Nasogastric Intubation as Health and Safety Risk in Equine Practice—A Questionnaire

Placing a nasogastric tube can be a life-saving act for a horse but is considered an occupational hazard for veterinarians. An online questionnaire was performed to assess and specify potential risks. 123 equine veterinarians completed the survey, and the majority admitted using the mouth to handle the end of the nasogastric tube (sucking or blowing air) and having accidentally swallowed or aspirated stomach content or medications. This can potentially lead to aspiration pneumonia or pneumonitis. Mineral oil seems to be especially dangerous as aspiration may be asymptomatic at the beginning and lipoid pneumonitis may develop. Furthermore, 60% of responders would also handle the tube with their mouth if the horse was presented with fever and diarrhea or reflux formation, which might be affected by Salmonella sp. or Clostridium difficile producing toxins. The fact that nasogastric tubes are rarely being disinfected increases the risk of infection. 50% of veterinarians would use their mouth to suck or blow air into the tube during nasogastric intubation, even if the patient was presented with suspected poisoning. Rodenticide zinc phosphide is particularly dangerous as its breakdown product is a highly toxic gas. Inhalation leads to serious symptoms in humans, including pulmonary edema and neurological signs. Alternatives to mouth use (lavage, big syringe, or suction pump) when passing a tube should be considered, especially if a patient is presented with duodenitis—proximal jejunitis, diarrhea, or suspected poisoning. Awareness needs to be raised among veterinarians that nasogastric intubation is an extremely hazardous occupational practice.     

Post‐anesthetic pulmonary edema in two horses

Case 1 A two‐year old, 462 kg Standard bred horse was anesthetized for arthroscopy and castration. During anesthesia, hyperemia of the mucosal membranes and urticaria were noticed. During 5 hours of anesthesia subcutaneous edema of the eyelids and neck region developed. In the recovery box, the orotracheal (OT) tube was left in situ and secured in place with tape. Following initial attempts to stand, the horse became highly agitated and signs consistent with pulmonary edema developed subsequently. Arterial hypoxemia (PaO₂: 3.7 kPa [28 mmHg]) and hypocapnia (PaCO₂: 3.1 kPa [23 mmHg]) were confirmed. Oxygen and furosemide were administered. The horse was assisted to standing with a sling. Therapy continued with bilateral intra‐nasal oxygen insufflation. Ancillary medical therapy included flunixin meglumine, penicillin, gentamycin and dimethylsulfoxide. Following 7 hours of treatment the arterial oxygen tensions began to increase towards normal values. Case 2 An 11‐year old, 528 kg Paint horse was anesthetized for surgery of a submandibular mass. The 4‐hour anesthetic period was unremarkable. The OT tube was left in situ for the recovery. During recovery, the horse was slightly agitated and stood after three attempts. Clinical signs consistent with pulmonary edema and arterial hypoxemia (PaO₂: 5 kPa [37.5 mmHg]) subsequently developed following extubation. Respiratory signs resolved with medical therapy, including unilateral nasal oxygen insufflation, furosemide, flunixin meglumine and dimethylsulfoxide. The diagnosis of pulmonary edema in these horses was made by clinical signs and arterial blood‐gas analysis. While pulmonary radiographs were not taken to confirm the diagnosis, the clinical signs following anesthesia support the diagnosis in both cases. The etiology of pulmonary edema was most likely multifactorial.     

Removal of a nasogastric tube fragment from the stomach of a standing horse

An 82-cm fragment of nasogastric tube was removed from the stomach of an adult horse under standing sedation by use of an endoscope and electrocautery snare. This is the first report of successful non-surgical removal of a nasogastric tube fragment from the stomach of a horse.     

