Letters to Editor
was an increase in the peak pressures and the end-tidal carbon dioxide (EtCO 2). To rule out any mechanical obstruction as the plausible cause, the anesthesia circuit was checked for any kink or obstruction. The problem was diagnosed when a 10 F suction catheter could not pass through the ETT. The distal end of the connector was found to have an extremely narrow orifice, in comparison to the standard 4 mm ETT connector [Figure 1]. The connector was removed and replaced with another same size ETT connector. There was immediate improvement in ventilation. The peak pressures and the EtCO2 came down to normal limits. The rest of the surger y was uneventful. Difficult ventilation following successful endotracheal intubation could be due to acute bronchospasm, malfunction or obstruction of breathing circuit, kinking, obstruction of ETT by foreign body or malfunctioning defects of different parts of ETT e.g., inflation line, ETT connector.[2-5] In spite of the several case reports of manufacturing errors, such mishaps continue to occur. Reporting of such critical events re-emphasizes the need for thorough check of each and every part of the anesthetic equipment prior to its use and highlights the role of a vigilant clinician in timely detection of such errors and thereby avoiding anaesthetic mishaps. Divya Jain, Indu Bala Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Divya Jain, H. No-2036, Sector 21-C, Chandigarh - 160 022, India. E-mail: [email protected]
References 1.
2.
3.
4.
5.
Szekely SM, Webb RK, Williamson JA, Russell WJ. The Australian Incident Monitoring Study. Problems related to the endotracheal tube: An analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:611-6. Yang CH, Chen KH, Lee YE, Lin CR. Anesthetic breathing circuit obstruction mimicking severe bronchospasm: An unusual manufacturing defect. Acta Anaesthesiol Taiwan 2012;50:35-7. Chacon AC, Kuczkowski KM, Sanchez RA. Unusual case of breathing circuit obstruction: Plastic packaging revisited. Anesthesiology 2004;100:753. Hajimohammadi F, Taheri A, Eghtesadi-Araghi P. Obstruction of endotracheal tube; a manufacturing error. Middle East J Anesthesiol 2009;20:303-5. Bharti N, Bala I, Sharma K. Endotracheal tube connector defect as a cause of high airway pressure. Paediatr Anaesth 2012;22:502-3. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.142889
Nasogastric tube coiled around endotracheal tube Sir, Nasogastric tube (NGT) insertion is done routinely in abdominal surgeries. However, it can be really difficult in some cases such as head injury and facial trauma, esophageal narrowing, heavy built patients, and intubated patients.[1] Various complications such as endotracheal insertion, intracranial insertion, blockade, and nasal bleeding have been reported.[2] It is not uncommon for NGT to coil around into a knot in the pharynx; but, we came across a case where malpositioned NGT coiled around the endotracheal tube (ETT). We report a case of a 60-year-old male posted for perforation peritonitis for which NGT was inserted, which coiled around the ETT and formed a knot. Literature on the same reveals that it is a rarest of the rare complication, which can be lifethreatening.
Figure 1: The narrow orifice endotracheal tube connector and the standard connector
584
A 60-year-old male, American Society of Anesthesiologists physical Status II was admitted as a case of perforation
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Letters to Editor
peritonitis with gas under the diaphragm. He was planned for explorator y laparotomy and repair. Patient was brought into the operation theatre with an 18 FG NGT in the right naris until first mark and was thought to be rightly placed. Preoperative suction of NGT showed no collection. However, at the time of laryngoscopy NGT could not be seen in the oral cavity, so it was removed and another NGT was tried. As suction did not reveal anything, further maneuvers were performed, which were unsuccessful. While trying to pull the NGT out it was found that it is not moving, and there is concomitant movement of ETT with the NGT. Finally, decision was taken to insert the NGT under direct visualization using a laryngoscope and forcep. It was noticed that NGT has coiled around the ETT and formed a knot [Figure 1]. Laryngoscopy was done, knot was released using magill’s forcep and NGT was taken out. Care was taken not to extubate the patient unintentionally. Finally, a 16 FG NGT was inserted successfully. Various cases of malpositioning have been reported when NGT is inserted blindly. However, sometimes conditions arise when slightest manipulation of a malpositioned NGT can be life-threatening. Any resistance felt during insertion or removal of NGT in an intubated patient, which is associated with concurrent motion of ETT, a coiled NGT knotted around ETT should be suspected.[1] In the case reported above, the various failed attempts to remove the NGT and concomitant movement of ETT with NGT led to the possibility of NGT being coiled around ETT. Similar cases have been reported in few other case reports, but managing it is makes it a unique one and gives us a learning experience.[3,4] Further management will depend upon condition of the airway, ease of intubation, need of
