Study Objective: Establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature. Measurements: An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus, and Google Scholar was performed applying the search terms “ gastric tube ” , “ complications ” , “ decompression ” , “ blind insertion ” , “ perioperative ” , “ intraoperative ” in various order sequences. A five-year limit was applied to limit the number and timeliness of articles selected. Main Results: Patients are exposed to potentially serious morbidity and mortality from blindly inserted gastric tubes. Risk factors associated with malposition include blind insertion, the presence of endotracheal tubes, altered sensorium, and previous tube misplacements. Pulmonary aspiration risk prevention remains the only indication for anesthesia-related intraoperative use. There are no singularly effective tools that predict or verify the proper placement of blindly inserted gastric tubes. Current placement facilitation techniques are perpetuated through anecdotal experience and technique variability warrants further study. Conclusion: In the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of gastric tubes.
According to a healthcare study published by the Society of Actuaries in 2010, over 19 billion healthcare dollars were spent in the United States on preventable medical errors [
The sump drainage tube is the most often deployed device during the perioperative period and features a dual lumen design. One lumen allows for drainage or as a conduit for medications and lavage while the second lumen functions to permit air passage. Lacking this innovation, negative pressure can result in a stomach lining injury or promote a mechanical obstruction. This design helps mitigate this risk and is intended to prevent the mucosal wall from refluxing back into the tubing. The dual lumen sump drainage tube is often inserted in emergency room patients requiring emergent gastric decompression or lavage and is used regularly in the perioperative and postoperative management of surgical patients. When used intraoperatively, the gastric tube is used to evacuate air or fluid retained in the stomach. Gastric tubes are often placed in patients undergoing general anesthesia even in the absence of a surgical indication. Those supporting its practice believe that routine gastric content decompression can ameliorate postoperative nausea and vomiting (PONV). Other providers maintain that this practice reduces aspiration risk by evacuating gastric contents that are produced throughout the intraoperative period. However, literature advocating gastric decompression by anesthesia providers is largely deficient. This was compellingly illustrated in an editorial aptly named “The other tube in the airway: what do we know about it?” by Martin & Aunspaugh [
The purpose of this literature review is to establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature. Due to the multitude of terms that have resulted from manufacturer branding, the tube’s primary purpose, and terminal tip location, “gastric tube (GT)” will be applied throughout the remainder of this review. It will be generically applied to any artificial enteric device inserted orally or nasally to decompress, lavage, and/or administer medication and nutrients to the alimentary tract.
To maintain validity and for the purpose of disseminating the most current evidence directed at this review’s objective, a five year limit was applied to exclude any literature published prior to 2009. Pre-search inclusion criteria were literature reviews, randomized controlled trials, and cohort studies in the English language (or those foreign articles conveniently translated into English.) All subject age groups were included for review since the practice of gastric tube insertion, regardless of age, lies within an anesthesia provider’s scope of practice. Exclusion criteria included literature that described a singular case study or literature reviewing case studies and articles whose primary purpose was related to the goal of perioperative gastric decompression.
An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus and Google Scholar was performed applying the search terms “gastric tube”, “complications”, “decompression”, “blind insertion”, “perioperative” and “intraoperative” in various order sequences. The various orders sequences employed were gastric tube + complications; gastric tube + decompression; gastric tube + perioperative; gastric tube + intraoperative; gastric tube + blind insertion. This literature search strategy revealed no review articles or prospective/retrospective investigation of any kind related to complications associated with blind GT intubations by anesthesia professionals during the perioperative period. However, evidenced by the amount of complication case reports and GT placement facilitation methods published in anesthesia and surgical peer-reviewed journals, one would surmise that a problem does exist and warrants further investigation. The described five year limitation and data extraction measures were applied. Twenty-one case studies were selected for this review after they were carefully scrutinized to make certain that those involved in the GT insertion or management of the affected patient were anesthesia professionals (see
