Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : UC05 - UC09 Full Version

Comparison Between the Reverse Sellick’s and SORT Manoeuvres of Nasogastric Tube Insertion in Anaesthetised, Intubated, Adult Patients- A Randomised Clinical Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55297.16446
Debdeep Chakraborty, Sanjay Maitra, Jayanta Chakraborty , Mohanchandra Mandal

1. Postgraduate Student, Department of Anaesthesiology, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India. 2. Associate Professor Department of Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata ,West Bengal, India. 3. Professor, Department of Anaesthesiology, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal,India. 4. Professor, Department of Anaesthesiology, Institute of Post Graduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Mohanchandra Mandal,
House No- 57/4 B.T. Road, Kolkata, West Bengal, India.
E-mail: drmcmandal@gmail.com

Abstract

Introduction: In the perioperative period and critical care unit, nasogastric tube (NGT) placement is a simple procedure which turns in to a difficult one in anaesthetized, intubated patient. The SORT manoeuvre (a combination of Sniffing position, Orientation of nasogastric tube, Rotating the patient’s head to the contralateral side, and Twisting movements of operator’s hand) has been studied sparingly. Reverse Sellick’s manoeuvre is a commonly applied method for NGT placement where cricoid cartilage is lifted by the performer with non-dominant hand during placement of NGT.

Aim: To ascertain the success rate of SORT manoeuvre in comparison with the reverse Sellick’s manoeuvre for NGT placement in anaesthetized and intubated adults.

Materials and Methods: This single-blinded, randomised study was conducted in N.R.S. Medical College and Hospital (tertiary care centre), Kolkata, West Bengal, India, from March 2020 to August 2021. Total 102 adults patients, scheduled for abdominal surgeries under general anaesthesia with intubation, were included. The patients received NGT placement either by applying reverse Sellick’s manoeuvre (group A, n=51) or using SORT manoeuvre (group B, n=51), following a random allocation method. The number and percentage of patients having successful NGT placement within first attempt in each group was recorded. The time to perform the procedure and any incidence of adverse event were recorded. Quantitative variables were compared using Independent t-test between the two groups. Qualitative variables were compared using Chi-square test/Fisher’s exact test, as appropriate. A p-value ≤0.05 was considered statistically significant.

Results: Successful placement of NGT within single attempt was feasible in 48 patients (94.1%) using the SORT manoeuvre in contrast with 38 (74.5%) applying the reverse Sellick’s manoeuvre (p-value=0.006). Longer procedure time was observed with the SORT manoeuvre compared to the reverse Sellick’s manoeuvre (22.3±4.4 vs 20.1±3.8 seconds), respectively; p-value=0.008). Use of SORT manoeuvre in comparison with reverse Sellick’s manoeuvre resulted in apparently lower incidence of adverse events (Coiling 1.96% vs 19.6%; Kinking 1.96% vs 3.92%, respectively); however, found statistically not significant (p-value=0.305). However, overall incidence of adverse events was considerably more in reverse Sellick’s manoeuvre compared with the SORT manoeuvre (25.5 % and 5.8%, respectively, p-value=0.006).

Conclusion: The SORT manoeuvre appears to be advantageous over the reverse Sellick’s manoeuvre for NGT placement in adult patients undergoing surgery under general anaesthesia with intubation, in terms of higher success rate and lower incidence of adverse events.

Keywords

Cricoid cartilage, Nasopharynx, Oesophagus, Pharynx, Whooshing sound

Placement of Nasogastric Tube (NGT) is an essential instrumentation for several abdominal as well as thoracic surgeries. It is as such a simple procedure and usually executed by the anaesthesiologists. However, correct placement of this tube often becomes difficult in adult patients while they are in the intubated state under general anaesthesia. The distal part of the tube having several holes in the wall, is vulnerable to kink, coil or form a knot, mostly in the pharynx or oesophagus when it faces slight resistance during its natural path (1). Conventional method of NGT placement is placement of the tube blindly through the nasal route, keeping the position of the head as neutral- i.e., neither flexed nor extended. with the head in a neutral position without Also, external laryngeal manipulation and any change of head position are not allowed during this classic conventional method which has a failure rate of around 50% (2).

