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Fractured OG tip: a case report.


NG/OG tubes can be made of PVC, polyurethane, or silicone, but are most commonly made of PVC (Salem Sump[TM]) for gastric tubes used in the perioperative setting. PVC gastric tubes are stiffer than their counterparts and are more irritating long term, but this factor does not influence its use in anesthesia as OG tubes are most often removed at the conclusion of the procedure prior to emergence. The OG tube that is most commonly used is the Salem Sump[TM], which is also the OG tube used in our institution. It has two lumens consisting of a larger diameter lumen (for suction or irrigation) and a smaller diameter lumen. The smaller diameter lumen can serve the purpose of venting to the atmosphere so that the distal suction ports of the OG tube do not adhere to the stomach lining and cause mucosal injury after suctioning of gastric contents. OG and NG tubes are not limited to anesthesia and are used frequently through many areas of medicine and surgery to include treatment of bowel obstruction, routine placement in intubated patients in the ICU, gastric lavage, etc. NG and OG tubes are not commonly associated with morbidity; however, complications such as esophageal rupture, worsened reflux, GI tract irritation, and pulmonary abscess have been reported. (1)

Case Presentation

A 50 year old patient was scheduled to undergo an elective anterior-posterior cervical spinal fusion. The patient was appropriately pre-oxygenated in the operating room and then underwent a routine induction and intubation. The OG tube was placed after induction non-traumatically with return of gastric fluid. The surgery and anesthetic were performed without complication, and the OG tube was removed at the end of the case seemingly without incident. The case lasted approximately seven hours. During the case, the patient was never witnessed to cough, buck, or bite down on either the endotracheal tube or OG tube, even upon removal. The patient was transported to the PACU, where shortly after arrival he began to cough. The patient was evaluated and shortly thereafter coughed up a foreign object. Upon further inspection, the foreign object appeared to be the tip of an OG tube. The original OG tube was immediately sought out and found in the trash can of the OR with an exact symmetric match to the tip coughed up by the patient (Fig 1). After the OG tip was expelled from the patient, the patient went on to have an uneventful recovery.


The rationale behind using an OG tube in anesthesia is that gastric distension increases after bag mask ventilation. The gas mixture entrained during bag mask ventilation will often contain volatile anesthetics. The presence of gastric distension and volatile agents within the stomach are both thought to increase the incidence of PONV. (2) The use of an OG tube after induction to decrease the gastric distension and to remove volatile anesthetics has been considered a safe and effective non-pharmacologic method of decreasing PONV. Some recent studies have cast doubt as to whether this is actually true; (3) but regardless, many clinicians still place OG tubes in clinical practice.

One of the reasons that OG tubes are still common in clinical practice despite the fact that their use is equivocal in preventing PONV or improving aspiration risk, is that the complication rate is relatively low. However, complications do exist and the clinician should be aware of them. Coiling, kinking, or knotting can occur along any portion of the GI tract including the pharynx and pyriform sinus. When not placed carefully, esophageal perforation can occur. Gastric mucosal injury or necrosis can occur if the OG tube is left on continuous high suction for the duration of the procedure. The presence of an OG tube also weakens the lower esophageal sphincter tone. These complications are not limited to the GI tract, as inadvertent placement in the respiratory tract can also lead to a similar spectrum of complications from ulceration to perforation. An inadvertent OG tube placed in the respiratory tract that goes unrecognized postoperatively and is left in can lead to serious complications if the tube is used for feeds or medications. These complications include pneumonia, abscess, or pneumonitis. A search of the literature failed to find any reported incidences of a fractured OG tip retained in the patient upon removal. We contacted the manufacturer and were told that the matter would be looked into and they would provide us with a formal response; additionally, the event was reported to the FDA medwatch. We postulate several mechanisms for this occurrence: 1) the tip may have been damaged prior to placement, 2) the tip was damaged upon removal and not recognized as such, or 3) a combination of the two.


This patient was fortunate and did not develop any complications from the incident. The patient could have swallowed the OG tip or even aspirated the OG tip coated in gastric contents. This case report serves as an interesting example of a complication that providers should be made aware of and why the clinician must remain ever vigilant when caring for patients.


(1.) Hodin RA, Bordeianou L. Nasogastric and Nasoenteric Tubes. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.

(2.) Hovorka J, Kortilla K, Erkola O. The experience of the person ventilating the lung does influence postoperative nausea and vomiting. Acta Anaesthesiol Scand 1990;34:203-5.

(3.) Kerger KH, Mascha E, Steinbrecher B, et al. Routine Use of Nasogastric Tubes Does Not Reduce Postoperative Nausea and Vomiting. Anesth Analg 2009; 109: 768-73.

George Ranier, MD

WVU School of Medicine, Dept. of Anesthesiology, Morgantown, WV

Kevin Costello, MD

WVU School of Medicine, Dept. of Anesthesiology, Morgantown, WV
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Title Annotation:Scientific Article
Author:Ranier, George; Costello, Kevin
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Sep 1, 2013
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