Esophageal Guidewire-Assisted Nasogastric Tube Insertion in Anesthetized and Intubated Patients: A Prospective Randomized Controlled Study

BACKGROUND: Nasogastric tube (NGT) insertion is indicated almost routinely in patients undergoing abdominal surgery to decompress the stomach intraoperatively and postoperatively, and to allow postoperative tube feeding. NGTs are made of nonreinforced polymer plastic materials and are prone to kinking and coiling during insertion. This often poses difficulty in blind NGT placement or placement assisted by variously described techniques. We hypothesized that esophageal guidewire-assisted NGT insertion with manual forward laryngeal displacement can significantly improve the first-attempt success rate over the technique of head flexion and lateral neck pressure during its insertion in anesthetized and tracheally intubated patients. METHODS: Four hundred eighty adult patients presenting for abdominal surgery under general anesthesia with neuromuscular relaxation were randomized to an experimental technique of esophageal guidewire with manual forward displacement of the larynx (group 1) or a control technique of head flexion and lateral neck pressure (group 2) for insertion of the NGT. The success rates (and failure rate) of the first and second attempts (and overall) were assessed along with the incidence of coiling and kinking of the NGT, procedure-related nasal bleeding and pharyngeal bleeding, and the incidence of moderate and life-threatening complications. RESULTS: The first-attempt success rate was 99.2% in group 1 compared with 56.7% in group 2 (P < 0.001). Thus, the first-attempt failure rate was 0.8% in group 1 compared with 43.3% in group 2 (P < 0.001, absolute risk reduction of first-attempt failure rate = 42.5%, 95% confidence interval [CI] = 36.0%-49.9%; numbers needed to treat = 2, 95% Cl = 2-3; relative risk reduction of first-attempt failure rate = 98.1%, 95% Cl = 92.3%-99.5%). The median time required to insert the NGT was significantly shorter in group 1 (55 vs 60 seconds); P < 0.001, 95% Cl for the difference in means = 3.2 to 6.8 seconds. The incidences of kinking/coiling, bleeding, and moderate injuries were significantly lower in group 1. CONCLUSIONS: Esophageal guidewire-assisted insertion with manual forward laryngeal displacement technique most frequently resulted in correct positioning of the NGT in anesthetized and tracheally intubated patients after the first attempt. This technique is also associated with a lower incidence of procedure-related injuries and is less time-consuming than conventional insertion techniques. (Anesth Analg 2012;114:343-8)