To overcome the difficulties and to increase the success rate of above-mentioned blind method, clinicians have adopted different techniques such as ‘head flexion’ (2), ‘neck flexion with lateral pressure’ (3), ‘reverse Sellick’s manoeuvre’ (anterior lifting of the cricoids cartilage) (4), or ‘frozen NGT’ methods (a silicone NGT is filled up with distilled water and subsequently freezing it) (5). All of which achieved a success rate of above 80%. Several other methods for NGT placement are mentioned in the literature [3, 6-10] The use of Glide Scope and ‘King Vision’ video laryngoscope was also found to facilitate NGT placement in lesser time (11),(12). The flood of literature with so many methods, modification of previous technique, frequent arrival of new technique i.e., all indicate that no one method is universally acceptable with high success rate and the quest for the best is still on in this arena.

The reverse Sellick’s manoeuvre was first described by Parris WC, in the year of 1989. It is the forward or anterior displacement of the cricoid cartilage using the fingers. It facilitates the insertion of NGT by opening the oesophagus more widely and its success rate is about 75-80% (4). Although a higher success rate of about 94% has been reported by other researchers (13). In the year of 2016, Najafi M introduced a novel technique for nasogastric tube insertion (14). It is the SORT manoeuvre. The word SORT is the acronym for the following steps of the manoeuvre i.e., Sniffing position, Orientation of the nasogastric tube, Rotation of the head to the contralateral side of insertion with external pressure at the pyriform fossa and at last Twisting motion of the NGT while gently pushing it into the oesophagus. The placement of NGT is facilitated by using of visual aids.

Although the technique SORT manoeuvre has been mentioned in that article, its success rate has not been assessed (14). At the time of framing the present study, no data was available regarding the success rate of this particular manoeuvre. An article depicting the manoeuvre, a case report describing its use and one review article was the only literature available at that time. Thus, a lacuna was identified in the existing literature (14),(15),(16).

Hence, the present study was designed to evaluate (to determine and compare) the success rates, procedure time for NGT insertion and incidence of adverse events (coiling, kinking and bleeding), if any, among the SORT manoeuvre and the reverse Sellick’s manoeuvre. The primary objective was comparison of the success rate of patients in whom successful nasogastric tube insertion could be possible using either the SORT manoeuvre or the reverse Sellick’s manoeuvre at a single attempt. Other outcome measures were to compare the procedure time, and the incidences of adverse events between the two groups.

Material and Methods

This randomised clinical study was conducted in the N.R.S. Medical College and Hospital, Kolkata, West Bengal, India, from March 2020 to August 2021. The Institutional Ethical Committee had approved the study (No. NMC/436, dated 27.01.2020). An informed consent was taken from every patient. They were also given the option to opt out from the study at any time.

Sample size calculation: From the literature, it was noted that the reverse Sellick’s manoeuvre had a success rate of 75% (4). It was assumed that at least 20% increase in success rate using the SORT manoeuvre (as compared with reverse Sellick’s manoeuvre) would be clinically significant. Hence, the effect size was 0.20. Setting the confidence level at 95% (α=0.05) and the power (1-β) of the study at 80%, a sample size of 46 per group was obtained. The formula of comparing two proportions as mentioned in the article of Das S et al., was followed (17). Expecting a 10% dropout, a total of 102 patients were enrolled for this study.

Total 110 patients were screened in the preanaesthesia clinic for recruitment in the current study. However, three of them did not turn up for surgery. Five patients changed their mind and refused to participate in the study. Thus, finally 102 patients were subjected for random allocation. The data from all 102 patients were available for analysis.

Inclusion criteria: All adult patients (18 years and above), scheduled for abdominal surgeries under general anaesthesia with intubation and subsequent requirement of placement of NGT were included in the study.