decompression according to the surgery and position of the knot considering cutting and untying of knot. Knot can be left in position until extubation in the end of surgery, immediate extubation and reintubation,[5] cutting the NGT under direct visualization with laryngoscope or fiberoscope.[6] Our management was based on a number of considerations that the surgical procedure required a patent NGT for intraoperative gastric decompression. Because the coiled NGT was in access and the knot seemed to be loose, an attempt was taken to untie the knot under direct vision using a laryngoscope and Maggil’s forcep which was successful. Every measure was taken not to accidentally extubate the patient. Knotting of NGT can be prevented by its proper placement using special maneuvers such as acute flexion of head, manual forward displacement of the trachea,[6] applying lateral pressure on the neck,[7] freezing the gastric tube or inserting a guide wire or Fogarty catheter to increase the rigidity, lubrication using jelly, or direct guidance using laryngoscope and Magill’s forcep.[8] If while withdrawing a NGT, resistance is felt and there is concomitant motion of ETT, then a NGT coiled around ETT should be suspected. It is also to be noted that continued attempt at extraction may lead to fatal complications such as respiratory compromise or laryngospasm and irreversible repair.[9] Hence, this case is a learning experience for all anesthesiologists in clinical practice and can avert unintentional extubation. Gaurav Acharya1, Kishore Kumar Arora1, Dewesh Kumar2 1 Department of Anesthesiology, MGM Medical College, Indore, Madhya Pradesh, 2Department of Preventive and Social Medicine, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Gaurav Acharya, MGM Medical College, Indore - 452 001, Madhya Pradesh, India. E-mail: [email protected]
References 1. 2. 3. 4.
5. 6. Figure 1: Arrow shows the coiling loops of nasogastric tube around endotracheal tube
Pousman RM, Koch SM. Endotracheal tube obstruction after orogastric tube placement. Anesthesiology 1997;87:1247-8. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract 2006;21:40-55. Dorsey M, Schwinder L, Benumof JL. Unintentional endotracheal extubation by orogastric tube removal. Anesth Rev 1988;15:30-3. Au-Truong X, Lopez G, Joseph NJ, Salem MR. A case of a nasogastric tube knotting around a tracheal tube: Detection and management. Anesth Analg 1999;89:1583-4. Bautista EM. Complications of nasogastric tube insertion. Chest 1988;93:1119-20. Perel A, Ya’ari Y, Pizov R. Forward displacement of the larynx for nasogastric tube insertion in intubated patients. Crit Care Med 1985;13:204-5.
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
585
Letters to Editor 7.
8.
9.
Ozer S, Benumof JL. Oro-and nasogastric tube passage in intubated patients: Fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43. Lind LJ, Wallace DH. Submucosal passage of a nasogastric tube complicating attempted intubation during anesthesia. Anesthesiology 1978;49:145-7. Young MJ, Ehrenfeld JM. Knotting of an orogastric tube around an endotracheal tube. J Clin Anesth 2012;24:254-5. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.142891
Is computed tomography scan the ultimate modality for airway evaluation? Sir, Patients with anterior mediastinal mass pose special anesthetics challenges, and they are prone to perioperative complications particularly from airway collapse.[1] We present anesthetic challenges in a 78-year-old patient suffering from a retrosternal goiter and thymic cyst presented with compressive symptoms. Written informed consent was obtained for publication of this case. A 78-year-old man was admitted to our hospital with the complaints of cough and expectoration for 5 months. He also complained of inability to lie down in left lateral posture but did not have any difficulty in the supine position even during sleep. There was also no history of respiratory distress and stridor neither at rest nor with activity. Computed tomography (CT) scan of neck and thorax revealed a thyroid swelling extending from the neck into the superior mediastinum along with a thymic cyst. Both CT scan [Figure 1] and a chest X-ray found a deviation of the trachea, and moderate compression of thoracic trachea, with a compression of the laryngeal vestibule and cervical trachea was noted [Figure 1]. The minimum internal diameter of the thoracic trachea was found to be 6.0-7.0 mm. All other investigations were within normal limit. General anesthesia with endotracheal (ET) intubation along with thoracic epidural catheter for postoperative pain management was planned. Awake fiberoptic bronchoscope 586
