New technique of Rylestube insertion
- Conditions
- All patients requiring nasogastric tube
- Registration Number
- CTRI/2017/02/007832
- Lead Sponsor
- Nizams institute of medical sciences
- Brief Summary
SYNOPSIS
**Title:**
**Comparison of theease of Nasogastric tube insertion in standard sniffing position and furtherflexion.â€**
**Background:**
Nasogastric tube insertion is a common/mandatory procedurefor all major surgical procedures, sometimes it is technically challengingparticularly in anesthetised , paralyzed,and intubated or unconscious patients with reported failure rates of nearly 50%on the first attempt with the head in neutral position.(1-3) After a failure, subsequent attempts are usually unsuccessful due to coiling,kinking, or knotting of the NG tube as it loses stiffness due to warming tobody temperature. The memory effect also contributes to subsequent failures;once kinked, the NG tube is subsequently more likely to kink at the same place.It has been acknowledged that most difficulties in NGT insertions are due toanatomic reasons(4).The most common sites of impaction of the NG tube are piriform sinuses, thearytenoid cartilage(5)and the esophagus, which becomes compressed by the inflated cuff of anendotracheal tube. Maneuvers to keep the NG tube along the lateral or posteriorpharyngeal wall during insertion encourages the smooth passage into theesophagus.(1, 2, 4). Commonmethods used to facilitate NG tube insertion include the use of a slitendotracheal tube, forward displacement of the larynx and the use of variousforceps, the use of an ureteral guidewire as a stylet, head flexion, lateralneck pressure, and the use of a gloved finger to steer the NG tube afterimpaction.(2, 6-8) Sofar there are no guidelines/protocols/position for its insertion.
We hypothesized that slight modifications in NG tubeinsertion technique would improve the rate of successful insertion. We want tostudy the ease of insertion of NG tube with the head in sniffing position inthe first group and in second group the neck will be further flexed by usingadditional pillow . This study will be unique in nature where it will study theease of insertion in two different positions sniffing and in further flexionpositions and may guide the insertion in difficult scenarios.
**AIM**
To compare the ease of insertion of NG Tube between thestandard sniffing position and in further neck flexion using an additionalpillow. we determine the success rate,average time for insertion.
Secondary end point being incidence of complications, suchas bleeding, coiling and kinking.
**METHODS**
This is a randomized, observational study wherein, onehundred patients will be enrolled. The patients will be randomized into twogroups by computer generated random numbers.
Group 1: Here the NG tube will be inserted in the standardsniffing position.
Group 2: the NG tubeis inserted with neck flexed using an additional head ring, then the tube istaken out and reinserted with the head in standard position, i.e with a singlehead ring. The starting point of the procedure is the time when NG tubeinsertion is begun. The end point is the time when there is successfulinsertion of the NG tube.
Failure is defined as:
1. Not able to insert the tube in 2 attempts,
2. Using more than one alternative technique suchas jaw lift, laryngeal lift, use of laryngoscope, magills,
3. Time more than 30 sec.
The success rate of the technique, duration of insertionprocedure, and the occurrence of complications (bleeding, coiling,) are noted.
**Inclusion criteria:**
Patients coming forelective surgeries, requiring insertion of NG tube and are
ASA I or II
Age 18 - 65 years
**Exclusion criteria:**
ASA status III, IV,
Pregnant patients
Patients with risk ofpulmonary aspiration of gastric contents,
Patients requiring rapidsequence induction,
Patients with cervical spinepathology,
Patients on anticoagulants or on aspirin
Patients with neck mass,
Patientswith raised intracranial tension,
Patients withgastro-esophageal reflux disease and
Patients with airway distortion or trauma willbe excluded from the study
A detailed preoperative assessment with respect to history andexamination will be performed. The patients age, sex, weight, height, body massindex (BMI) will be noted, along with the presence of any comorbidities. Thefollowing airway assessment measurements will be noted.
1. Thyromental distance - It is defined as the distance from the mentumto the thyroid notch while the patient’s neck is fully extended. Thismeasurement helps in determining how readily the laryngeal axis will fall inline with the pharyngeal axis when the atlanto-occipital joint is extended.Alignment of these two axes is difficult if the T-M distance is < 3 fingerbreadths or < 6 cm in adults; 6-6.5cm is less difficult, while > 6.5 cm is normal.
2. Sternomental distance- It’s thedistance from the suprasternal notch to the mentum. It is measured with thehead fully extended on the neck with the mouth closed.
3. Neckcircumference- It is thecircumference of the neck at the level of thyroid cartilage.
4. Bodymass index: calculated asthe weight in kilograms divided by the square of the height in meters. Obesityis defined as a body mass index greater than 30kg/m 2 .
