ARTICLE IN PRESS
YBJOM-4470; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
Prevention of intraoperative pressure injuries caused by nasogastric tubes A. Graham ∗ , D. Sutton Oral Surgery, St Lukes Hospital, Little Horton Lane, Bradford, West Yorkshire BD5 0NA, United Kingdom Accepted 1 March 2015
Keywords: Nasogastric tube; Pressure sore
Nasal pressure sores caused by sustained pressure from nasotracheal intubation have been widely reported, and technical notes on how they can be prevented have been published in this journal.1,2 We report a simple and inexpensive technique to reduce their risk intraoperatively. Impaired swallowing, risk of aspiration, protection of a flap, nutritional supplementation, and administration of medication are all indications for temporary enteral feeding in patients who have had operations for cancer of the head and neck. When prolonged enteral feeding is anticipated, a gastrostomy tube may be placed preoperatively. Operations that involve resection, neck dissection, and reconstruction, can last several hours, and it is crucial that the patient is correctly positioned and protected from pressure injuries. We commonly place the nasogastric tube after induction of anaesthesia. Preparation of the surgical site usually involves covering the head with a turban drape, and while techniques vary, draping across the nose can press a nasogastric tube against the alar rim and cause a pressure injury. To prevent these injuries we cushion the nasogastric tube with a Merocel® (Medtronic Limited, Watford, UK) nasal pack before the operative field is draped. These packs are normally used in the management of epistaxis. The polyvinyl alcohol (PVA)-based sponge is rigid when removed from the packaging but becomes soft and conforms to the space when moistened (Fig. 1).
∗
Corresponding author. E-mail address: [email protected] (A. Graham).
Fig. 1. Merocel® nasal pack.
A Merocel® standard dressing is cut to about 4 cm in length and the tip is moistened with saline to soften it as it is inserted into the nostril. The pack is positioned between the nasogastric tube, the nasal rim, and the anterior nasal mucosa. Saline is added to it while it is held in position to achieve the best support for the nasogastric tube. Once this is absorbed and the pack expanded, it cushions the tube and protects the nasal tissue (Fig. 2). When the position of this type of nasogastric tube is confirmed radiographically, the internal guide wire is not needed, and its removal can further reduce pressure on the delicate tissue. Tying the Merocel® pack to the nasogastric tube using the attached thread can reduce the risk of it being dislodged. When the tube and pack are in position, draping can proceed in the standard way. The pack is removed at the end of the procedure and can be added to the swab count.
http://dx.doi.org/10.1016/j.bjoms.2015.03.001 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Graham A, Sutton D. Prevention of intraoperative pressure injuries caused by nasogastric tubes. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.03.001
YBJOM-4470; No. of Pages 2
2
ARTICLE IN PRESS A. Graham, D. Sutton / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
and inexpensive technique is a valuable preventative measure against potentially painful and cosmetically damaging injuries.
Conflict of interest We have no conflicts of interest
Ethics statement/confirmation of patient permission Appropriate consent obtained.
References
Merocel®
Fig. 2. (in white).
pack supporting nasogastric tube and bridle clip on tube
Operations on the head and neck can be lengthy, and surgical drapes must be placed securely so they do not move. The risk of a pressure injury should be anticipated and steps taken to avoid it where possible. We find that this simple
1. Iwai T, Goto T, Maegawa J, et al. Use of a hydrocolloid dressing to prevent nasal pressure sores after nasotracheal intubation. Br J Oral Maxillofac Surg 2011;49:e65–6. 2. Anand R, Turner M, Sharma S, et al. Use of a polyvinyl acetyl sponge (Merocel) nasal pack to prevent alar necrosis during prolonged nasal intubation. Br J Oral Maxillofac Surg 2007;45:601.
Please cite this article in press as: Graham A, Sutton D. Prevention of intraoperative pressure injuries caused by nasogastric tubes. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.03.001
YBJOM-4470; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
Prevention of intraoperative pressure injuries caused by nasogastric tubes A. Graham ∗ , D. Sutton Oral Surgery, St Lukes Hospital, Little Horton Lane, Bradford, West Yorkshire BD5 0NA, United Kingdom Accepted 1 March 2015
Keywords: Nasogastric tube; Pressure sore
Nasal pressure sores caused by sustained pressure from nasotracheal intubation have been widely reported, and technical notes on how they can be prevented have been published in this journal.1,2 We report a simple and inexpensive technique to reduce their risk intraoperatively. Impaired swallowing, risk of aspiration, protection of a flap, nutritional supplementation, and administration of medication are all indications for temporary enteral feeding in patients who have had operations for cancer of the head and neck. When prolonged enteral feeding is anticipated, a gastrostomy tube may be placed preoperatively. Operations that involve resection, neck dissection, and reconstruction, can last several hours, and it is crucial that the patient is correctly positioned and protected from pressure injuries. We commonly place the nasogastric tube after induction of anaesthesia. Preparation of the surgical site usually involves covering the head with a turban drape, and while techniques vary, draping across the nose can press a nasogastric tube against the alar rim and cause a pressure injury. To prevent these injuries we cushion the nasogastric tube with a Merocel® (Medtronic Limited, Watford, UK) nasal pack before the operative field is draped. These packs are normally used in the management of epistaxis. The polyvinyl alcohol (PVA)-based sponge is rigid when removed from the packaging but becomes soft and conforms to the space when moistened (Fig. 1).
∗
Corresponding author. E-mail address: [email protected] (A. Graham).
Fig. 1. Merocel® nasal pack.
A Merocel® standard dressing is cut to about 4 cm in length and the tip is moistened with saline to soften it as it is inserted into the nostril. The pack is positioned between the nasogastric tube, the nasal rim, and the anterior nasal mucosa. Saline is added to it while it is held in position to achieve the best support for the nasogastric tube. Once this is absorbed and the pack expanded, it cushions the tube and protects the nasal tissue (Fig. 2). When the position of this type of nasogastric tube is confirmed radiographically, the internal guide wire is not needed, and its removal can further reduce pressure on the delicate tissue. Tying the Merocel® pack to the nasogastric tube using the attached thread can reduce the risk of it being dislodged. When the tube and pack are in position, draping can proceed in the standard way. The pack is removed at the end of the procedure and can be added to the swab count.
http://dx.doi.org/10.1016/j.bjoms.2015.03.001 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Graham A, Sutton D. Prevention of intraoperative pressure injuries caused by nasogastric tubes. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.03.001
YBJOM-4470; No. of Pages 2
2
ARTICLE IN PRESS A. Graham, D. Sutton / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
and inexpensive technique is a valuable preventative measure against potentially painful and cosmetically damaging injuries.
Conflict of interest We have no conflicts of interest
Ethics statement/confirmation of patient permission Appropriate consent obtained.
References
Merocel®
Fig. 2. (in white).
pack supporting nasogastric tube and bridle clip on tube
Operations on the head and neck can be lengthy, and surgical drapes must be placed securely so they do not move. The risk of a pressure injury should be anticipated and steps taken to avoid it where possible. We find that this simple
1. Iwai T, Goto T, Maegawa J, et al. Use of a hydrocolloid dressing to prevent nasal pressure sores after nasotracheal intubation. Br J Oral Maxillofac Surg 2011;49:e65–6. 2. Anand R, Turner M, Sharma S, et al. Use of a polyvinyl acetyl sponge (Merocel) nasal pack to prevent alar necrosis during prolonged nasal intubation. Br J Oral Maxillofac Surg 2007;45:601.
Please cite this article in press as: Graham A, Sutton D. Prevention of intraoperative pressure injuries caused by nasogastric tubes. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.03.001
