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Letters to the Editor

The most common sites of impaction of a nasogastric tube during insertion are pyriform sinus and arytenoids cartilages leading to bending and coiling (1). Various techniques have been developed to address the problem of impaction and to aid insertion (2,3). Also, a good effort at swallowing by the patient during insertion is vital and greatly facilitates the procedure. We describe the technique followed by us in which a patient’s effort to swallow is taken advantage of during insertion of nasogastric tubes. Several minutes after putting nasal decongestant in the nostrils, the nasal passage and the nasogastric tube are well lubricated with lidocaine jelly. The nasogastric tube is gently passed up to the oropharynx. An assistant puts 0.5 mL (approximately eight drops) of sterile preservativefree saline through a syringe into the patient’s mouth. As the saline slowly trickles down the throat, the patient makes an effort to swallow, as seen by the movement of thyroid cartilage. At the same time, the operator quickly inserts the tube, taking advantage of the voluntary phase of the swallowing effort. Further insertion is facilitated by the involuntary phase of swallowing. In our institution, anesthesia consultation for nasogastric tube insertion is obtained when the primary physician fails in his attempt. During the last 3 years, successful insertion was achieved in 24 out of 30 patients on the first attempt. In 2 patients, a repeat attempt was successful. A third attempt failed in 4 patients and the procedure was performed using laryngoscopy and sedation. Failure of coordination between the operator and the assistant led to failure in two cases; this was corrected on the second attempt. We do not make more than three attempts, as repeated attempts may result in trauma and a more irritable and uncooperative patient. Close coordination between the two clinicians is important and can be achieved with a little practice. Even if the patient is unable to swallow, this small amount of saline generally does no harm to the patient. This technique is especially recommended for patients who are in “the corridor of uncertainty,” that is, with altered sensorium, doubtful swallowing reflex, but at the same time not allowing laryngoscopy or other instrumentation to aid the insertion, and where sedation is to be avoided. These patients usually require nasogastric insertion for administering medications and are mostly encountered in neurological or nephrological emergency departments. Om P. Sanjeev, DA Prakash K. Dubey, MD Department of Anesthesiology & Critical Care Medicine Indira Gandhi Institute of Medical Sciences Patna, India http://dx.doi.org/10.1016/j.jemermed.2013.08.141

REFERENCES 1. Mahajan R, Gupta R. Another method to assist nasogastric tube insertion. Can J Anesth 2005;52:652–3. 2. Bong CL, Macachor JD, Hwang NC. Insertion of the nasogastric tube made easy. Anesthesiology 2004;101:266. 3. Flegar M, Ball A. Easier nasogastric tube insertion. Anaesthesia 2004;59:197.

, COMMENTS ON “MEDICAL OUTCOMES ASSOCIATED WITH NONMEDICAL USE OF METHADONE AND BUPRENORPHINE” , To the Editor: We read with interest the recent article comparing the effects of nonmedical exposures of methadone and buprenorphine reported to the American Association of Poison Control Centers’ National Poison Data System (1). We commend the authors for noting the inherent difficulty with the use of these data due to the problems with lack of confirmatory testing, reporting biases, and accuracy of information obtained through intermediaries. One additional clarification that should be made regarding the comparison between nonmedical buprenorphine and methadone use is the difference in the populations who generally use these drugs and the clinical syndromes they cause. Nonmedical methadone exists as a street opioid, causing symptoms consistent with opioid toxicity commonly recognized as miosis, sedation, and respiratory depression. The data reported in this report are consistent with this, as 64.9% of the nonmedical methadone patients received naloxone to antagonize these opioid effects. In contrast, it seems the patients with nonmedical buprenorphine exposures were suffering from opioid withdrawal. A significant number presented with agitation, vomiting, and abdominal pain. Further, they required sedation with benzodiazepines. Patients who use nonmedical buprenorphine seem to be aware of its role in opioid maintenance programs but are unaware of its biochemical actions or the clinical consequences of use. As a high-affinity partial agonist at the m receptor and full agonist at the k receptor, there is reduced risk of respiratory depression in overdose situations, but buprenorphine exposure can result in opioid withdrawal when other m agonists are present. We believe this study demonstrates that patients who presented with nonmedical methadone use were opioid toxic, whereas those who presented with nonmedical buprenorphine use were in opioid withdrawal. The relative safety of these two syndromes is quite different. Opioid toxicity is a frequent cause of death due to respiratory depression, whereas opioid withdrawal is very uncomfortable, but

The Journal of Emergency Medicine

rarely life threatening. The authors cite prior research reporting that toxicities to buprenorphine and methadone are indistinguishable (2). In this analysis, they show that exposure to these two medications differs greatly, but the question of whether the toxicity (meaning clinical manifestations of overdose in opioid-naı¨ve patients) from these medications is similar is not addressed. Nicholas J. Connors, MD Robert S. Hoffman, MD Division of Medical Toxicology Department of Emergency Medicine New York University/Bellevue Medical Center

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New York City Poison Control Center New York, New York http://dx.doi.org/10.1016/j.jemermed.2013.09.041

REFERENCES 1. Lee S, Klein-Schwartz W, Welch C, Doyon S. Medical outcomes associated with nonmedical use of methadone and buprenorphine. J Emerg Med 2013;45:199–205. 2. Megarbane B, Buisine A, Jacobs F, et al. Prospective comparative assessment of buprenorphine overdose with heroin and methadone: clinical characteristics and response to antidotal treatment. J Subst Abuse Treat 2010;38:403–7.

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