To the Editor:—
Surgeons sometimes request, either before or after induction, that a nasogastric tube be inserted for the postoperative period. This can be problematic when using the ProSeal ™ laryngeal mask airway (PLMA; Laryngeal Mask Company, San Diego, CA), because the drain tube only facilitates orogastric tube placement. A potential solution to the preinduction request is to insert the nasogastric tube before PLMA placement; however, in principle this might (1) impede placement of the PLMA, (2) reduce the efficacy of seal with both the respiratory and gastrointestinal tracts by altering the shape of the pharynx, (3) increase the frequency of mechanical airway obstruction by reducing the hypopharyngeal space, and (4) render the nasogastric tube nonfunctional by compression of its lumen between the cuff and pharynx. We report our retrospective experience of this technique in 48 adults undergoing elective intraabdominal surgery. Ethical committee approval was obtained to publish these data.
Patients were induced with alfentanil, midazolam, and propofol. No muscle relaxants were given. The size 4 was used for women, and the size 5 was used for men. The mean (range) age, height, and weight were 58 (19–85) yr, 68 (45–125) kg, and 170 (144–198) cm, respectively. The male:female ratio was 29:19. The nasogastric tube, either a 12 or 14 French gauge, was successfully placed using a laryngoscope and Magill forceps in all patients, although three required more than one attempt. PLMA placement was successful at the first attempt in all patients with use of the laryngoscope-guided, gum elastic bougie–guided technique.1Oropharyngeal leak pressure, fiberoptic position of the airway tube, and ventilatory capability were similar to those in previous studies with no nasogastric tube.2There were no airway management problems, and gastric insufflation was not detected during positive-pressure ventilation. The nasogastric tube was patent in all patients. There were no problems with displacement of the nasogastric tube during removal of the PLMA.
We conclude that this technique is feasible and does not interfere with the function of the PLMA or nasogastric tube. If there are doubts about the patency of the nasogastric tube, an orogastric tube can always be inserted down the drain tube. In situations where the surgeon’s request comes after induction, perhaps the best solution is to slide the nasogastric tube behind the cuff of the PLMA, as described for the LMA-Classic ™ (Laryngeal Mask Company).3Alternatively, the nasogastric tube can be inserted when the patient is awake.
*James Cook University, Cairns Base Hospital, Cairns, Australia. firstname.lastname@example.org