guided intubation with airway block, and topical anesthesia was planned. To anesthetize upper airway, 5 ml of 4% lignocaine nebulization was done for 10 min, followed by 2 ml 4% lignocaine injected into the trachea. We used real-time ultrasound to identify trachea as it was deviated. In the operating room, after attaching all the monitors, fiberoptic bronchoscopy was attempted through oral route using an oral bite block. We noted a near total compression of the trachea started just below the vocal cord extending up to just above the carina. It was on the contrary to the preoperative CT scan finding. However, we were able to introduce the fiberscope in the trachea and a 7.0 mm ID cuffed flexo-metallic ET tube was rail-roaded over the scope. The tip of the ET tube was kept just above the carina passing the distal end of tracheal compression. The fiberscope was taken out under vision, and anesthesia was induced with 250 mg intravenous thiopentone sodium and after confirmation of bilateral air entry, 25 mg atracurium was given. At the end of the surgery, elective postoperative ventilation was planned. After, a check fiberoptic bronchoscopy, we exchanged the flexo-metallic ET tube with an 8.0 mm ID cuffed ET tube over an airway exchange catheter. On the next day, he was extubated uneventfully in the surgical intensive care unit. Computed tomography scan is one of the most commonly used diagnostic modality for this purpose. CT scan predicts perioperative complications in these patients.[2,3] In our case, CT scan correctly delineated compression of the larynx and cervical trachea, but failed to detect a significant thoracic tracheal compression. As CT scan provides only static image,[4] fiberoptic bronchoscopy does have a role in such patients because it provided dynamic imaging.[5] As magnetic resonance imaging (MRI) provides excellent soft tissue contrast,[6] so it is an important preoperative investigation for tumors of the mediastinum.[7,8] We suggest a preoperative MRI for proper anesthetic planning in such patients. Souvik Maitra, Gopi Krishnan, Dalim Kumar Baidya, Sunil Chumber1 Departments of Anaesthesiology and 1Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Dalim Kumar Baidya, Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail: [email protected]
References 1.
Gardner JC, Royster RL. Airway collapse with an anterior mediastinal mass despite spontaneous ventilation in an adult. Anesth Analg 2011;113:239-42.
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
was an increase in the peak pressures and the end-tidal carbon dioxide (EtCO 2). To rule out any mechanical obstruction as the plausible cause, the anesthesia circuit was checked for any kink or obstruction. The problem was diagnosed when a 10 F suction catheter could not pass through the ETT. The distal end of the connector was found to have an extremely narrow orifice, in comparison to the standard 4 mm ETT connector [Figure 1]. The connector was removed and replaced with another same size ETT connector. There was immediate improvement in ventilation. The peak pressures and the EtCO2 came down to normal limits. The rest of the surger y was uneventful. Difficult ventilation following successful endotracheal intubation could be due to acute bronchospasm, malfunction or obstruction of breathing circuit, kinking, obstruction of ETT by foreign body or malfunctioning defects of different parts of ETT e.g., inflation line, ETT connector.[2-5] In spite of the several case reports of manufacturing errors, such mishaps continue to occur. Reporting of such critical events re-emphasizes the need for thorough check of each and every part of the anesthetic equipment prior to its use and highlights the role of a vigilant clinician in timely detection of such errors and thereby avoiding anaesthetic mishaps. Divya Jain, Indu Bala Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Divya Jain, H. No-2036, Sector 21-C, Chandigarh - 160 022, India. E-mail: [email protected]
References 1.
2.
3.
4.
5.
Szekely SM, Webb RK, Williamson JA, Russell WJ. The Australian Incident Monitoring Study. Problems related to the endotracheal tube: An analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:611-6. Yang CH, Chen KH, Lee YE, Lin CR. Anesthetic breathing circuit obstruction mimicking severe bronchospasm: An unusual manufacturing defect. Acta Anaesthesiol Taiwan 2012;50:35-7. Chacon AC, Kuczkowski KM, Sanchez RA. Unusual case of breathing circuit obstruction: Plastic packaging revisited. Anesthesiology 2004;100:753. Hajimohammadi F, Taheri A, Eghtesadi-Araghi P. Obstruction of endotracheal tube; a manufacturing error. Middle East J Anesthesiol 2009;20:303-5. Bharti N, Bala I, Sharma K. Endotracheal tube connector defect as a cause of high airway pressure. Paediatr Anaesth 2012;22:502-3. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.142889
Nasogastric tube coiled around endotracheal tube Sir, Nasogastric tube (NGT) insertion is done routinely in abdominal surgeries. However, it can be really difficult in some cases such as head injury and facial trauma, esophageal narrowing, heavy built patients, and intubated patients.[1] Various complications such as endotracheal insertion, intracranial insertion, blockade, and nasal bleeding have been reported.[2] It is not uncommon for NGT to coil around into a knot in the pharynx; but, we came across a case where malpositioned NGT coiled around the endotracheal tube (ETT). We report a case of a 60-year-old male posted for perforation peritonitis for which NGT was inserted, which coiled around the ETT and formed a knot. Literature on the same reveals that it is a rarest of the rare complication, which can be lifethreatening.
