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Table of Contents    
LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 5  |  Page : 1367-1368

Guidewire-assisted Nasogastric Tube Insertion in Post Stroke Patients: A Simple Bedside Trick


1 Department of Neuroanaesthesia, Aster CMI Hospital, Bangalore, Karnataka, India
2 Department of Neuroanaesthesia, NIMHANS, Bangalore, Karnataka, India

Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Soumya Madhusudhan
Senior Specialist, Department of Neuroanaesthesia, Aster CMI Hospital, No. 43/2, New Airport Road, NH 44, Sahukar Nagar, Hebbal, Bengaluru -560 092, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.271240

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How to cite this article:
Madhusudhan S, Srinivasaiah B, Pai RK, Gopalaiah VK. Guidewire-assisted Nasogastric Tube Insertion in Post Stroke Patients: A Simple Bedside Trick. Neurol India 2019;67:1367-8

How to cite this URL:
Madhusudhan S, Srinivasaiah B, Pai RK, Gopalaiah VK. Guidewire-assisted Nasogastric Tube Insertion in Post Stroke Patients: A Simple Bedside Trick. Neurol India [serial online] 2019 [cited 2019 Dec 9];67:1367-8. Available from: http://www.neurologyindia.com/text.asp?2019/67/5/1367/271240




Sir,

Dysphagia occurs in more than one-third of patients with stroke admitted to intensive care units in India. Approximately half of these patients have evidence of aspiration, and approximately 20% of these patients develop aspiration pneumonia.[1]

Due to the inability to swallow normally, patients are unable to meet this elevated nutritional demand leading to undernutrition and increased mortality and morbidity. Both intradeglutitive aspiration and postdeglutitive aspiration occur in stroke due to abnormalities of the opening muscles of the upper esophageal sphincter, old age, long-standing reflux, and muscular disorders. Therefore, aspiration risk is often an indication for nutritional support using nasogastric tubes (NGTs).[2]

NGT feeding is a classic, a classic technique to facilitate enteral nutrition and administration of drugs in patients with dysphagia. However, the insertion of NGT using a blind technique in stroke patients is not easy due to oropharyngeal discoordination. The rate of failed blind nasal insertion is about 50% in the first attempt in intubated patients.[3] Unsuccessful insertion increases the incidences of mucosal bleeding and hemodynamic complication.[4] Hence, scrupulous technique must be followed for atraumatic insertion of NGT. NGTs are made of nonreinforced polymer plastic material which is prone to kinking and coiling the oropharynx upon exposure to the temperature of the body. This contributes significantly to the difficulty of the insertion process.

Here, we describe a simple bedside technique for the successful placement of NGT in intubated patients. The guidewire present in the FREKA nasojejunal feeding tube was placed in cidex 2% and autoclaved and used for insertion. The spiral Teflon-coated guidewire about 100 cm in length was loaded into Romolene NGT [Figure 1]. After loading the guidewire, the luer lock remained outside for operator handling. The nasogastric guidewire assembly was advanced along the nasal cavity into the oropharynx and was advanced up to the calculated length. Subsequently, the guidewire was retracted with a circular motion keeping the NGT stationary. Successful insertion of the NG tube was confirmed by auscultating over the epigastrium after injecting 20 mL of air through the nasal end of NGT. Guidewire was decontaminated with 2% cidex solution and set aside for autoclave sterilization.
Figure 1: Freka tube guidewire

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Several alternate methods used to facilitate insertion include the use of angiography catheter guidewire,[5] the use of a tracheal tube as a conduit,[6] the use of a videolaryngoscope for insertion,[7] the use of ureteral guidwire as a stylet[8] and the forward displacement of the larynx. NGT increases the chance of coiling once the tube passes beyond 20 cm. Even on direct laryngoscopy and visualization of passing of tube, the tip cannot be maneuvered effectively. In contrast, the usage of the guidewire increases the stiffness at the tip improving manipulation through the passage of the tube during in potentially difficult scenarios.

Direct laryngoscopy and repeated attempts are not always feasible options in patients with dysphagia, head injury, or with narrow mouth opening and thus limited airway access. Hence, the guidewire-assisted passage of NGT is less time-consuming as well as a cost-effective, quick and safe option available at the bedside.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaker R, Geenen JE. Management of dysphagia in stroke patients. Gastroenterol Hepatol(N Y) 2011;7:308-32.  Back to cited text no. 1
    
2.
Mekhail TM, Adelstein DJ, Rybicki LA, Larto MA, Saxton JP, Lavertu P. Enteral nutrition during the treatment of head and neck carcinoma: Is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer 2001;91:1785-90.  Back to cited text no. 2
    
3.
Bong CL, Macachor JD, Hwang NC. Insertion of the nasogastric tube made easy. Anesthesiology 2004;101:266.  Back to cited text no. 3
    
4.
Chun DH, Kim NY, Shin YS, Kim SH. A randomized, clinical trial of frozen versus standard nasogastric tube placement. World J Surg 2009;33:1789-92.  Back to cited text no. 4
    
5.
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconsciousintubated patient. N Am J Med Sci 2013;5:68-70.  Back to cited text no. 5
    
6.
Appukutty J, Shroff PP. Nasogastric tube insertion using different techniques in anesthetized patients: A prospective, randomized study. Anesth Analg 2009;109:832-5.  Back to cited text no. 6
    
7.
Moharari RS, Fallah AH, Khajavi MR, Khashayar P, Lakeh MM, Najafi A. The GlideScope facilitates nasogastric tube insertion: A randomized clinical trial. Anesth Analg 2010;110:115-8.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    


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