Effect of an indwelling nasogastric tube on gastric emptying rates of liquids in horses

OBJECTIVE: To evaluate the effect of an indwelling nasogastric tube on gastric emptying of liquids in horses. ANIMALS: 9 healthy adult horses. PROCEDURE: A randomized block crossover design was used. For treatment group horses, a nasogastric tube was placed and 18 hours later, acetaminophen was administered; the nasogastric tube remained in place until the experiment was complete. For control group horses, a nasogastric tube was passed into t stomach, acetaminophen was administered, and the nasogastric tube was removed immediately. Serial blood samples were collected 15 minutes before and after administration of acetaminophen. Serum concentration of acetaminophen was determined by use of fluorescence polarization immunoassay. The variables, time to maximum acetaminophen concentration (Tmax) and the appearance constant for acetaminophen (Kapp), were determined. The values for Kapp and Tmax in horses with and without prolonged nasogastric tube placement were compared. RESULTS: No significant difference was found in Kapp between horses with and without prolonged nasogastric tube placement; the median difference in Kapp was 0.01 min(-1) (range, -0.48 to 0.80 min(-1). No significant difference was found in Tmax between horses with and without prolonged nasogastric tube placement; the median difference in Tmax was 5 minutes (range, -30 to 50 minutes). Reanalysis of data following the removal of possible outlier values from 1 horse resulted in a significant difference in Tmax between horses with and without prolonged nasogastric tube placement. CONCLUSIONS AND CLINICAL RELEVANCE: Although no clinically important impact of 18 hours of nasogastric intubation was found on gastric emptying in healthy was found among horses.     

Complications associated with the use of the cuffless endotracheal tube in the horse

Complications following the use of the cuffless large animal endotracheal tube during general anesthesia in 2 horses are reported. One horse developed laryngeal edema during recovery. The edema was treated successfully with dexamethasone, but severe laryngeal trauma was confirmed 24 hours later at necropsy. The second horse had a swollen tongue and had difficulty eating for 3 days after anesthesia. The condition resolved without treatment. this report is a reminder of the potential damage which can occur from endotracheal intubation.     

Use of a hydro-pool system to recover horses after general anesthesia: 60 cases

OBJECTIVE: To report complications observed using a hydro-pool recovery system after general anesthesia in horses. STUDY DESIGN: Retrospective study. ANIMALS: Sixty horses. METHODS: Retrospective review of the medical records and quality of recovery from anesthesia of 60 horses that had surgical or diagnostic procedures under general anesthesia. RESULTS: Mean total anesthesia time was 182 minutes (range, 25 to 390 minutes). Mean time in the hydro-pool was 108 minutes (range, 20 to 270 minutes). One horse that had bilateral rear limb extensor weakness while recovering in a padded recovery stall was moved to the hydro-pool and maintained for 12 hours. Ten horses developed some pulmonary edema; in 3 horses, the signs of pulmonary edema were severe; and 1 horse died from related complications. One horse developed septic arthritis of an operated stifle joint, and 2 horses developed incisional infections. Two horses incurred multiple skin abrasions on the distal aspect of their limbs during violent attempts to leave the pool. CONCLUSIONS: A hydro-pool system was useful for recovering horses from general anesthesia when difficult recoveries were anticipated because of the horse's injury, size, demeanor, duration of anesthesia, or risk of further injury. Recovery using the hydro-pool was more time and labor intensive than a standard stall recovery. Pulmonary edema that required treatment was a serious complication that occurred in 17% of the horses. Careful closure of the skin with cyanoacrylate glue and pressure from bandages were used to prevent postoperative incisional infections. CLINICAL RELEVANCE: A hydro-pool system is a useful method for recovering horses from general anesthesia when difficult recoveries are anticipated.     

Removal of a fragmented nasogastric tube from the transverse colon of a horse undergoing exploratory celiotomy for colic

This report describes the clinical course and surgical findings of a 5-year-old Warmblood gelding referred for colic with a previous history of intermittent colic episodes, and gastric ulcers diagnosed by gastroscopy in the preceding months. The horse underwent medical treatment but remained painful and surgery was elected. The horse underwent an exploratory laparotomy during which an impaction was identified in the transverse colon that was associated with an approximately 1 metre segment of nasogastric tube. The foreign body was removed via an enterotomy in the left dorsal colon, and the horse recovered well from surgery. No complications were encountered post-operatively.     

