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5 Complications of Nasogastric Intubation
Julie E. Dechant DVM, MS, DACVS, DACVECC
School of Veterinary Medicine, University of California–Davis, Davis, California
Overview
Nasogastric intubation is performed to check for gastric reflux, relieve gastric distension, or administer enteral fluids, laxatives, or medications. Nasogastric intubation is achieved by directing and maintaining the nasogastric tube into the ventral meatus of the nasal cavity, without traumatizing the nasal turbinates and the ethmoid turbinates. The tube is blindly manipulated within the nasopharynx to the esophageal opening, avoiding the dorsal pharyngeal recess and the salpingopharyngeal plica. Once in the esophagus, the nasogastric tube is gently advanced aborally to enter the cardia of the stomach.
The blind manipulation and passage of the tube can result in trauma to the associated tissues along the intended pathway, and trauma to structures if the tube is misdirected. Misplacement of the tube can result in further problems (fragmentation of the tube or administration of fluid into the lungs) if not recognized.
List of Complications Associated with Nasogastric Intubation
Epistaxis
Misplacement of tube
Esophageal/pharyngeal trauma
Fragmentation of tube
Administration of fluid into lungs
Sinusitis
Epistaxis
Definition
Epistaxis is the presence of hemorrhage from the nares.
Risk factors
Inexperience, although hemorrhage may occur with skillful intubation in a compliant horse
Non‐compliant horse
Pathogenesis
Epistaxis is the most common complication from nasogastric intubation [1–3]. Hemorrhage can occur when the respiratory mucosa, nasal turbinates, or ethmoid turbinates are traumatized.
Prevention
The risk of epistaxis may be minimized by careful and gentle technique and assuring advancement of tube into ventral nasal meatus using well‐lubricated tubes that are in good condition and free of external defects or roughening. Tube diameter should be selected to be an appropriate size for the patient, with the dimensions of the ventral nasal meatus being most limiting. Although water often provides sufficient lubrication in most circumstances, additional lubrication using carboxymethylcellulose or lubricating gel at the end of the tube may reduce risk of epistaxis in small patients, patients with dry or friable mucosa, or animals with restricted nasal passages. Pre‐emptive intranasal application of phenylephrine spray, which causes local vasoconstriction of vessels within the nasal mucosa, may be of benefit. Patients should be adequately restrained, which may require use of a nose twitch or sedation.
Diagnosis
Epistaxis occurs during placement or immediately after removing the nasogastric tube.
Treatment
Mild elevation of the head may speed resolution of bleeding, because lowering the head increases venous congestion, which would delay hemostasis. Extreme elevation of the head should be avoided because it increases the risk of aspiration and pneumonia [1]. Packing of the affected nasal cavity is an option, but the technique may simply divert hemorrhage into the nasopharynx and not reduce the volume of bleeding. Intranasal application of phenylephrine or epinephrine may be useful in providing local vasoconstriction; however, ongoing bleeding may limit the amount and distribution of drug that is absorbed by the nasal mucosa.
Expected outcome
Bleeding may be minor or more significant, and is usually self‐limiting [2]. In rare circumstances, hemorrhage may be severe enough to require blood transfusion and the administration of drugs to promote coagulation and prevent fibrinolysis. It is recommended that horses should not be anesthetized while there is ongoing nasal hemorrhage, because the head is generally positioned lower than the heart during anesthesia, which would exacerbate hemorrhage, and the cardiovascular consequence of ongoing blood loss is less tolerated during the cardiovascular depressant effects of most anesthetic drugs.
Misplacement of Tube
Definition
The tube is inadvertently misdirected into tracheal lumen, guttural pouch or retroflexes at the back of the nasopharynx and enters the oral cavity, or exits out the contralateral nostril while advancing the tube.
Risk factors
Uncooperative patients, inadequate restraint or assistance, and inexperience with the procedure are predominant risk factors.
Excessively pliable nasogastric tubes increase the risk of misplacement or misdirection of the tube.
Smaller diameter tubes may increase the risk of misplacement of the tube within the guttural pouch (Figure 5.1).
Pathogenesis
Misplacement of the nasogastric tube is a common complication of nasogastric intubation. The esophageal opening is directly dorsal to the arytenoid cartilages of the larynx and it is relatively easy to enter the trachea, especially in horses that do not swallow or are resisting the intubation procedure. Retroflexion of the tube into the oral cavity can occur at the leading edge of the tube when trying to enter the esophagus. Alternatively, it may happen along any part of the length of the tube if the esophagus spasms around the tube and prevents its advancement. Further efforts to advance the tube against esophageal resistance results in the pharyngeal part of the tube retroflexing into the oropharynx. Misplacement of the tube in the guttural pouch with subsequent perforation of the medial compartment has been described [4].
Figure 5.1 Lateral radiograph of the pharyngeal region of a miniature horse undergoing