Case Reports. Invasive medical procedures convey some level of risk; however, it is the blind unassisted method of insertion that gives the GT the potential for serious harm. The ipsilateral piriform sinus and arytenoid cartilages are recog-
nized as the most common points of resistance as the tube enters the hypopharynx [
In the absence of gastric aspirate or with the suspicion of malposition several case reports have identified intrapulmonary misplacement precluding injury. This type of malposition can occur due to the shared anatomic pathway and the close proximity of the glottis in relationship to the opening of the esophagus. Govindarajulu et al. identified an endobronchial placed GT by direct laryngoscopy (DL) subsequent to a ventilator leak [
Case Study | Demographics | Attempts | Complications | Outcomes |
---|---|---|---|---|
Hynh 2009 | 67 year-old male Esophagectomy | One | Gastric fistula | Emergent thoracotomy |
Hirshoren 2009 | 77 year-old female Embolectomy | Multiple | Pharyngeal injury, infected hematoma | Irrigation and debridement of infected wound |
Hegde 2010 | 60 year-old male Intensive care unit | Multiple | Bronchial malposition | Pneumonia, death (may not be related to gastric tube) |
Khanna 2012 | 22 year-old male Gastric pull-up | One | Indeterminate position | No adverse sequel |
Lin 2012 | 47 year-old male Peptic ulcer repair | Two | Endotracheal tube coiling and constriction | Pulmonary edema |
Daliya 2012 | 32 year-old male Laparotomy | Not specified | Gastric perforation | Emergent laparotomy |
Nanjegowda 2013 | 45 year-old male Cholecystectomy | One | Tracheal malposition | Recurrent laryngospasm |
Ranier 2013 | 50 year-old Anterior/posterior spinal fusion | One | Fractured tip | Coughed up fractured tip in recovery room |
Kerforne 2013 | 44 year-old female Gastric bypass | One | Tracheal malposition | Tracheal aspiration of dye |
Turabi 2014 | 39 year-old female Shoulder surgery | Multiple | Esophageal perforation, pneumothorax | Esophageal stent, chest tube |
Ching 2014 | 78 year-old male Esophagogastrectomy | One | Unsuccessful attempt | Surgical facilitation to prevent further injury |
Govindarajuru 2014 | 60 year-old male Cholecystectomy | One | Tracheal malposition | Removed without sequel |
Joseph 2014 | 66 year-old female Tracheostomy | One | Pulmonary malposition | Ventricular tachycardia, pleural effusion, pneumonia |
Isik 2014 | 70 year-old male Cholecystectomy | Not specified | Esophageal perforation | Emergency thoracotomy, esophageal repair |
Burad 2014 | 52 year-old female Aneurysm coiling | Two | Laryngeal injury | Esophagoscopy |
Acharya 2014 | 60 year-old male Laparotomy | Two | Gastric tube knotting around endotracheal tube | Removed without sequel |
Sahu 2015 | 31 year-old Cholecystectomy | One | Tracheal malposition | Removed without sequel |
Bagharwal 2015 | 17 year-old female Gastric pull-up | Multiple | Gastric tube and nasopharyngeal temperature probe entanglement | Nasal bleeding |
Kalava 2015 | 64 year-old male Mandibular surgery | One | Bronchial malposition | Removed without sequel in recovery room after x-ray revealed misplacement |
Garg 2015 | 35 year-old female Cholecystectomy | One | Self knotting of gastric tube through supraglottic device | Removed objects en masse without sequel |
Raut 2015 | 70 year-old male Coronary bypass & graft | One | Bronchial malposition | Removed without sequel in intensive care unit after x-ray revealed misplacement |
incurring injury. Kavala et al. reported an uncomplicated GT insertion, not recognized intra-operatively, that was endobronchially malpositioned diagnosed by chest x-ray in the post-anesthesia care unit [
Complications are sometimes related to the mechanics of the tube itself and even correctly placed tubes can create a quandary or contribute to an injury. Tube coiling and knotting were described in 4 case studies with 2 GTs wrapping around endotracheal tubes (ETTs), one self-knotting through a supraglottic device and an intranasal temperature probe/GT entanglement. Acharya et al, Chaudhary et al, and Garg & Kapoor all recount intraoperative events where the GT became entangled around other insitu devices or self knotted preventing unhindered GT removal [
Mucosal or soft tissue trauma is not always avoidable and is primarily due to the blind nature of the insertion. Without the ability to visualize the entire placement and the presence of fragile and often friable structures lying in the path of the GT, blind insertions can contribute to serious harm. Traumatic injury resulting in superficial damage, perforation or fistula formation was reported in 6 case studies and either urgent or emergent procedures ensued as a result of this complication. Burad et al. [
Gastric tubes should be inspected after removal in the same fashion as one would a central line or other invasive tube. A fractured portion of the GT was coughed up by a patient in the post anesthesia care unit reported by Ranier & Costello [
Resistance or inability to advance the GT should alert the practitioner to a possible difficult placement. Many of the reports described resistance or difficulty in the primary placement while others depicted more than one or multiple attempts. Resistance encountered should therefore prompt the practitioner to abort any more attempts and instead use alternate methods of insertion especially with a patient specific condition that would predispose them to injurious sequelae. Ching et al. describe a case in which after meeting resistance avoided further re-insertions to prevent an injury in a post-esophagogastrectomy patient [
