Do you place NGTs prior to induction for bowel obstructions?

[drlee]

I hear different opinions and approaches on this matter. Some of our patients coming to the O.R. for bowel obstructions do not have NGTs placed beforehand by the surgeon. I am aware of the risk of aspiration if gastric decompression isn't performed prior to induction, especially since sux increases intragastric pressure and therefore increases the probability of reflux and therefore aspiration.
However, it seems most anesthesiologists prefer to decompress the stomach after induction with the ETT already placed, rather than torture an awake patient by having the NGT put in before induction.
I feel gastric decompression with an NGT should be ALWAYS ordered by the surgeon prior to the patient's arrival to the O.R. Unfortunately, this isn't the case at my institution.
How many of you guys decompress the stomach prior to induction?

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[deleted126335]

I hear different opinions and approaches on this matter. Some of our patients coming to the O.R. for bowel obstructions do not have NGTs placed beforehand by the surgeon. I am aware of the risk of aspiration if gastric decompression isn't performed prior to induction, especially since sux increases intragastric pressure and therefore increases the probability of reflux and therefore aspiration.
However, it seems most anesthesiologists prefer to decompress the stomach after induction with the ETT already placed, rather than torture an awake patient by having the NGT put in before induction.
I feel gastric decompression with an NGT should be ALWAYS ordered by the surgeon prior to the patient's arrival to the O.R. Unfortunately, this isn't the case at my institution.
How many of you guys decompress the stomach prior to induction?

It depends. I have seen lots of patients come to the OR for a bowel obstruction withut an n/g. I have placed a few awake n/g's. Also induced GA without placing one (much more common). In general, if the airway looks straightforward I will generally not place one. Decision is modified based on if abdomen is distended, or patient looks uncomfortable-I interpret this too meant more likely to have a bellyful.

 

[CrazyJake]

If they don't have one, they get one. It's no worse in the MOR before going to sleep than in the ER.
If they aspirate on induction, to me I'm not sure what my answer would be for the guys in the cheap suits.

 

[OB1🤙]

...especially since sux increases intragastric pressure and therefore increases the probability of reflux and therefore aspiration.

No. Sux increases LES tone more than it increases the intragastric pressure. So as long as the patient has an anatomically and physiologically normal LES, sux will not increase the risk of aspiration.

What DOES, however, decrease LES tone, is cricoid pressure. So if you use it (and I do), you need to do it right. Which is a whole 'nother thread in and of itself.

No time for references for the above right now. As to your original point, sure, it'd be nice to have suctioned the stomach prior to induction, but even if you have, they're still a full stomach technically. I wouldn't absolutely insist on it, nor would I place one myself.

I would, however, RSI in the head up position, with an assistant performing proper cricoid and not letting go.

 

[cincincyreds]

If they don't have one, they get one. It's no worse in the MOR before going to sleep than in the ER.
If they aspirate on induction, to me I'm not sure what my answer would be for the guys in the cheap suits.

It is sad we have to do certain things for the lawyers and not for the patients. Is there a double blind study which states the correct thing to do in this situation?

 

[Mac4]

It is very unlikely they come without a NG. I mean, the first order of any SBO is NG placement. However, if they do not have a NG, place one. you have to prevent aspiration at all costs for SBO patient. It is in-defensible if you go head with RSI only and they aspirate during induction

 

[pgg]

I put NG tubes in the ones who don't come with them.

Usually the ER has already done it, or the surgeon has if it's an inpatient.

 

[Idiopathic]

anyone else take them out prior to induction? i do, i believe that it stents the esophagus open and promotes aspiration.

 

[OB1🤙]

I understand the sentiment of always placing GTs. But assuming that the awake patient is not actively aspirating, there exists some competent barrier. This must be one of three possibilities: the LES, the UES (or cricopharyngeus muscle), or the height of the glottis relative to the stomach.

