American Journal of Emergency Medicine 33 (2015) 177–180

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Original Contribution

Endotracheal tube–assisted orogastric tube insertion in intubated patients in an ED☆,☆☆ Oh Sung Kwon, MD, Gyu Chong Cho, MD, PhD ⁎, Choong Hyun Jo, MD, Young Suk Cho, MD, PhD Department of Emergency Medicine, School of Medicine, Hallym University, 445 Gil-dong, Gang-dong gu, Seoul, 134-701, Korea

a r t i c l e

i n f o

Article history: Received 24 September 2014 Received in revised form 3 November 2014 Accepted 4 November 2014

a b s t r a c t Background and aims: Inserting a nasogastric tube (NGT) in intubated patients may be difficult because they cannot follow swallowing instructions, resulting in a high rate of first-attempt failure. We introduce a simple technique for inserting an orogastric tube in an emergency department (ED). Methods: Fifty-six patients in the ED, who were intubated and required NGT insertion, were randomly allocated to 2 groups. We inserted the NGT using a conventional technique from the nostril (control group) and an endotracheal tube (ET)-assisted technique from the mouth (ET group). The procedures' success rate, insertion duration, and complications were compared between the groups. Results: There was a significantly higher overall success rate in the ET group than the control group (100% vs 64%, P b .001). Endotracheal tube group showed 100% first-attempt success rate, but 50% of the control group failed at first attempt. Mean duration of the first trial was not significantly different between the ET and control groups (58.0 ± 16.9 vs 57.3 ± 29.5 seconds, P = .903), but total time for successful insertion was longer in the control group than the ET group (58.0 ± 16.9 vs 111.7 ± 74.5 seconds, P b .001). There was less NGT kinking and more mucosal bleeding in the ET group than in the control group (0% vs 16%, P = .019; 16% vs 7%, P = .225, respectively). Conclusion: Endotracheal tube–assisted orogastric tube insertion technique showed a higher rate of successful insertion and shorter total duration. With this result, ET-assisted orogastric tube insertion would be useful in ED. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Insertion of a nasogastric tube (NGT) sometimes is required in intubated, unconscious patients in the emergency department (ED) for gastric decompression or irrigation of the stomach in case of intoxication. Cooperation of the patients by swallowing as instructed while the NGT is inserted is important. Unconscious patients cannot follow these swallowing instructions, however, and is an important reason for high first-attempt failure rates of nearly 50% [1,2]. After a failure, subsequent attempts are usually unsuccessful because of NGT coiling, kinking, or knotting, as it loses stiffness from warming to the body temperature. The memory effect also contributes to subsequent failure; once kinked, the NGT is subsequently more likely to kink at the same place. The most common sites of NGT impaction are the pyriform sinuses and arytenoid cartilage [3]. The modern soft and less traumatic NGTs are made of polyurethane that becomes softer on exposure to a patient's body temperature [4]. In addition, several nonopposing lateral eyes tend to open near the tip, making the NGT more prone to kink [5]. Moreover, a curved NGT (when it is in the packet) promotes coiling in the mouth more than a straight tube does [6]. In intubated patients,

the tracheal tube's inflated balloon can cause obstruction of the NGT, especially in a setup, where cuff pressure measurement is not common [7]. We introduce a simple technique for orogastric tube insertion . We inserted a tube through the mouth with the assistance of an endotracheal tube (ET). This study was designed to investigate whether our modified technique would facilitate the passage of an orogastric tube in unconscious and intubated patients compared with the conventional NGT insertion technique in the ED. 2. Methods 2.1. Trial design This study was conducted in patients who were intubated in the ED of our hospital. It was approved by the institutional review board of our hospital and was conducted according to the Declaration of Helsinki. Written informed consent was obtained from each patient's caregiver before undertaking the interventions. 2.2. Participants

☆ Conflict of interest: The authors declare that they have no conflict of interests. ☆☆ Funding source: None. ⁎ Corresponding author. Tel.: +82 2 2225 2869; fax: +82 2 2224 2683. E-mail address: [email protected] (G.C. Cho). http://dx.doi.org/10.1016/j.ajem.2014.11.004 0735-6757/© 2014 Elsevier Inc. All rights reserved.

Participants of our research were intubated patients who needed an NGT inserted and who visited the ED between July 1 and December 31, 2013. Patients who were younger than 18 years old or who had known coagulopathy (abnormal prothrombin time, partial thromboplastin