Complication & Risk Factors―Medical Literature. Malpositioning was identified as the most common complication [
Thoracic injuries were identified in five of the seven complication articles with pneumothorax cited as one of the severe adverse sequelae that resulted in death [
Other sites for misplacements are associated with overzealous handling, unintentional tube coiling, kinking of the tube within the alimentary tract, or inadequate length insertion. Esophageal placements due to dislodgement or tube coiling are other areas where malpositioning can occur. Esophageal placement increases aspiration risk [
Risk Factors. Certain predisposing risk factors have been attributed to blind GT malpositioning; factors of which every practitioner engaging in this particular practice should be cognizant. Sparks et al. found mechanical ventilation a factor in 113/187 (60.4%) misplacements with no difference with respect to ventilator setting or presence of ETT or tracheostomy [
Radiographs remain the standard to which all other verification methods are compared when testing for accuracy. Although the gold standard, the routine use of radiographs as a verification technique is limited by cost, time constraints and is subject to incorrect interpretation. Misinterpretation of radiographs was highlighted in a 6-month prospective re-audit that identified a 17% rate of reading errors by radiologists [
Several portable verification methods are currently available for use and are extensively discussed throughout nursing and medical literature. Capnometry or capnography, biochemical testing, and ultrasonography are all methods available for use in the operating room. These techniques carry significant advantage over radiographs in their portability and ready availability of equipment.
Unsupported Methods. The auscultation method involves the instillation of air while simultaneously listening over the epigastrium for noise caused by turbulent airflow entering the stomach. Air instillation, even with broncho-pul- monary or esophageal misplacement, can elicit a noise similar to that heard with correct gastric placement and often mistakenly results in a false prediction assessment [
Tube aspirate can be obtained to visually distinguish between intestinal and GT placements. However, due to color and consistency similarities shared by gastric and pulmonary aspirates, this method is unreliable with broncho-pul- monary misplacements [
Aspirate and Biochemical Markers. Bilirubin, pH, and pepsin/trypsin are biochemical markers that can be identified by testing fluid aspirated from the GT and used in the prediction of terminal tip location. A systematic review, with stringent inclusion criteria and quality assessments, determined that pH testing alone was unreliable [
Capnometry/Capnography. Carbon dioxide (CO2) detection is a verification method readily available to anesthesia providers. Capnometry and capnography are fundamentally similar except capnography provides a continuous analysis of CO2 by waveform and capnometry is conceptually a point of care modality. The strongest level of evidence pertaining to CO2 as a verification tool is a meta-analysis that supports the use of capnography/capnometry [
Ultrasonography. Ultrasonography machines, found in almost every anesthesia department, provide a non-invasive and radiation-free modality that decreases body fluid borne contagion exposure. Five publications discussed ultrasonography were selected for review of which three (all cohort studies) supported its use as a predictive measure [
This is a problem plaguing providers and has produced unique correct GT placement methodologies dating back to the 1960s [
Neck manipulative techniques. Neck flexion, cited by two RCTs, with/ without lateral pressure reported an 88% - 92% success rate [
Facilitators requiring specialized equipment or tube modifications. Several articles depict methods that employ specialized equipment with or without tube modifications or replacements. The Glidescope and King Vision video laryngoscopes corroborated higher success rates when used to facilitate placement compared to controls [
Ultimately, the conclusions of any previously described employment methods are severely limited by lack of trial reproduction in current literature and their anecdotal nature. In addition, all described methods are limited by the absence of technique standardization and the potential exclusion of subjects that would provide a more representative patient sample. Although these techniques require a dataset with larger, more methodologically sound clinical trials for complete endorsement as placement facilitators most of the described facilitation methods were significantly associated with higher rates of correct GT placement. Therefore, it would be prudent to consider adopting a method that suits your specific skillset given the cumulative morbidity risk exposure of repeat attempts.
A myriad of unsupported rationales for the intraoperative use of GT can be accredited to the perpetuation of misinformation that has been instrumental in its continued practice. The only described rationales, discussed in peer-reviewed literature, are for PONV and aspiration risk prevention. Any other rationale professed by anesthesia providers for its intraoperative employment is spurious and unsupported.