If the LES is competent and is the barrier to regurgitation awake (which will be the case the vast majority of the time), an RSI with sux will not affect that barrier pressure, and will actually increase it. That said, I still think it's prudent to elevate the head (and therefore glottis) above the stomach. If holding cricoid, the LES tone will decrease, and the force exerted by your CP better be enough to occlude the esophagus. The best studies on this are by Vanner, who finds a force of 30 Newtons (or the same force as a 3kg weight resting on the cricoid) sufficient. Barash cites these studies in its recommendation for 30N force.

The above would not hold true for hiatal hernia or people with a strong h/o GERD 2/2 LES incompetence.

So sure, place an NG awake if it isn't already there for fear of the lawyers, but if the LES is competent it shouldn't matter. If it isn't, it probably matters quite a bit more.

Unless of course the belly is taut, rigid, and the patient seems to be forcibly holding back spew from the mouth. Then yeah, decompress them.

The preceding mental masturbation is my opinion, and my opinion only.

 

[secoy]

Its rare for our bowel obstructions to arrive without an NGT. Furthermore, since we preops pts before they arrive to our holding area; we order an NGT on the patient's floor for all bowel obstruction cases. That being said, I would place one preop if somehow pt arrived without one.

 

[proman]

There was a recent malpractice verdict against an anesthesiologist for inducing a SBO who then aspirated without having placed a preop NG. I personally think it's absurd, but the jury obviously didn't.

 

[Idiopathic]

There was a recent malpractice verdict against an anesthesiologist for inducing a SBO who then aspirated without having placed a preop NG. I personally think it's absurd, but the jury obviously didn't.

pretty clear cut to me, at least when described to a jury. no excuse for not placing one.

 

[dhb]

I think it's something that we probably should do (although impossible to demonstrate) but that we will often overlook being caught in the desire to keep things moving in the OR and because we believe in our ability to secure the airway rapidly.

If the patient doesn't have one you are going to place it after induction so why not do it before?

 

[deleted126335]

I think it's something that we probably should do (although impossible to demonstrate) but that we will often overlook being caught in the desire to keep things moving in the OR and because we believe in our ability to secure the airway rapidly.

If the patient doesn't have one you are going to place it after induction so why not do it before?

-unpleasant for patient.
-might bloody up the airway
-half the time the thing is coiled in the esophagus.

 

[TrustMe]

Had a colleague recently do a case in the OR for partial SBO. Pt. had had an NG a couple days before but belly pain improved so they pulled it. Developed pain again so they decided to explore her and they didn't put one back in prior to surgery. Colleague didn't place one in pre-op. Pt. vomitted and aspirated on induction. Severe ARDS in ICU to the point they were discussing ECMO for oxygenation. They had already called the CT surgeon on call to discuss ECMO. Checked one more ABG and PaO2 was above 60 (on 100% fiO2 and 14 of PEEP) so they didn't do it. Made me more aware of these pt.'s not having NG prior to induction.

 

[OB1🤙]

Pt. vomitted and aspirated on induction.

Well, you kinda yadayadayada'd over the important part there. How was the induction carried out?

There's an important distinction between "vomiting," which is an active process involving the abdominal muscles- impossible in a paralyzed patient- and "regurgitating," which is passive and will be governed by such things as gravity and pressure gradients. When patients aspirate during induction, it is due to regurgitation, not vomiting. You know that, I just think the semantics are important.

I'm not trying to be a lone ranger here standing up for not putting in NG tubes, just to be clear. I just think that if intragastric pressure is not sky high, a patient is unlikely to regurgitate if the induction is properly carried out. Patients hatehatehate awake NG tubes and they can muck up the airway, so it's not a procedure devoid of downside.

I do think this (evidence-based step-by-step mechanics of the induction of a truly full stomach) is an area that we all can agree is an important cornerstone of our practice, but curiously, it is poorly taught in residency, if it's taught at all. I took an interest in this stuff after a peri-induction aspiration as a CA-2, hence my verbosity on the subject.