Exclusion criteria: Any structural abnormalities in the nasal or oropharyngeal area such as cleft palate, considerable deviated nasal septum and patients with nasal or oropharyngeal masses, patients with oesophageal stricture or other pathologies, those with considerable injuries involving the head and neck region over head or neck and those with suffering from thrombocytopaenia or coagulopathies were excluded from the study.

Procedure

Once the patient was received in the Operation Room, the preanaesthesia check-up report was verified. An intravenous access was established with an 18 G cannula. Continuous monitoring was done using Electrocardiogram (ECG), End tidal carbon dioxide (EtCO2) and SpO2 while continual monitoring was done with measurement of Non Invasive Blood Pressure (NIBP). Before induction of general anaesthesia, the optimum nostril for NGT placement was selected based on the better fogging procedure on a metal tongue depressor during exhalation. Premedication was done, as appropriate for each patient, using fentanyl (2 mcg/kg), glycopyrrolate (4 mcg/kg), and ondansetron (0.1 mg/kg). Propofol (2 mg/kg) or thiopentone (3-4 mg/kg) was the induction agent depending on the patient’s 6variables. Depolarising muscle relaxant, succinylcholine (2 mg/kg) was used for intubation by laryngoscope. Endotracheal tube of appropriate size was used depending on patient variables. Muscle relaxation was maintained with atracurium.

After induction of anaesthesia and intubation, the patients were randomly into two groups with ‘sealed envelope’ technique, to receive placement of NGT using either reverse. Reverse Sellick’s manoeuvre (group A; n=51) or using the ‘SORT’ manoeuvre (group B; n= 51). There were 102 sealed envelopes each containing a piece of paper marked with numbers ranging from 1 to 102. The envelopes were placed in a container and then reshuffled. After induction of anaesthesia, one envelope picked up at random and opened to find the number. On getting an ‘even’ number, the reverse Sellick’s manoeuvre was followed, and in case of finding an ‘odd’ number the SORT manoeuvre was used . The used envelope with the paper slip was then discarded . Thus, the issue of ‘selection bias’ was averted to some extent. The procedure of NGT placement was performed by a single anaesthesiologist who remain fully aware of the particular technique being used . Owing to the anaesthetised state, the patients remain unaware (blind) about the technique followed. Thus, the interobserver variability was minimised and the study was single-blinded (Table/Fig 1).

In both the groups, prior to NGT insertion, the cuff of the endotracheal tube was deflated and the tip of the NGT was lubricated with 2% lignocaine jelly. The length of the NGT to be inserted was determined by measuring the distance from the ipsilateral nostril to the ipsilateral tragus, and further to the xiphoid process (7). Once the NGT was successfully placed, the cuff of the endotracheal tube was re-inflated.

Confirmation of correct position of NGT was done primarily by auscultation of a ‘whooshing’ sound over epigastrium while injecting air into NGT through a 10 mL syringe. The procedure time for successful placement of NGT was recorded from the moment of insertion of NGT into nostril till the confirmation of its correct position by auscultation over epigastrium. A case was termed ‘successful’ if the NGT can be properly placed in the first attempt. Any adverse event occurring during the procedure was recorded.

Group A (reverse Sellick’s manoeuvre)

After intubation with appropriate size endotracheal tube, the patient’s head was kept in neutral position. Then anterior displacement or lifting of cricoid cartilage by using fingers of non-dominant hand of anaesthetist was done and then NGT was inserted through the patient’s nostril by the dominant hand of anaesthetist. After placement, the correct position of tube was verified by pushing 10 ml of air into the tube, and finding a ‘whoosh’ sound on auscultation. If the tube was found to be correctly placed in the ‘first attempt’, the case was taken as ‘successful’.

