Pneumothorax from intrapleural placement of a nasogastric tube.

Nasogastric tube insertion is a commonly performed procedure that can be associated with significant morbidity and even mortality. There is no universally accepted technique to confirm correct placement. Most confirmatory methods are performed after placement, therefore misplacement and potential complications may have already occurred. We report a case where a commonly used bedside confirmatory test gave false reassurance that the nasogastric tube was properly positioned, but a plain chest X-ray revealed a massive pneumothorax due to inadvertent intrapleural placement of the tube. Due to the deficiencies of traditional confirmatory bedside techniques, and the limitations of modern and more sophisticated confirmatory methods, the plain chest X-ray remains the gold standard test to confirm correct nasogastric tube placement. We appraise the methods commonly employed to confirm nasogastric tube placement, and discuss factors that may increase the risk of misplacement.

Role of chest radiography after the insertion of a subclavian vein catheter for ambulatory chemotherapy.

OBJECTIVE: To determine the need for routine chest radiography after the insertion of a catheter via the subclavian vein for ambulatory chemotherapy. METHODS: The case notes of all patients who had undergone catheter insertion between 1994 and 1998 were reviewed retrospectively. RESULTS: Of 3844 cases, there were 52 (1.4%) complications detected on chest radiographs after catheter insertion, 46 of which were pneumothoraces; 15 of the 46 patients had a clinical risk factor at insertion (technical difficulty or symptoms), and 14 had a risk factor after insertion (respiratory symptoms and signs). For 22 (47.8%) pneumothoraces, there was no clinical risk factor identified; 3 of these patients required intercostal drain insertion. Other complications (n = 6) included catheter malposition and kinking, and chest radiography made an important contribution to management in at least 1 of these cases. CONCLUSION: In approximately 0.1% of cases of catheter insertion in the subclavian vein, chest radiography detected a clinically occult complication significant enough to require intervention.

Percutaneous insertion of Hickman-type catheters.

Hickman lines may be used for long-term venous access in patients having chemotherapy, bone marrow transplantation, parenteral nutrition, or in others needing prolonged venous access. This article describes the technique of percutaneous insertion, some of the problems that may be encountered at insertion, and ways of minimizing these problems.

Carbon dioxide versus water for cystoscopy: a comparative study.

In a prospective study of 120 patients, the cystoscopic views provided by carbon dioxide (CO2) insufflation of the bladder were compared with the views obtained during standard water cystoscopy. The clarity of vision was uniformly good during CO2 cystoscopy and in 21 patients with haematuria the views were significantly better than those obtained by standard water cystoscopy. There was no evidence of any significant absorption of CO2. This safe and simple technique would seem to have considerable advantages in the investigation of patients with haematuria.

Extradural opioids for postoperative analgesia. A double-blind comparison of pethidine, fentanyl and morphine.

Pethidine 50 mg, fentanyl 100 microgram and morphine 2 mg administered to the extradural space, were compared in the treatment of pain following surgery. All three drugs produced a rapid decrease in pain scores as assessed using a visual linear analogue, morphine being the least effective. Fentanyl had a relatively short duration of action (2 h), whereas morphine appeared to be the longest acting. It is suggested that the best relief of pain would be obtained by incremental doses given extradurally. All drugs produced an increase in sedation, but there was no respiratory depression as assessed by PaCO2 measurement.