 

[Planktonmd]

Who said an NG tube prevents aspiration?
We know that aspiration might happen more frequently and more severely on induction in patients with SBO.
But we don't know if the presence of an NG tube actually makes aspiration less likely or less severe.
It actually might be the exact opposite!
An NG tube might keep the GE sphincter open and increase the possibility of regurgitation.
So, if the abdomen is clearly distended and the airway is questionable then it might be a good idea to place an NG pre-op.
Otherwise there is no point in torturing the patient for uncertain benefit.

 

[pgg]

Well, you kinda yadayadayada'd over the important part there. How was the induction carried out?

There's an important distinction between "vomiting," which is an active process involving the abdominal muscles- impossible in a paralyzed patient- and "regurgitating," which is passive and will be governed by such things as gravity and pressure gradients. When patients aspirate during induction, it is due to regurgitation, not vomiting. You know that, I just think the semantics are important.

I'm not trying to be a lone ranger here standing up for not putting in NG tubes, just to be clear. I just think that if intragastric pressure is not sky high, a patient is unlikely to regurgitate if the induction is properly carried out. Patients hatehatehate awake NG tubes and they can muck up the airway, so it's not a procedure devoid of downside.

I do think this (evidence-based step-by-step mechanics of the induction of a truly full stomach) is an area that we all can agree is an important cornerstone of our practice, but curiously, it is poorly taught in residency, if it's taught at all. I took an interest in this stuff after a peri-induction aspiration as a CA-2, hence my verbosity on the subject.

I agree with everything you've written here, but even in my malpractice-friendly environment, I still want a NG tube.

The hard question is how long I'd persist with torturing a patient if placement was difficult. Certainly not "forever" ... but my feeling is that a documented failed good faith effort would look far better in court than no attempt at all.

I don't believe a couple of attempts at placement are going to muck up the airway. If indeed I was so concerned about the airway that I thought it might, that patient probably deserves an awake FOI in the first place.

I would, however, RSI in the head up position, with an assistant performing proper cricoid and not letting go.

Even proper cricoid is probably worthless in most cases (eg this MRI study offers evidence that it's just a bunch of feelgood voodoo crap), if not actually counterproductive due to the LES relaxing you mentioned.

But - if it's passive regurgitation that's the concern, wouldn't head-down be better? In a paralyzed patient, gastric contents don't seem likely to flow uphill into the trachea. Head-up seems higher risk than flat, actually.

 

[PMPMD]

I agree with everything you've written here, but even in my malpractice-friendly environment, I still want a NG tube.

The hard question is how long I'd persist with torturing a patient if placement was difficult. Certainly not "forever" ... but my feeling is that a documented failed good faith effort would look far better in court than no attempt at all.

I don't believe a couple of attempts at placement are going to muck up the airway. If indeed I was so concerned about the airway that I thought it might, that patient probably deserves an awake FOI in the first place.




Even proper cricoid is probably worthless in most cases (eg this MRI study offers evidence that it's just a bunch of feelgood voodoo crap), if not actually counterproductive due to the LES relaxing you mentioned.

But - if it's passive regurgitation that's the concern, wouldn't head-down be better? In a paralyzed patient, gastric contents don't seem likely to flow uphill into the trachea. Head-up seems higher risk than flat, actually.

The only thing it seems to do is reduce the settlement amount:

Cases in which cricoid pressure was not used and patients had risk factors for aspiration typically led to a judgment of substandard care. Such cases also tended to result in substantially larger damage awards than if the procedure did take place ($513,125 vs. $211,500, respectively).
Anesthesiology News
Oct 2010, Vol: 36:10

 

[OB1🤙]

I don't believe a couple of attempts at placement are going to muck up the airway. If indeed I was so concerned about the airway that I thought it might, that patient probably deserves an awake FOI in the first place.

Agree.

Even proper cricoid is probably worthless in most cases (eg this MRI study offers evidence that it's just a bunch of feelgood voodoo crap), if not actually counterproductive due to the LES relaxing you mentioned.

I see your 2003 MRI study and raise you a 2009 MRI study that suggests it "works" after all: http://www.ncbi.nlm.nih.gov/pubmed/19843793

I find Vanner's work (Google brings up most of it) a worthwhile read as well. I do cricoid because I think you never really know how the LES presented to you will function, and I think it works when done right. But I also think a reasonable person could look at the available evidence for and against and disagree with that conclusion. Hence the controversy.