5. ModifiedMallampatti grading-
TheMallampatti classification correlates tongue size to pharyngeal size. This testis performed with the patient in the sitting position, head in a neutralposition, the mouth wide open and the tongue protruding to its maximum.
**Anaesthetic management**:
All the patients will be premedicated with Alprazolam 0.5 mg andRanitidine 150mg night before and on the morning of surgery.
In the operating room, baseline HR, SBP, DBP and SpO2 will be monitored.After obtaining iv access, Inj.glycopyrrolate 0.1mg intravenous 5 minutes before the induction will be given.Analgesia will be provided with Inj. fentanyl 2mcg/kg intravenously. All thepatients will be preoxygenated with 100% oxygen for 3 minutes. Standardinduction included Inj. thiopentone 4mg/kg intravenously or till the loss ofeyelash reflex and Inj. atracurium 0.5 mg/kg intravenously for musclerelaxation. Using a laryngoscope, intubation will be performed with appropriatesized endotracheal tube.
Then the NG tube will be inserted according to the random group that thepatient has been assigned.
Group 1: The NG tube is inserted in the standard sniffingposition with a single head pillow. In group 2 the head will be further flexedwith an additional head pillow and then the nasogastric tube will beinserted. The ease of insertion will beassessed by the following
The starting point of the procedure is the time when NG tubeinsertion is begun. The end point is the time when there is successfulinsertion of the NG tube.
The following manoeuvres will be used if NG tube if unable to insert in first attempt
First Jaw lift
Laryngeal lift
Use of ureteral guide wire
Use of Magills forceps
Change of nostril.
The success rate of the technique, duration of insertionprocedure, and the occurrence of complications (bleeding, coiling,) are noted.
Failure is defined as:
1. Not able to insert the tube in 2 attempts,
2. Using more than one alternative technique suchas jaw lift, laryngeal lift, use of laryngoscope, magills,
3. Time more than 30 sec.
**Data collection:**
Airway measurements will be noted during the pre anaestheticcheck-up. After induction of anesthesia Nasogastric tube insertion will beperformed and the time taken for insertion, need for additional manoeuvres,presence of any complications will be noted.
**Data analysis:**
The time taken for insertion, need for additionalmanoeuvres, presence of any complications will be noted and statisticalanalysis will be done using SPSS version 17.1.
**References**
1. Bong CL, Macachor JD, Hwang NC. Insertionof the Nasogastric Tube Made Easy. Anesthesiology.2004;101(1):266.
2. Kayo R, Kajita I,Cho S, Murakami T, Saito H. [A study on insertion of a nasogastric tube inintubated patients]. Masui The Japanese journal of anesthesiology.2005;54(9):1034-6.
3. Mahajan R, GuptaR. Another method to assist nasogastric tube insertion. Canadian journal ofanaesthesia = Journal canadien d’anesthesie. 2005;52(6):652-3.
4. Ozer S, BenumofJL. Oro- and nasogastric tube passage in intubated patients: fiberoptic descriptionof where they go at the laryngeal level and how to make them enter theesophagus. Anesthesiology. 1999;91(1):137-43.
5. Parris WC.Reverse Sellick maneuver. Anesthesia and analgesia. 1989;68(3):423.
6. Flegar M, Ball A.Easier nasogastric tube insertion. Anaesthesia. 2004;59(2):197.
7. Sprague DH,Carter SR. An alternate method for nasogastric tube insertion. Anesthesiology.1980;53(5):436.
8. Campbell B. Anovel method of nasogastric tube insertion. Anaesthesia. 1997;52(12):1234.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Not Yet Recruiting
- Sex
- All
- Target Recruitment
- 200
Patients coming for elective surgeries, requiring insertion of NG tube ASA I or II Age 18.
ASA status III, IV, Bleeding diathesis Pregnant patients Patients with risk of pulmonary aspiration of gastric contents, Patients requiring rapid sequence induction, Patients with cervical spine pathology, Patients on anticoagulants or on aspirin Patients with neck mass, Patients with raised intracranial tension, Patients with gastro-esophageal reflux disease, esophageal varices and.
Study & Design
- Study Type
- Interventional
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method Ease if insertion of nasogastric tube in sniffing position and in further flexion position There is no specific time points for this study. Ease will be assessed at the time of insertion. Necessary manoeuvres will be applied as per the protocol
- Secondary Outcome Measures
Name Time Method bleeding trauma
Trial Locations
- Locations (1)
NIMS,Hyderabad
🇮🇳Hyderabad, ANDHRA PRADESH, India
NIMS,Hyderabad🇮🇳Hyderabad, ANDHRA PRADESH, IndiaDr J NirmalaPrincipal investigator9849422749njonnavithula@gmail.com