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time, and platelet disorders), nasal stenosis, nares obstruction, nasal septal deviation, upper respiratory tract diseases or anomalies, or oesophageal disorders were excluded from this study. 2.3. Interventions Before sedation and tracheal intubation were undertaken in the ED, patients were randomly allocated into 2 groups according to a computer-generated randomization order. In the control group, patients had a lubricated 18F catheter NGT inserted gently through the selected nostril, with the head being maintained in a neutral position. Successful insertion of the NGT was confirmed, when the tube passed smoothly, and a gurgling sound was heard on auscultation over the epigastrium, when injecting 10 mL of air through the NGT. Patients allocated to the ET-assisted orogastric tube insertion technique (ET group) had an 8.5F catheter ET prepared. Before insertion, the distal and proximal ends of ET needed to be cut with sterile scissors. The distal end of the ET was trimmed and rounded to prevent mucosal damage, when it inserted. From the proximal end of the tube, the lubricated orogastric tube was inserted, until the tip of tube was sit at the distal edge of ET. We gently opened the mouth with 2 fingers as with endotracheal intubation and used the laryngoscope to lift the tongue. The laryngoscope does not need to be placed deeply in the oral cavity as with endotracheal intubation; the laryngoscope is for lifting the tongue and making it easier to insert the tube. The fully lubricated ET (~27 cm) was gently slid into the oesophagus approximately 20 cm (±2 cm depending on the patient's height). The orogastric tube was inserted approximately 65 cm (±5 cm depending on the patient's height). Successful insertion of the NGT was confirmed, when a gurgling sound was heard on auscultation over the epigastrium, when injecting 10 mL of air through the orogastric tube. The orogastric tube was held to ensure it did not fall out, when the trimmed ET was gently removed. The trimmed ET was cut vertically with sterile medical scissors, when the tube was fully taken out from the mouth. The fully cut ET was peeled away from the orogastric tube. Last, the orogastric tube was fixed to the existing ET, which was placed already for ventilation (Fig. 1). All procedures were performed by 3 paramedics who had more than 3 years of work experience in our hospital ED. They had 8 hours of education and practice on mannequins for this procedure. The procedure start time was defined as when the tube insertion was begun through the nostril, or laryngoscope insertion was begun through the mouth. The procedure end time was defined as the time of finishing the first attempt. The procedure duration was measured

with a stopwatch. If the first attempt failed, the NGT was fully withdrawn and cleaned. Lubricating jelly was applied generously, and the procedure was repeated using the same technique. If both attempts at insertion using the selected technique were unsuccessful, then the technique was considered a failure. Then, we crossed over to the other technique and attempted the insertion using that same technique. The procedure could be repeated twice. If both attempts failed, no more NGT insertion attempts were made in the ED. The following data were collected: (1) Patients' age, height, weight, and sex (2) Success rate of selected technique: first trial, second trial, and overall failure (3) Duration of first insertion attempt and total time for successful insertion (4) Complications during insertion: kinking and bleeding 2.4. Sample size The sample size was calculated using G-power 3.1.7 software. A pilot study of 10 cases per group suggested an approximate 40% improvement (from a base of 50%-90%) in success rate using these techniques. Consequently, a power calculation (α = .05 and β = .1) indicated a minimum of 28 patients for each group. 2.5. Statistical analysis Data were analyzed using SPSS 19.0 software for Windows (IBM, Inc, Armonk, NY). Demographic data were analyzed by the 2-tailed t test and Pearson χ 2 test. The time of NGT insertion was analyzed by the 2-tailed t test, and the success and complication rates of NGT insertion were analyzed by the Pearson χ2 test and Fisher exact test. The cumulative success rate associated with time to NGT insertion was analyzed using Kaplan-Meier analysis. A value of P b .05 was considered to be statistically significant. 3. Results Fifty-eight patients were included during the research period, and 2 of them refused the trial. As a result, a total of 56 patients were enrolled into this study. There were no statistically significant differences in demographic data (age, sex, height, and weight) between the 2 groups (Table 1). The overall success rate of tube insertion was 18 (64%) of 28

Fig. 1. Endotracheal tube–assisted orogastric tube insertion technique. A, An 8.5F catheter ET and a trimmed 8.5F catheter ET with inserted NGT. B, The laryngoscope does not need to be put deep into the oral cavity for endotracheal intubation; it is simply to lift the tongue and make it easy to insert the tube. The fully lubricated ET (~27 cm) is gently slid into the oesophagus approximately 20 cm (±2 cm depending on the patient's height). C, Insert the lubricated NGT approximately 65 cm (±5 cm depending on the patient's height). The trimmed ET is cut vertically with sterile medical scissors, when the tube is fully taken out of the mouth. D, The fully cut ET is peeled away from the NGT.