But - if it's passive regurgitation that's the concern, wouldn't head-down be better? In a paralyzed patient, gastric contents don't seem likely to flow uphill into the trachea. Head-up seems higher risk than flat, actually.

Once the gastric contents have made their way to the level of the glottis, sure, you'd rather be head down to keep badness out of the trachea. I prefer to keep gastric contents in the stomach where they belong, which being head up will accomplish most of the time, especially given either an intact LES or adequate cricoid, if you believe in it. But again, if you said that you're willing to suffer a relatively frequent occurrence of regurgitating some crap in the pharynx to make sure none of it ever got into the lungs, I'd say that was reasonable.

 

[TrustMe]

Well, you kinda yadayadayada'd over the important part there. How was the induction carried out?

There's an important distinction between "vomiting," which is an active process involving the abdominal muscles- impossible in a paralyzed patient- and "regurgitating," which is passive and will be governed by such things as gravity and pressure gradients. When patients aspirate during induction, it is due to regurgitation, not vomiting. You know that, I just think the semantics are important.

I was not there for the case but I helped take care of the pt. for the next 2 weeks in the ICU. I was told RSI with cricoid (not sure how or who held it). Followed immediately by "regurgitation" (I'll give you the sematics, b/c I feel they are important in some cases), intubation, and suctioning feculent material out of the ETT after it was placed, followed by sats in the low 90's (i.e. 90%) on 100% fiO2 for the remainder of the case. Sucky part was that they only found a few adhesions and were only in the belly for about 45 minutes.

 

[OB1🤙]

http://www.anesthesia-analgesia.org/content/109/5/1360.long

SUMMARY

CP substitutes for the loss of tone in the cricopharyngeus, nature's normal defense mechanism. The findings of Rice et al. lend strong support to the efficacy of Sellick's maneuver in occluding the alimentary tract posterior to the cricoid cartilage. There is strong evidence that gastric insufflation can be prevented by CP, and that mask ventilation can be applied safely during RSII. On the other hand, there are circumstances in which CP or RSII is undesirable or contraindicated. These situations should be respected and other alternative management strategies sought. In the clinical setting, the decision to use CP should be a balance between the potential benefits that have been demonstrated repeatedly, and rare potential complications that are likely a result of improper application of the technique34 but that can easily be taught.31 It is our duty as clinicians to make Sellick's great contribution a safe practice.

(Less enthusiastic editorial here: http://www.anesthesia-analgesia.org/content/109/5/1363.long)

 

[aneftp]

This was a case at one of my buddy's old practice. Usually aspiration, SBO situation. They sued anesthesiologist for aspiration....didn't put NG tube in

http://articles.orlandosentinel.com...cf-20110807_1_barbara-hicks-wurm-harold-hicks

What I find sad is the family didn't sue the medical center. Duh? Didn't the ER doc or surgeon first order in the ER for NG tube placement. It's like passing the buck along. Why didn't they sue the medical center if the other doctors ordered the NG tube before they even went to the OR?

My friend says that medical center can be dangerous anyways. And the scary thing is it's near Disney World. So lots of tourists may end up there. There was this case some 18 year old got privileges as a PA at the same center in the nurse. And some other nurse who was a sexual predator.


"
In preparation for the operation, Kissimmee anesthesiologist Dr. Scott Wurm ordered a breathing tube inserted down Hicks' throat, according to the suit the family filed against Wurm and his medical group.
The surgeon ordered Hicks' bloated stomach to be pumped before the operation started. The lawsuit contends that is the preferred procedure and should have been done. Nurses failed to accomplish it, and neither Wurm nor his nurse-anesthetist did it, the suit said.
Wurm assigned the nurse-anesthetist to intubate Hicks. Wurm then left the room. The lawsuit contends that standard practice and hospital policy says the doctor should stay and supervise during anesthesia.
After the nurse inserted the tube, Hicks threw up and then breathed the vomit into his lungs, nearly suffocating him and causing brain damage, according to a report filed with the state by the doctor's insurer.

