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LETTER TO THE EDITOR
Year :   |  Volume :   |  Issue :   |  Page :
 

Confirmation of ryle's tube placement by bubble in jelly technique: A quick and convenient way during laparoscopic surgery


 Department of Anesthesia, Critical Care and Pain, NEIGRIHMS, Shillong, Meghalaya, India

Date of Submission25-Mar-2021
Date of Decision17-Apr-2021
Date of Acceptance20-Apr-2021
Date of Web Publication02-Jun-2021

Correspondence Address:
Prakash Deb,
Quarter B8F, NEIGRIHMS Campus, NEIGRIHMS, Shillong, Meghalaya
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_110_21




How to cite this URL:
Deb P, Bhattacharyya P. Confirmation of ryle's tube placement by bubble in jelly technique: A quick and convenient way during laparoscopic surgery. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=317436


Dear Sir,

Intra-operative gastric decompression by Ryle's tube or nasogastric tube (NGT) for improvement of laparoscopic view and prevention of accidental gastric injury during trocar insertion is a common practice. In awake patients, swallowing technique makes NGT insertion easy; however, in anesthetised patients due to a lack of cough and swallowing, reflex NGT may remain coiled up in the oropharynx or wrongly placed in the respiratory tract. NGT placement in such patients is usually done blindly using reverse Sellick's manoeuvre, digital assistance or with a Magill forceps under direct or video laryngoscope guidance.[1]

NGT placement in stomach may be confirmed using various techniques such as looking at the content of aspirate, assessing pH of NGT aspirate using pH indicator strips, auscultation of sound in epigastrium produced by passage of air with a 50 ml syringe, ultrasonography, capnography, manometric method, electromagnetic NGT placement and X-Ray confirmation. Most of them are either expensive, time consuming or inaccurate. To avoid fatal complications of wrongly placed NGT particularly if used for feeding purpose, the National Health Service has advised against many routinely used techniques for confirmation of NGT placement.[2] X-ray is commonly used in intensive care unit setup for the confirmation of correct placement of NGT before the initiation of feeding or giving medications. Although considered gold standard, X-ray may not be confirmatory always.

During laparoscopic surgery, a simple and quick confirmation of NGT is necessary. Sometimes, the draping and cleaning of the abdomen starts immediately with anaesthesia induction to save time, so auscultation of the gush of delivered air may not be possible. In a properly fasted patient or one without any obstructive pathology, assessment of the aspirate may not be reliable and sometimes gastric or respiratory secretions may be indistinguishable. If there is doubt about NGT placement, re-confirmation or re-insertion may be required using laryngoscope and thus delaying the procedure.

We routinely use gas bubble formation, an interesting way to quickly confirm the position of NGT when used for the purpose of gastric decompression during laparoscopic procedure. As the tube passes into the gastrointestinal tract, air from stomach comes out through the opening of base or distal end of NGT and causes formation of a bubble if a drop of jelly is placed on it [Figure 1]. The same will not happen if the tube remains in the oral cavity. In case of tube placement in the trachea, there will be volume loss as detected by ventilator along with a continuous gush of air through the port at base or distal end.[3],[4]
Figure 1: Bubble formation in jelly at the distal tip of nasogastric tube confirming its placement in stomach

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This is a quick and useful method for NGT placement confirmation when used for gastric decompression in laparoscopic surgeries. The same method along with other confirmatory tests may be tried in non-laparoscopic procedure also. However, the NGT placement should always be confirmed by X-ray or other confirmatory methods when used for indications such as feeding, administration of medicine, gastric lavage or prevention of aspiration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kandeel A, Elmorhedi M, Abdalla U. Digital assistance of nasogastric tube insertion in intubated patients under general anesthesia: A single-blinded prospective randomized study. Saudi J Anaesth 2017;11:283-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Coombes R. NHS safety agency issues guidance on nasogastric tubes. BMJ 2005;330:438.  Back to cited text no. 2
    
3.
Prasad G, Garg R. The 'bubble technique': An innovative technique for confirming correct nasogastric tube placement. J Clin Anesth 2011;23:84-5.  Back to cited text no. 3
    
4.
Sriramka B, Pattnaik SK. Accidental insertion of Ryle's tube in the airway in an intubated patient causing ventilator malfunction. Saudi J Anaesth 2017;11:361-2.  Back to cited text no. 4
[PUBMED]  [Full text]  


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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04