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Difficult Removal of a Nasogastric Tube Because of Knot Formation Around a Nasotracheal Tube: A Case Report

Abe, Sayumi DDS; Osaka, Yoshimune MD, PhD; Morita, Yoshihisa MD, PhD

doi: 10.1213/XAA.0000000000000776
Case Reports
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Knotting of a nasogastric (NG) tube around a left nasotracheal tube occurred in the pharynx during its blind insertion via the right nares. Unusual resistance was encountered during its advancement and attempted withdrawal. The nasotracheal tube moved in tandem with the NG tube. The NG tube was cut and the lower portion removed via the mouth and the upper portion removed via the right nares.

From the Department of Anesthesiology, Kawasaki Municipal Hospital, Kawasaki, Japan.

Accepted for publication March 6, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Yoshimune Osaka, MD, PhD, Department of Anesthesiology, Kawasaki Municipal Hospital, 12-1 Shinkawa St, Kawasaki-ku, Kawasaki City, Kanagawa 210-0013, Japan. Address e-mail to bluesapphire1226@gmail.com.

Several complications of nasogastric (NG) tube placement have been reported. Although knot formation is a well-recognized complication associated with its use, NG tube knotting around a nasotracheal tube is rare. Methods to remove the knotted NG tubes through the nose1,2 and the mouth3 have recently been reported, but the removal of the NG tube surrounding a nasotracheal tube has not.

Written consent was obtained from the patient for publication of this report.

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CASE DESCRIPTION

Figure.

Figure.

A 57-year-old woman (height, 155 cm; weight, 49 kg; American Society of Anesthesiologists physical status II) was scheduled for tongue cancer resection. After induction of general anesthesia, a 6.5-mm (inside diameter) cuffed nasotracheal tube (Polar Preformed Tracheal Tube; Smith Medical International Ltd, Tokyo, Japan) was easily placed under direct laryngoscopic guidance via the left naris. A 16F NG (Salem Sump; Covidien Japan Co, Ltd, Shizuoka, Japan) was blindly inserted via the right naris, but a slight resistance was encountered during advancement of the tube. When we attempted to withdraw the NG tube, unusual resistance was felt and the tracheal tube moved in tandem with the NG tube. Examination of the oral cavity revealed knotting of the nasotracheal tube in the oropharynx (Figure). The NG tube was cut and the lower portion removed via the mouth and the upper portion removed via the right nares. Another NG tube was subsequently inserted uneventfully through the right naris under direct laryngoscopic guidance.

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DISCUSSION

In intubated, anesthetized patients in the supine position, the posterior tilt of the intubated larynx causes the NG tube to head toward the piriform sinuses and arytenoid cartilages. The cuffed tracheal tube itself can also interfere with the advancement of the NG tube. Therefore, curling or coiling of the tube could occur within the pharynx. Attempts to withdraw the curled or coiled tube may cause a loop that may be tightened into a knot. Once a knot formation around a tracheal tube occurs, forceful removal of the tube may result in unanticipated extubation. Although a rare complication, NG tube knotting should be suspected when unusual resistance is felt and concurrent movement of the endotracheal tube is noted during withdrawal of the NG tube.

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DISCLOSURES

Name: Sayumi Abe.

Contribution: This author helped perform the anesthetic management of the case and write the manuscript.

Name: Yoshimune Osaka, MD, PhD.

Contribution: This author helped perform the anesthetic management of the case and write the manuscript.

Name: Yoshihisa Morita, MD, PhD.

Contribution: This author helped with manuscript preparation, critical comment, and final approval.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

1. Chavda V, Alhammali T, Farrant J, et al. Nasogastric tube knotting: a rare and potentially overlooked complication among healthcare professionals. BMJ Case Rep. 2017;2017:bcr2017220287.
2. Hirwa KD, Toshniwal N. Knotted nasogastric tube in the posterior nasopharynx: a case report. Qatar Med J. 2016;2016:11.
3. Ravind R, Prameela CG, Gurram BC, Dinesh M. Naughty knot: a case of nasogastric tube knotting. BMJ Case Rep. 2015;2015:bcr2015209937.
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