 

[Planktonmd]

Here is the deal:
From a malpractice point of view you should inset an NG tube in everyone who has bowel obstruction and do cricoid pressure on every rapid sequence induction, but even if you do these things there is no guarantee that you will not get sued.
From a scientific point of view: The evidence supporting the benefit of inserting an NG tube pre-op to prevent aspiration is non existent and is at best anecdotal.
And the evidence supporting that cricoid pressure has any clinical benefit is very shaky and almost laughable.
But no one can tell you what to do... you are a consultant anesthesiologist, practicing in a highly litigious environment so you do what in your best judgement is better for you and your patient.

 

[deleted126335]

Here is the deal:
From a malpractice point of view you should inset an NG tube in everyone who has bowel obstruction and do cricoid pressure on every rapid sequence induction, but even if you do these things there is no guarantee that you will not get sued.
From a scientific point of view: The evidence supporting the benefit of inserting an NG tube pre-op to prevent aspiration is non existent and is at best anecdotal.
And the evidence supporting that cricoid pressure has any clinical benefit is very shaky and almost laughable.
But no one can tell you what to do... you are a consultant anesthesiologist, practicing in a highly litigious environment so you do what in your best judgement is better for you and your patient.

Nailed it.

 

[Arch Guillotti]

Had a colleague recently do a case in the OR for partial SBO. Pt. had had an NG a couple days before but belly pain improved so they pulled it. Developed pain again so they decided to explore her and they didn't put one back in prior to surgery. Colleague didn't place one in pre-op. Pt. vomitted and aspirated on induction. Severe ARDS in ICU to the point they were discussing ECMO for oxygenation. They had already called the CT surgeon on call to discuss ECMO. Checked one more ABG and PaO2 was above 60 (on 100% fiO2 and 14 of PEEP) so they didn't do it. Made me more aware of these pt.'s not having NG prior to induction.

I have seen this except the patient dies. It truly was a horrific scene.

 

[Arch Guillotti]

What I find sad is the family didn't sue the medical center. Duh? Didn't the ER doc or surgeon first order in the ER for NG tube placement. It's like passing the buck along. Why didn't they sue the medical center if the other doctors ordered the NG tube before they even went to the OR?

eh I don't know if I agree with that assessment. We are the ones pushing the patient back to the OR and can do what we see fit beforehand. The buck stops with us.

 

[Arch Guillotti]

yeah, but... I have dropped a couple of preop ng tubes and sucked out a few liters of junk. Made me very glad I did it.

Here is the deal:
From a malpractice point of view you should inset an NG tube in everyone who has bowel obstruction and do cricoid pressure on every rapid sequence induction, but even if you do these things there is no guarantee that you will not get sued.
From a scientific point of view: The evidence supporting the benefit of inserting an NG tube pre-op to prevent aspiration is non existent and is at best anecdotal.
And the evidence supporting that cricoid pressure has any clinical benefit is very shaky and almost laughable.
But no one can tell you what to do... you are a consultant anesthesiologist, practicing in a highly litigious environment so you do what in your best judgement is better for you and your patient.

 

[Arch Guillotti]

The hard question is how long I'd persist with torturing a patient if placement was difficult. Certainly not "forever" ... but my feeling is that a documented failed good faith effort would look far better in court than no attempt at all.

I don't believe a couple of attempts at placement are going to muck up the airway. If indeed I was so concerned about the airway that I thought it might, that patient probably deserves an awake FOI in the first place.

Seems like the most reasonable approach. An NG tube isn't torture if it goes in OK. Patients get them all the time. I probably wouldn't perseverate forever or significantly delay going to the OR though.

 

[imfrankie]

According to my reading of page 46 discussion in the ASA Newsletter which arrived today:

Such a claim as above "no excuse for not placing one (NGT)" would violate ASA Guideline B2 of The ASA Guidelines for Expert Witness Qualification and Testimony.

Sounds like ole Dr. Katz got himself censured for same.