O.S. Kwon et al. / American Journal of Emergency Medicine 33 (2015) 177–180 Table 1 Demographics of participated patients

Age (y) Height (cm) Weight (kg) Gender (male:female)

Control group (n = 28)

ET group (n = 28)

P

65.3 ± 13.8 161.4 ± 11.2 57.2 ± 11.4 16:12

65.6 ± 15.0 164.6 ± 9.3 60.2 ± 11.4 17:11

.941 .243 .918 .786

Values are presented as mean ± SD.

patients in the control group and 28 (100%) of 28 patients in the ET group, and there was a significantly higher success rate in the ET group than in the control group (P b .001). In the ET group, all patients had successful NGT insertions on the first attempt. In the control group, 14 (50%) of 28 and 4 (14%) of 28 patients had successful NGT insertions on the first and second attempts, respectively. As a result, there were 10 failures in the control group. Successful rescues of the failed cases in the control group were achieved in all cases by using the new ET technique. The mean duration of the first trial was not significantly different between the ET and control groups (58.0 ± 16.9 vs 57.3 ± 29.5 seconds, P = .903), but total time for successful insertion was longer in the control group than in the ET group (58.0 ± 16.9 vs 111.7 ± 74.5 seconds, P b .001). The cumulative success rate related to the time of tube insertion was significantly higher in the ET group (P b .001) (Fig. 2). Kinking of the tube and mucosal bleeding were the most common complications. Kinking occurred in 5 patients (16%) in the control group and did not occur in the ET group, resulting in significantly higher kinking rate in the control group compared with the ET group (P = .019). Mucosal bleeding occurred in 2 patients (7%) in the control group and in 5 patients (16%) in the ET group. There was no statistical difference between the 2 groups (P = .225) (Table 2). 4. Discussion Our study confirmed that ET-assisted orogastric tube insertion technique has a much higher success rate on a first attempt than conventional technique. In addition, the total duration of successful insertion was much shorter than in the control group. Gastric intubation via the nasal or oral passage is a common procedure in most EDs, which provides access to the stomach for diagnostic and therapeutic purposes, including gastric lavage after poisoning or overdose, medication administration, gastrointestinal decompression for small-bowel obstruction, and evaluation of upper gastrointestinal bleeding. But inserting a tube into unconscious patients is sometimes very difficult and traumatic. There have been several modified techniques to insert NGTs, including neck flexion with lateral pressure, using a tied intubation stylet to an NGT, and inserting a urethral guidewire or angiography catheter into the NGT [2,8]. Considering the faults of NGT materials, some authors suggest stiffening the NGT before

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Table 2 Comparison of the success rate, duration, and complications between the 2 study groups during NGT insertion

Overall success (%) Success on first trial (%) Success on second trial (%) Overall failure (%) Mean duration of first trial (s) Total time for successful insertion (s) Complication (%) Kinking Mucosal bleeding

Control group (n = 28)

ET group (n = 28)

P

18 (64) 14 (50) 4 (14) 10 (36) 57.3 ± 9.5 111.7 ±74.5

28 (100) 28 (100) 0 (0) 0 (0) 58.0 ±16.9 58.0 ±16.9

b.001 b.001

5 (16) 2 (7)

0 (0) 5 (16)

.903 b.001

.019 .225

insertion. Suggested methods include immersion of the NGT into distilled water and keeping it in a refrigerator [8-11]. Neck flexion, in combination with the curve of the NGT, tends to keep the tube in close proximity to the posterior pharyngeal wall, facilitating its smooth passage into the esophagus but is unsafe for patients with unstable cervical spine and head injuries. The frozen NGT insertion technique is one way to prevent kinking during insertion. Frozen and distilled water inside the NGT melts quickly on contact with body temperature. The water might leak and fill the oral cavity, causing fluid aspiration [8,9]. The techniques of a tied intubation stylet or urethral guidewire attached to the NGT are more complex than ET-assisted method. Last, similar to our method is that of inserting the NGT through the nostril, using Magill forceps to pull it out from the oral cavity and then inserting the NGT into an ET. The remaining steps are the same as our method [2,12]. It takes time and can cause bleeding complications, when the NGT is pulled out with forceps. We did not find kinking in the ET group but did find a few bleeding complications. Bleeding was not severe and stopped in 1 minute for all 5 cases. Before the research, to prevent mucosal bleeding as described in the Interventions section, we cut the ET from the upper site of the ballooning part and trimmed the end of the ET in a circle. Before insertion, we lubricated the tube enough, and the procedure proceeded as gently as possible. However, if the ET material is little bit softer, round, and thin, we expect to decrease mucosal bleeding. We found a few limitations of our study during the research. First, all the procedures were done by 3 paramedics. Physicians and nurses might be the more common person to be placing gastric tubes. However, they have several years of work experience in the ED. Second, when the patients were intubated, ballooning pressures of the ETs usually were not measured. Because high ballooning pressure was one of the important reasons for kinking, it could cause a higher failure rate in the control group. Third, it is not always reliable to confirm the location of tube placement by auscultation at the level of the stomach, when air is pushed through the tube. The current criterion standard for determining NGT placement is by chest radiography, but chart review was not done to look for radiologic confirmation during the study period. 5. Conclusion In our study, ET-assisted orogastric tube insertion technique showed a much higher rate of successful insertion and saving of insertion time. With this result, ET-assisted orogastric tube insertion technique would be helpful and useful in ED. References

Fig. 2. Comparison of cumulative success rate between the 2 techniques.

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Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED.

Inserting a nasogastric tube (NGT) in intubated patients may be difficult because they cannot follow swallowing instructions, resulting in a high rate...
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