatric Dentistry, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Hanako Ohke
- Division of Dental Anesthesiology, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Hiroyo Yoshimoto
- Division of Dental Anesthesiology, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Misato Kobashi
- Division of Pediatric Dentistry, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Masato Saitoh
- Division of Pediatric Dentistry, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Makoto Terumitsu
- Division of Dental Anesthesiology, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
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Behera BK, Misra S. Use of flexible video bronchoscope for verification of nasogastric tube position in the intubated patient. J Clin Monit Comput 2021; 36:593-594. [PMID: 34240261 DOI: 10.1007/s10877-021-00740-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/01/2021] [Indexed: 11/25/2022]
Abstract
We propose a novel method for verifying the nasogastric tube (NGT) position and tip localization using flexible video bronchoscopy in anesthetized and intubated adult patients. The length of the scope used is 65 cm and can thus, track the NGT up to the pyloric canal. We have used this technique in patients with success. For the prevention of fogging of the scope tip, 2 L/min of oxygen is insufflated through the working channel, which also helps in the opening of the esophagus during endoscopy. Gastric distension due to oxygen insufflation is prevented by repeated suctioning. The course of the NGT can be seen in its entirety in the esophagus and stomach. The esophagus is identified by the pale mucosa and symmetrical delicate folds (Fig. 1a). The stomach is identified by the red mucosa and random tortuous folds (Fig. 1b). The pyloric canal can be identified by the convergence of gastric mucosal folds leading to the pyloric opening (Fig. 1c). In each case, the subdiaphragmatic position of NGT was verified with radiography, which is a routine practice in our institute.
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Affiliation(s)
| | - Satyajeet Misra
- All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
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Ohbe H, Matsui H, Fushimi K, Yasunaga H. Small-bore feeding tube versus large-bore sump tube for early enteral nutrition in mechanically ventilated patients: A nationwide inpatient database study. Clin Nutr 2021; 40:4113-4119. [PMID: 33610423 DOI: 10.1016/j.clnu.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/13/2021] [Accepted: 02/01/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS When physicians start nasogastric tube feeding in mechanically ventilated patients, they have two choices of feeding tube device: a large-bore sump tube or a small-bore feeding tube. Some physicians may prefer to initiate enteral nutrition via the large-bore sump tube that is already in place, and others may prefer to use the small-bore feeding tube. However, it remains unknown whether small-bore feeding tubes or large-bore sump tubes are better for early enteral nutrition. The present study aimed to compare outcomes between these two types of feeding tubes in mechanically ventilated patients. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified adult patients who underwent invasive mechanical ventilation for ≥2 days in intensive care units and received nasogastric tube feeding within 2 days of starting mechanical ventilation. We categorized these patients as receiving early enteral nutrition via small-bore feeding tube (8- to 12-Fr single-lumen tubes) or via large-bore sump tube. Propensity score-matched analyses were performed to compare 28-day in-hospital mortality and hospital-acquired pneumonia between the two groups. RESULTS A total of 79,656 patients were included. Of these patients, 20,178 (25%) were in the small-bore feeding tube group. One-to-one propensity score matching created 20,061 matched pairs. Compared with those in the large-bore sump tube group, patients in the small-bore feeding tube group had significantly higher 28-day in-hospital mortality (17.0% versus 15.6%; hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14) and a significantly higher prevalence of hospital-acquired pneumonia (9.3% versus 8.5%; odds ratio, 1.11; 95% confidence interval, 1.02 to 1.21). CONCLUSIONS This nationwide observational study suggests that small-bore feeding tubes may not be associated with better clinical outcomes but rather with increased mortality and hospital-acquired pneumonia. Because of the uncertainty regarding the mechanism of our findings, further studies are warranted.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan.
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan.
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Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract 2019; 25:739-743. [PMID: 30548370 DOI: 10.1111/jep.13086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE AIMS AND OBJECTIVES Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event. METHODS This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration. RESULTS The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases. CONCLUSION These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.
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Affiliation(s)
- Ashley Szabo Eltorai
- Department of Anesthesiology, Cardiac Division, Yale University School of Medicine, New Haven, Connecticut
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Tollinche LE, Li D, Salamanca-Cardona L, Tan KS, O'connor D, Teng H, Yang G, Long M, Yeoh CB. The incidence of intraoperative gastric tube malposition verified by Point-of-Care Ultrasound. Minerva Anestesiol 2019; 85:1168-1174. [PMID: 31124621 DOI: 10.23736/s0375-9393.19.13530-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Over a million gastric tubes are placed yearly for varying medical reasons including gastric decompression. In the operating room (OR), this is performed blindly, and position is confirmed by auscultation, aspiration, or palpation by a surgeon. Despite the known risks of malpositioned gastric tubes, there is limited data in anesthesia literature about the incidence of intraoperative malpositioned gastric tubes. In this study, we use Point-of-Care ultrasonography (POCUS) to confirm gastric tube placement in the OR. METHODS Prospective observational study with a total of 149 subjects, all over 18 years of age, undergoing surgery with general endotracheal anesthesia and intraoperative blind placement of a gastric tube by an anesthesia provider. The primary objective of this study is to determine the incidence of malposition of blindly placed gastric tubes. RESULTS In our analysis, we found that out of 149 patients 110 patients were successfully visualized; the incidence of malposition was 0.14 [95% CI: 0.08-0.21]. We did not find age, Body Mass Index, or sex to be associated with predisposing patients to intraoperative malposition of gastric tube. However, increasing years of experience of anesthesia provider correlated with higher malposition rates. CONCLUSIONS In summary, we demonstrated that the incidence of malposition of blindly gastric tubes was 14%. Given the attendant risks of malpositioned gastric tubes, this data should inform decision algorithms for the blind placement of gastric tubes.
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Affiliation(s)
- Luis E Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA -
| | - Duan Li
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lucia Salamanca-Cardona
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay S Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David O'connor
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Howard Teng
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gloria Yang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Long
- Department of Anesthesiology, Marian University, Indianapolis, IN, USA
| | - Cindy B Yeoh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Sounds Impossible, but It's Knot. Anesthesiology 2019; 130:824. [PMID: 30632983 DOI: 10.1097/aln.0000000000002585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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