Comparative study of nasogastric tube insertion in anaesthetised intubated patients undergoing laparoscopic cholecystectomy in standard sniffing position and with reverse sellicks manoeuvre: a double blinded randomised control trial.

A nasogastric tube (NGT) is commonly inserted into patients undergoing abdominal surgeries to decompress the stomach intra operatively and post operatively, prevent post operative mechanical ileus, administer drugs and allow post operative feeding (1). It also helps to deflate stomach which obscures the view of camera during laparoscopic surgeries and also minimises the chance of gastric perforation(2) .However, in anaesthetised and intubated patients, the NGT gets coiled in oral cavity due to inability to swallow and due to the presence of an inflated cuff in the proximal trachea(2) .The distal part of the NGT has multiple apertures making it the weakest part, and hence increasing its susceptibility to kink, coil and knot, which is also precipitated by warming of the NGT due to body heat during insertion (1,3).  Furthermore, repeated trials could induce several complications such as nasal and pharyngeal bleeding, hypertension, tachycardia and arrythmia and several other adverse outcomes (1).The common position that we use for Ryles Tube insertion is the sniffing position (4),which may lead to impaction of the nasogastric tube in the pyriform sinus, arytenoid cartilage or the trachea (5).Different techniques of NGT insertion have been tried like use of guide wire, use of frozen NGT, use of split endotracheal tubes, videolaryngoscope aided methods, and several methods with varying degrees of complications. The reverse Sellick’s manoeuvre is a modified technique of NGT insertion where anterior displacement (lifting) of the cricoid cartilage is done, thus widening the esophageal opening further,  to facilitate the insertion of NGT(2) .The major advantage of this technique is simplicity and minimal complication as compared to instrumental facilitation (3).The purpose of this study, is to evaluate the effect of a modified technique of NGT insertion, i.e. Reverse Sellick’s manoeuvre in comparison with the conventional method of insertion, with respect to success rate, time needed for insertion and incidence of bleeding, coiling and kinking .  In this randomised control study the null hypothesis  that reverse sellick’s manoeuvre does not improve the success rate and time required for nasogastric tube insertion in anaesthetised intubated patients, undergoing laparoscopic cholecystectomy would be investigated.

REFERENCE:

1. Kim HJ, Lee HJ, Cho HJ, Kim HK, Cho AR, Oh N. Nasogastric tube insertion using airway tube exchanger in anesthetized and intubated patients. Korean journal of anesthesiology. 2016 Dec;69(6):568.
2. Siddhartha BV, Sharma NA, Kamble S, Shankaranarayana P. Nasogastric tube insertion in anesthetized intubated patients undergoing laparoscopic hysterectomies: A comparative study of three techniques. Anesthesia, essays and researches. 2017 Jul;11(3):550.
3. Jonnavithula N, Padhy S, Ravula R, Alekhya G. Comparison of ease of insertion of nasogastric tube in standard sniffing position and in additional flexion of the neck: A randomized control trial. Trends in Anaesthesia and Critical Care. 2019 Mar 23.
4. Miller’s Basics of Anaesthesia( 8th edition,2015) 1666-1667
5. Mandal MC, Dolai S, Ghosh S, Mistri PK, Roy R, Basu SR, Das S. Comparison of four techniques of nasogastric tube insertion in anaesthetised, intubated patients: A randomized controlled trial. Indian journal of anaesthesia. 2014 Nov;58(6):714.