Figure 1: The narrow orifice endotracheal tube connector and the standard connector
584
A 60-year-old male, American Society of Anesthesiologists physical Status II was admitted as a case of perforation
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Letters to Editor
peritonitis with gas under the diaphragm. He was planned for explorator y laparotomy and repair. Patient was brought into the operation theatre with an 18 FG NGT in the right naris until first mark and was thought to be rightly placed. Preoperative suction of NGT showed no collection. However, at the time of laryngoscopy NGT could not be seen in the oral cavity, so it was removed and another NGT was tried. As suction did not reveal anything, further maneuvers were performed, which were unsuccessful. While trying to pull the NGT out it was found that it is not moving, and there is concomitant movement of ETT with the NGT. Finally, decision was taken to insert the NGT under direct visualization using a laryngoscope and forcep. It was noticed that NGT has coiled around the ETT and formed a knot [Figure 1]. Laryngoscopy was done, knot was released using magill’s forcep and NGT was taken out. Care was taken not to extubate the patient unintentionally. Finally, a 16 FG NGT was inserted successfully. Various cases of malpositioning have been reported when NGT is inserted blindly. However, sometimes conditions arise when slightest manipulation of a malpositioned NGT can be life-threatening. Any resistance felt during insertion or removal of NGT in an intubated patient, which is associated with concurrent motion of ETT, a coiled NGT knotted around ETT should be suspected.[1] In the case reported above, the various failed attempts to remove the NGT and concomitant movement of ETT with NGT led to the possibility of NGT being coiled around ETT. Similar cases have been reported in few other case reports, but managing it is makes it a unique one and gives us a learning experience.[3,4] Further management will depend upon condition of the airway, ease of intubation, need of
decompression according to the surgery and position of the knot considering cutting and untying of knot. Knot can be left in position until extubation in the end of surgery, immediate extubation and reintubation,[5] cutting the NGT under direct visualization with laryngoscope or fiberoscope.[6] Our management was based on a number of considerations that the surgical procedure required a patent NGT for intraoperative gastric decompression. Because the coiled NGT was in access and the knot seemed to be loose, an attempt was taken to untie the knot under direct vision using a laryngoscope and Maggil’s forcep which was successful. Every measure was taken not to accidentally extubate the patient. Knotting of NGT can be prevented by its proper placement using special maneuvers such as acute flexion of head, manual forward displacement of the trachea,[6] applying lateral pressure on the neck,[7] freezing the gastric tube or inserting a guide wire or Fogarty catheter to increase the rigidity, lubrication using jelly, or direct guidance using laryngoscope and Magill’s forcep.[8] If while withdrawing a NGT, resistance is felt and there is concomitant motion of ETT, then a NGT coiled around ETT should be suspected. It is also to be noted that continued attempt at extraction may lead to fatal complications such as respiratory compromise or laryngospasm and irreversible repair.[9] Hence, this case is a learning experience for all anesthesiologists in clinical practice and can avert unintentional extubation. Gaurav Acharya1, Kishore Kumar Arora1, Dewesh Kumar2 1 Department of Anesthesiology, MGM Medical College, Indore, Madhya Pradesh, 2Department of Preventive and Social Medicine, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Gaurav Acharya, MGM Medical College, Indore - 452 001, Madhya Pradesh, India. E-mail: [email protected]
References 1. 2. 3. 4.