Group B (SORT manoeuvre)

The patient’s head was placed as ‘sniffing the morning air’ position, with the lower cervical spine flexed and atlanto-occipital joint extended. The curvature of the NGT was oriented to align with the anatomy, leading from the nose to the oesophagus. Then the patient’s head then rotated contralateral to the side of insertion and external pressure was applied at the pyriform fossa to obliterate the fossa. At last, the NGT was gently pushed into the oesophagus with a twisting motion (14). The confirmation of correct placement and consideration of ‘successful’ placement was ascertained in the same way that was done in group A.

The following study variables were noted-

• The number of cases with successful NGT placement in the first attempt
• The time taken for the procedure
• Any adverse events (coiling, kinking, bleeding) occurring during the procedure.

Statistical Analysis

The data entry was done using MS excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Categorical variables were presented as number of patients and proportion (%) and continuous variables were presented as mean ± Standard Deviation (SD). Data was found having normal distribution with the use of Kolmogorov-Smirnov test. Quantitative variables were compared using Independent t-test between the two groups. Qualitative variables were compared using Chi-square test/Fisher’s-exact test, as appropriate. A p-value of ≤ 0.05 was considered statistically significant.

Results

The demographic data were found to be comparable between the two groups (Table/Fig 2). The success rate was found considerably high using the SORT manoeuvre (Table/Fig 3). The procedure time was found considerably longer using the SORT manoeuvre (Table/Fig 4).

Considering all types of adverse events, the overall incidence of adverse events was found to be more in reverse Sellick’s manoeuvre compared with the SORT manoeuvre (25.5% and 5.8%, respectively) (Table/Fig 5). The vital parameters (heart rate and mean arterial pressure) were comparable between the groups at all time points of measurements (Table/Fig 6).

Discussion

In the present study two methods of NGT placement i.e., the SORT manoeuvre and the reverse Sellick’s manoeuvre were compared in terms of success rate, procedure time and adverse events. The present study found that the success rate for placement of NGT was higher using the SORT manoeuvre compared with the reverse Sellick’s manoeuvre (94.1% vs 74.5% respectively). At the time of framing the current study design, no data was available regarding the success rate of SORT manoeuvre. However, at the time of reporting the present study the observations of two reports have become available [18,19]. Sanaie S et al., found around 90% success rate in the first attempt using the SORT manoeuvre as compared to 17% using the ‘neck flexion with lateral presure’ technique (18). Dhakal SD et al., found 94% success rate in the first attempt using SORT maneuver in comparison with 77% using conventional blind method (19).

In the present study, time taken for placement of NGT using the SORT manoeuvre was found to be significantly higher compared with that applying reverse Sellick’s manoeuvre (about 22 seconds vs 20 seconds, respectively). Dhakal SD et al., (19) also reported longer procedure time for SORT manoeuvre in comparison with blind method, the median time 25 seconds and 22 seconds, respectively. The comparatively longer procedure time during SORT manoeuvre might be due to its four-step manipulations.

The increased success rate of SORT manoeuvre can be due to the combined effect of four separate manipulations. Placing the patient in sniffing position, the arytenoid cartilage is shifted away from oesophagus. The rotation of head to contralateral side (during SORT manoeuvre) obliterates the ipsilateral pyriform sinus. Twisting component is applied for ‘back and forth’ movement to reduce resistance during deep insertion though a collapsible structure, the oesophagus (18). Thus, the components help steering the NGT in to its intended course in a smoother way. The SORT manoeuvre tries to negotiate the NGT along the path of least resistance, thereby reducing injury.

