Ryles Tube Knotting around the Tracheal Tube: TwinMagills Forceps to our Rescue!-juniper Publishers
Juniper Publishers-Journal of Anesthesia
Abstract
Ryles' tube is generally inserted by
anaesthesiologists in the peri-induction period for gastric
decompression and other intra- and post-operative uses by the surgeons.
It can be inserted both before and after induction. In addition, either
the nasal or oral route can be chosen for their introduction. When
inserted nasally after endotracheal intubation, its path can be
deflected by the presence of the oral part of the tracheal tube. Ryles'
tube insertion is associated with several complications like nasal or
oropharyngeal bleeding, soft tissue trauma, infection, coiling,
inability to enter the pharyngeal opening, esophageal perforation and
nose-to-mouth migration. Coiling of the ryles' tube around the
endotracheal tube can occur, leading to knot formation, which can be
difficult to unwind. We hereby describe an uncommon complication of
ryles' tube insertion and its management.
Keywords: Ryles' tube; Endotracheal tube; Knotting; Magill's' forcepsIntroduction
Ryles' tube insertion [1]
is usually done in the perioperative period for gastric decompression
and for other intra-and post-operative use by the surgeons. Its
insertion is generally blind and may be fraught with several minor and
major complications. In difficult cases, gastric tube insertion can be
guided by direct laryngoscopy [2] or video-laryngoscopy, if available. Apart from trauma, bleeding, [3]
coiling and unsuccessful insertion, there are a few reports of its
inadvertent knotting around the endotracheal tube. This complication,
though uncommon, can be dangerous. We hereby report a case of accidental
ryles' tube knotting around the endotracheal tube and its successful
unwinding using Magills' forceps.
Case Report
A fifty-four year old, ASA grade 2, male patient was
scheduled for radical cystectomy with ileal conduit for carcinoma
bladder under standard general anaesthesia. After induction and
endotracheal intubation, a nasogastric tube (NG tube) was introduced
into the right nostril after lubrication. After a while, there was
resistance to its insertion and the ryles' tube could not be advanced
into the esophagus. A direct laryngoscopy was performed to visualise the
path of the nasogastric tube. The NG tube was found to be coiled around
the oral part of the endotracheal tube (ETT), with the formation of a
spontaneous knot. Trying to withdraw the NG tube would have been risky
as it can lead to accidental tube displacement or extubation, apart from
trauma and bleeding. Untying of the knot is difficult inside the oral
cavity with the endotracheal tube in-situ, as there is less space to
work, along with the risk of tube obstruction from further tightening of
the knot. Hence, we had two mammoth tasks in this patient. One was to
untie the knot and the second was to uncoil the loops of the NG tube
around the ETT, both without compromising the airway and patient safety.
With an independent anaesthesiologist performing
direct laryngoscopy, the second anaesthesiologist utilized two Magills'
forceps, one pediatric and the other adult, held on each hand to first
untie the knot. Tip of the NG tube was held by the pediatric forceps on
the left hand and the right hand-held adult forceps was used to loosen
the loop, so that the distal tip comes out of the loop. After untying
the knot successfully, the left hand was used to tightly hold the oral
part of the endotracheal tube. The right hand-held forceps were used to
gently uncoil the loops of the NG tube around the ETT, one-by-one. After
both untying and uncoiling, the NG tube was smoothly removed from the
right nostril and the nasal-oral cavity inspected for any bleeding or
trauma (Figure 1).
The entire procedure was uneventful, with no complications. The patient
maintained all vital parameterswithin normal limits. The ETT position
was found to be in place and the patient was ventilated adequately. A
fresh NG tube was successfully inserted gently through the left nostril
after adequate nasal preparation. The rest of the perioperative course
was uneventful.
Discussion
Our case highlights that a simple task of inserting an NG tube can be complicated [4]
with both common and uncommon problems. Knotting and coiling of the NG
tube around the ETT is a known, though rare complication [5].
It can prove deleterious to the patient, as it can lead to airway
compromise. Such coiled and knotted tubes should never be pulled out
forcefully, as it can lead to ET tube displacement, ET tube obstruction [6]
accidental extubation and loss of airway. Such disastrous complications
can be avoided by gentle unwinding of the knot followed by the loops
under vision. Magills’ forceps is very useful in such scenarios. The
first step in the wake of such complications is to promptly recognise
its presence and take necessary action immediately, after calling for
help. Our case was unique, as we had used two Magills’ forceps for the
procedure.There have been a few case reports highlighting the use of a
Magills forceps [7]
for this complication. Use of direct laryngoscopy or videolaryngoscopy
(if available), is recommended to proceed under vision. C-MACTM D-blade
video laryngoscope [8] is particularly useful in this regard.
Gentle handling of the tube and tissues is paramount
is avoiding bleeding and trauma. ETT displacement must be prevented at
all costs. Standard ASA monitoring must be continued and patient safety
should be given top-most priority.
Conclusion
Nasogastric tube insertions can be sometimes
complicated by their coiling and knotting around the endotracheal tube,
if inserted after intubation. Inadvertent pulling out of such coiled NG
tubes can result in accidental tube displacement, extubation and trauma.
The use of twin-Magills forceps can be advantageous in untying the knot
and uncoiling the NG tube from the ETT. Gentle manoeuvring must be
applied to prevent traumatic and other complications.
For more articles in Journal of Anesthesia
& Intensive Care Medicine please click on:
https://juniperpublishers.com/jaicm/index.php
https://juniperpublishers.com/jaicm/index.php
Comments
Post a Comment