Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference?

BACKGROUND: Divergent opinions exist regarding the routine use of nasogastric (NG) tubes in the postoperative management of patients undergoing abdominal surgery. Empiric use of an NG tube after abdominal surgery is presumed to prevent abdominal distension, vomiting, and ileus, which may complicate the postoperative course. To investigate the validity of this assumption, we compared the postoperative course of patients who underwent appendectomy for perforated appendicitis who subsequently either had or did not have an NG tube placed postoperatively. METHODS: A retrospective chart review of all children operated for perforated appendicitis between 1999 and 2004 was performed. Patients with prolonged hospitalizations were excluded to eliminate bias created by patients with multiple operations and opportunities for NG placement. The use of an NG tube, time to first and to full oral feeds, length of hospitalization, and complications were compared between groups. RESULTS: Patients with NG tubes left in place (N = 105) were compared with those who did not receive an NG tube (N = 54) following appendectomy for perforated appendicitis. Mean time to first oral intake was 3.8 d in those with NG tubes compared with 2.2 d in those without NG tubes (P < 0.001). Similarly, mean time to full feeds was 4.9 d when an NG tube was left compared with 3.4 d in those without tubes (P < 0.001). Mean length of stay was 6.0 d in those with NG tubes compared to 5.6 d in those without (P = 0.002). CONCLUSIONS: The use of NG decompression after an operation for perforated appendicitis does not appear to improve the postoperative course and we recommend that it is not routinely used in this patient population.     

Does the presence of a tracheal bronchus affect the margin of safety of double-lumen tube placement?

During double-lumen tube (DLT) placement, the anesthesiologist must be mindful of the margin of safety. We determined how this margin is affected by the presence of a tracheal bronchus by elucidating the mathematical relationship between some relevant physical dimensions of the trachea, bronchi, and DLT. Our results suggest that a tracheal bronchus only rarely affects the intrinsic margin of safety of DLT placement. When the tracheal bronchus is located much higher than its most frequently seen location (within 2 cm from the carina), however, there is increased risk that it could be blocked by the tracheal cuff of a left-sided DLT.     

Early versus late tube feeding initiation after PEG tube placement: Does time to feeding matter?

BackgroundVariation exists in the timing of tube feed initiation after percutaneous endoscopic gastrostomy (PEG) tube placement. The aim of our study was to review outcomes of early tube feed (ETF) versus late tube feed (LTF) initiation after PEG tube placement.MethodsWe performed a retrospective review of all trauma patients who underwent PEG tube placement from 1/2014 to 12/2018. ETF was defined as initiation < 24 h and LTF > 24 h after placement. The primary outcome measure was feeding intolerance and secondary outcomes included post-operative complications. All statistical analyses were performed using standard statistical methods (e.g. Pearson's Chi-squared, Fisher's exact and Mann Whitney-U tests).ResultsThere were 295 patients (164 ETF and 131 LTF) that received a PEG tube at our level 1 trauma center. There was no difference with feeding intolerance at 12 h (5% vs. 4%; p = 0.88), 24 h (1% vs. 2%; p = 1.00), and 48 h (4% vs. 4%; p = 1.00). There was no difference when comparing intolerance symptoms such as nausea and vomiting (1% vs. 2%; p = 0.79), abdominal tenderness (2% vs. 3%; p = 0.76), high gastric residuals (2% vs. 2%; p = 1.00) and aspiration (0% vs. 2%; p = 0.39). There was no difference when comparing post-operative complications (4% vs. 8%; p = 0.21).ConclusionsEarly tube feeding after PEG placement is safe and equivalent to late tube feeding in the adult trauma population. Future prospective studies are warranted to establish the optimal timing for initiation of tube feeds after PEG tube placement.     

Can insertion length for a double-lumen endobronchial tube be predicted?

It has been suggested that the appropriate length of insertion for double-lumen tubes can be estimated by external measurement. This study examined the accuracy of external measurement in estimating the actual length of insertion required in 130 patients. It also examined the relationship between the length inserted and the patient's height in 126 patients and their weight in 125 patients. Although there was a fair correlation between the measured external length and the final inserted length (r = 0.61), the 95% confidence intervals of slope and intercept allowed a large variation and the prediction was too wide to be clinically useful. Height was reasonably well correlated with the final length (r = 0.51) but an equally wide 95% confidence interval rendered it of little clinical value. There was no correlation between weight and final tube length. It is concluded that external measurement alone is not adequate to predict a clinically acceptable position of the double-lumen tube.     

Gastrostomy tube placement in infants and children: is there a preferred technique?

Purpose

Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques.

Methods

All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P ≤ .05 considered significant.

Results

Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room (P = .02).

Conclusion

Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.     

Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube?

A case of fatal upper gastrointestinal bleeding from a Mallory–Weisstear after transoesophageal echocardiography during cardiacsurgery is reported. After the echocardiographic examination,which is considered a safe procedure, a nasogastric tube wasinserted which immediately revealed bright red blood. Eventuallythe patient lost 9 litres of blood. The role of the echoprobeand the nasogastric tube in causing the Mallory–Weisstear is discussed. Although this case is not conclusive aboutthe mechanism of oesophageal damage, it is suggested that thesafety recommendations for transoesophageal echocardiographyalso apply for instrumentation of the oesophagus with a nasogastrictube after the transoesophageal echocardiographic examination.     

Fiberoptic-guided tracheal tube placement through the air-Q? Intubating Laryngeal Airway: a performance study in a manikin

Purpose  

This study characterizes the performance and success rate for fiberoptic-guided tracheal tube placement through the air-Q^? Intubating Laryngeal Airway (air-Q).     

So,you want to be a leader?

Every physician is a leader. We often lead teams of people, whether it is in an ambulatory clinic, the ICU, or the operating room. We have responsibility for our patients, and need to ensure our colleagues, advanced practice providers, and support teams are doing their jobs correctly. On a small scale, it is a physician in a solo practice or a surgeon in an operating room. On a larger scale it can be an academic chair or a dean. This article serves as a primer for those who will journey down the path of becoming a leader. Starting with a brief historical background of modern leadership theory, and a discussion on managing versus leading, we will then touch on what we believe are the key steps required to become a successful leader. We have drilled this down to four steps: 1) know yourself, 2) know others, 3) reality test your skill set, and finally, 4) become a servant leader. Numerous vignettes are written to help illustrate some of the lessons that should be learned when embarking on this journey.