In the present study, coiling of NGT has occurred more in reverse Sellick’s manoeuvre group compared with SORT manoeuvre group. Lifting of the cricoid cartilage with reverse Sellick’s manoeuvre not only make oesophagus more widely open but also increase the space around pyriform sinuses. The former can increase the success rate of proper NGT placement while the later may be the potential cause for impaction of NGT into the pyriform sinuses. The overall proportion of adverse events was higher in the revere Sellick’s manoeuvre group, compared with the SORT manoeuvre (25.5% vs 5.8%, respectively) considering summation of coiling, kinking and bleeding episodes in the two groups. In a recent study, the incidence of adverse events during SORT manoeuvre is reported as high as 31% (16). The difference in the incidence of adverse events between reverse Sellick’s manoeuvre and SORT manoeuvre could easily be explained due to the higher incidence of coiling in the reverse Sellick’s group. Although the SORT manoeuvre includes four-step method, the use of ‘to-and-fro’ as well as rotational movement during insertion provided a better scope for negotiation of the tube through a new passage that avoided coiling and kinking. In other words, application of undue force was strictly prohibited while performing the SORT manoeuvre. This had been emphasized repeatedly by Najafi M, the pioneer of this novel method (14). The essence of SORT manoeuvre is to minimize injury at the cost of lengthened procedure time. The use of polyurethane tubes could have reduced the mucosal injury. However, it should be kept in mind that such soft tube with increased flexibility can lead to more frequent coiling and kinking of the NGT (15), (20).

In the present study, some practical problems were faced in the SORT manoeuvre group during lateral rotation of the head. The endotracheal tube is usually fixed at the angle of mouth on right side. The problem arises if the clinician chooses to insert the NGT through the right nostril. When there is a need for rotation of the head towards left (contralateral rotation of head, a part of SORT manoeuvre), the movement become cumbersome with the fixed endotracheal tube along with the attached ventilator circuit. Extra care is warranted to ensure maintaining proper position of the endotracheal tube, keeping in mind about the significant dragging of the endotracheal tub. Since, the cuff of the endotracheal tube was deflated prior to insertion there is a risk of extubation at this stage while contralateral rotation of head is performed. During this lateral rotation of head, the endotracheal tube and the ventilator circuit hanging in front can also create a hindrance to the path of vision while performing NGT placement. This may be solved by keeping the endotracheal tube detached from the ventilator circuit during NGT insertion. The detachment of endotracheal tube from the circuit may not safe for frail patients as the procedure time may vary at times even for this simple procedure.

The auscultation method for confirmation of proper placement of NGT may not differentiate from artifacts such as the transmitted sound from lungs, oesophagus, duodenum or proximal jejunum in case of improper placement (21),(22),(23). X-ray is considered as the golden test for confirmation of proper placement of NGT (22), (24). The use of pH paper for detection of gastric secretion, combination of pH testing along with the use of biochemical markers such as bilirubin, trypsin and pepsin, and electromagnetic tracing (25),(26). All might be useful for confirmation of NGT position. Colorimetric CO2 detection and capnography is useful to detect improper placement of NGT in the lungs (27).

Limitation(s)

In the present study the confirmation of NGT placement was done by detecting a ‘whoose’ sound at epigastrium on auscultation while pushing 10 mL of air rapidly through NGT. This is simply for logistic reason. This auscultation method is simple and can be done easily at bedside without any advanced gadget. The radiological confirmation of NGT tip location was not possible in the operation theatre set up on regular basis. Also, the polyurethane made NGT could not be used owing to local unavailability due to logistic reasons.

Conclusion

To conclude, a considerable higher success rate for nasogastric tube placement can be achieved using the SORT manoeuvre as compared with the reverse Sellick’s manoeuvre in adult anaesthetised patients in the operation theatre set up. The procedure time appears to be longer using SORT manoeuvre. The incidence of adverse events is found to be lesser during SORT manoeuvre for insertion. The overall benefits to the patients may be considered greater with SORT manoeuvre in comparison with reverse Sellick’s manoeuvre. The SORT manoeuvre can be a better alternative to reverse Sellick’s manoeuvre for nasogastric tube placement in anaesthetised, intubated adult patients.

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DOI and Others

DOI: 10.7860/JCDR/2022/55297.16446

Date of Submission: Jan 29, 2022
Date of Peer Review: Feb 28, 2022
Date of Acceptance: Mar 09, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 02, 2022
• Manual Googling: Mar 08, 2022
• iThenticate Software: May 11, 2022 (22%)

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