5. 6. Figure 1: Arrow shows the coiling loops of nasogastric tube around endotracheal tube
Pousman RM, Koch SM. Endotracheal tube obstruction after orogastric tube placement. Anesthesiology 1997;87:1247-8. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract 2006;21:40-55. Dorsey M, Schwinder L, Benumof JL. Unintentional endotracheal extubation by orogastric tube removal. Anesth Rev 1988;15:30-3. Au-Truong X, Lopez G, Joseph NJ, Salem MR. A case of a nasogastric tube knotting around a tracheal tube: Detection and management. Anesth Analg 1999;89:1583-4. Bautista EM. Complications of nasogastric tube insertion. Chest 1988;93:1119-20. Perel A, Ya’ari Y, Pizov R. Forward displacement of the larynx for nasogastric tube insertion in intubated patients. Crit Care Med 1985;13:204-5.
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
585
Letters to Editor 7.
8.
9.
Ozer S, Benumof JL. Oro-and nasogastric tube passage in intubated patients: Fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43. Lind LJ, Wallace DH. Submucosal passage of a nasogastric tube complicating attempted intubation during anesthesia. Anesthesiology 1978;49:145-7. Young MJ, Ehrenfeld JM. Knotting of an orogastric tube around an endotracheal tube. J Clin Anesth 2012;24:254-5. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.142891
Is computed tomography scan the ultimate modality for airway evaluation? Sir, Patients with anterior mediastinal mass pose special anesthetics challenges, and they are prone to perioperative complications particularly from airway collapse.[1] We present anesthetic challenges in a 78-year-old patient suffering from a retrosternal goiter and thymic cyst presented with compressive symptoms. Written informed consent was obtained for publication of this case. A 78-year-old man was admitted to our hospital with the complaints of cough and expectoration for 5 months. He also complained of inability to lie down in left lateral posture but did not have any difficulty in the supine position even during sleep. There was also no history of respiratory distress and stridor neither at rest nor with activity. Computed tomography (CT) scan of neck and thorax revealed a thyroid swelling extending from the neck into the superior mediastinum along with a thymic cyst. Both CT scan [Figure 1] and a chest X-ray found a deviation of the trachea, and moderate compression of thoracic trachea, with a compression of the laryngeal vestibule and cervical trachea was noted [Figure 1]. The minimum internal diameter of the thoracic trachea was found to be 6.0-7.0 mm. All other investigations were within normal limit. General anesthesia with endotracheal (ET) intubation along with thoracic epidural catheter for postoperative pain management was planned. Awake fiberoptic bronchoscope 586
guided intubation with airway block, and topical anesthesia was planned. To anesthetize upper airway, 5 ml of 4% lignocaine nebulization was done for 10 min, followed by 2 ml 4% lignocaine injected into the trachea. We used real-time ultrasound to identify trachea as it was deviated. In the operating room, after attaching all the monitors, fiberoptic bronchoscopy was attempted through oral route using an oral bite block. We noted a near total compression of the trachea started just below the vocal cord extending up to just above the carina. It was on the contrary to the preoperative CT scan finding. However, we were able to introduce the fiberscope in the trachea and a 7.0 mm ID cuffed flexo-metallic ET tube was rail-roaded over the scope. The tip of the ET tube was kept just above the carina passing the distal end of tracheal compression. The fiberscope was taken out under vision, and anesthesia was induced with 250 mg intravenous thiopentone sodium and after confirmation of bilateral air entry, 25 mg atracurium was given. At the end of the surgery, elective postoperative ventilation was planned. After, a check fiberoptic bronchoscopy, we exchanged the flexo-metallic ET tube with an 8.0 mm ID cuffed ET tube over an airway exchange catheter. On the next day, he was extubated uneventfully in the surgical intensive care unit. Computed tomography scan is one of the most commonly used diagnostic modality for this purpose. CT scan predicts perioperative complications in these patients.[2,3] In our case, CT scan correctly delineated compression of the larynx and cervical trachea, but failed to detect a significant thoracic tracheal compression. As CT scan provides only static image,[4] fiberoptic bronchoscopy does have a role in such patients because it provided dynamic imaging.[5] As magnetic resonance imaging (MRI) provides excellent soft tissue contrast,[6] so it is an important preoperative investigation for tumors of the mediastinum.[7,8] We suggest a preoperative MRI for proper anesthetic planning in such patients. Souvik Maitra, Gopi Krishnan, Dalim Kumar Baidya, Sunil Chumber1 Departments of Anaesthesiology and 1Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Dalim Kumar Baidya, Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail: [email protected]
References 1.
Gardner JC, Royster RL. Airway collapse with an anterior mediastinal mass despite spontaneous ventilation in an adult. Anesth Analg 2011;113:239-42.
Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