PONV Prevention. Postoperative nausea and vomiting is the most common anesthesia side effect in the postoperative period with rates occurring up to 70% in certain high risk patients [
Four out of the six articles pertaining to PONV found decompression by GT to be ineffective. Three RCTs conducted on pediatric populations, all reported no statistical significance when compared to the control group [
Those finding gastric decompression either effective or reporting a significant change when compared to controls were both RCTs on adult patients undergoing various cardiac and ENT surgeries. Lavi et al, in 2011, randomized 202 patients undergoing cardiac surgery, and found vomiting significantly higher in the non-GT group [
Currently, the evidence is lacking and what is available is more questionable than supportive. The new consensus guidelines adopted by the American Academy of Anesthesiologist Assistants, the American Association of Nurse Anesthetists and the American Society of Anesthesiologists have removed GT use for PONV prevention citing Kerger et al. [
Aspiration risk prevention. Gastric tubes for aspiration risk prevention are supported by a recent review article by Salem et al. [
The main limitation to this review is the lack of complication-related articles that specifically pertain to GTs inserted by anesthesia providers. More prospective observational studies need to be performed to identify the incidence of GT malposition during the intraoperative period, the effectiveness of intraoperative gastric decompression and whether current verification methods are practical in the perioperative setting. Although medical literature suggests complication rates as high as 16%, too many differences exist between surgical and medical patients. These variables, which may include differences in population, use of muscle relaxants, qualification of the practitioner, and type of tube inserted, may not extrapolate to the intraoperative setting. Yet, similar risk factors are present between the two that warrant attention like the presence of an ETT and patients with altered sensorium. Finally, other limitations can be attributed to word selection used in the database key word search and the English language only inclusion criteria.
Invasive interventions, like blind GT insertions, may be employed more frequently because of the increased complexity of health conditions seen with an aging healthcare population [
Presently, evidence-based practice has decreased the utilization of GTs for postoperative decompression in abdominal surgical patients. The advent of new guidelines and pathway driven care has resulted in fewer morbidities and shorter hospitalizations [
Blind GT intubations have limited utility in elective scenarios and expose otherwise healthy patients to considerable harm. Therefore, more stringent criteria should be used when advocating its elective use in the intraoperative setting. It is the opinion of this reviews’ authors, that in the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of GTs in these patients undergoing GETA.
This review actually raises more questions than it answers and is consequent to the paucity of anesthesia literature pertaining to this “other tube.” Gastric tubes used intraoperatively are not associated with a decrease in aspiration risk, only a decrease in aspirate content. Also, the majority of aspirations (68%) occur during induction and emergence [
The intent of this review is to offer a comprehensive exploration and evaluation of literature that can be correlated with anesthesia provider GT practice. Current published literature is severely deficient in the coherent compilation of information related to GT utilization by anesthesia providers. It also provides a more complete dissemination of new information that will greatly complement previous review articles communicating related literature. Notably, this review disseminates clinically relevant information that is applicable to a potentially harmful practice modality employed by anesthesia providers. Its attention to possible complications, malposition risk factors, verification methods, and correct placement facilitating schemes could and have provided the groundwork for guideline/pathway derivation that can be aligned with previously proposed algorithms.
This is especially important with the enactment of the Patient Protection and Affordable Care Act (PPACA) and the role it will play toward quality improvement. One such quality improvement provision involves the Centers for Medicare & Medicaid Services (CMS) and its reimbursement practices. The CMS will no longer reimburse hospitals for preventable readmissions, which they estimate costs the taxpayer billions of dollars [
Long, M., Machan, M. and Tollinche, L. (2017) Intraoperative Gastric Tube Intubation: A Summary of Case Studies and Review of the Literature. Open Journal of Anesthesiology, 7, 43-62. https://doi.org/10.4236/ojanes.2017.73005
ASA American Society of Anesthesiologists
PONV Postoperative Nausea and Vomiting
GETA General Endotracheal Anesthesia
GT Gastric Tube
ETT Endotracheal Tube
EGD Esophagogastroduodenoscopy
RCT Randomized Controlled Trial
CO2 Carbon Dioxide
ERAS Enhanced Recovery After Surgery
NK Neurokinin
GABA gamma-Aminobutyric acid
CMS Centers for Medicare and Medicaid Services
PPACA Patient Protection and Affordable Care Act