Suspected air embolism associated with post-anesthetic pulmonary edema and neurologic sequelae in a horse

A 523 kg Quarter Horse was anesthetized for unilateral eye enucleation. The anesthetic period was unremarkable. During anesthetic recovery the cap on the jugular venous catheter became dislodged. Clinical signs of pulmonary edema associated with moderate arterial hypoxemia subsequently developed. Although pulmonary edema resolved with medical therapy, the day following anesthetic recovery, clinical signs of vestibular disease and blindness developed. Treatment included nasal oxygen insufflation, flunixin meglumine, furosemide, dexamethasone, thiamine, dimethylsulfoxide, antimicrobials, and phenylbutazone. The horse recovered and was discharged from the hospital after 7 days of treatment and was neurologically normal at 6 weeks. While venous air embolism was not confirmed in this case, the catheter cap complication followed by signs of pulmonary edema and neurologic sequelae support the presumptive pathogenesis of this horse's complications. Diagnostic confirmation of air embolism in horses with compatible acute clinical signs should be documented with echocardiography.     

Aspiration pneumonitis (Mendelson's syndrome) as perianaesthetic complication occurring in two horses: A case report

No published reports on the occurrence of Mendelson's syndrome (pneumonitis caused by aspiration during anaesthesia) in horses were found in the literature. Although the peculiar anatomy of the equine stomach makes horses less prone than other species to regurgitate, gastric reflux may still occur in horses with colic under certain circumstances. The colic horses in this report had in common stomach impaction, abdominal distention and preanaesthetic placement of a nasogastric tube, which was not withdrawn prior to induction. In both cases, a significant volume of gastric reflux was noted pouring from the endotracheal tube during general anaesthesia for exploratory laparotomy. It was hypothesised that the cause of gastric reflux was the combination of increased intra-abdominal pressure and patency of the cardia, and that inhalation of gastric content occurred at induction, before tracheal intubation. Treatment, which failed to improve oxygenation, consisted of repositioning of the horses to facilitate passive drainage of gastric content from the airways, active suction through the endotracheal tubes, ventilation strategies, improvement of haemodynamics to increase the pulmonary perfusion, and administration of bronchodilators. One horse was subjected to euthanasia owing to poor prognosis. Aspiration pneumonitis should be regarded as a life-threatening, although rare, perianaesthetic complication in equine colic cases. Patency of the cardia and increased intra-abdominal pressure are possible predisposing factors. Partial or even total withdrawal of the nasogastric tube prior to anaesthetic induction and tracheal intubation performed with the horse positioned in sternal recumbency may be undertaken as preventive measures in patients at high risk of developing Mendelson's syndrome.     

Intrathoracic esophageal perforation of unknown cause in four horses

Three horses (age 17 - 23 years) were referred to the equine clinic of the University of Berne due to colic, fever, tachycardia and tachypnea. All horses showed pleural effusion. Clinical findings in 2 of the horses were highly suggestive of an intra-thoracic esophageal perforation. Severe septic pleuropneumonia without suspicion of an esophageal lesion was diagnosed in the 3rd horse. In addition, an 11 year old stallion was referred to the equine clinic for treatment of a presumptive large colon impaction. The horse was given laxatives after nasogastric intubation. Subsequent dramatic clinical deterioration and signs consistent with severe pleuropneumonia suggest that esophageal perforation had occurred when passing the nasogastric tube. All 4?horses were euthanized due to a poor prognosis. Esophageal perforation was diagnosed or confirmed post mortem in all cases. A hypertrophy of the tunica muscularis of the intra-thoracic esophagus was found in 3 of 4?horses.     

Postanesthetic Pulmonary Edema In an Arab Stallion

A six-year-old arabian stallion was admitted to The Ohio State University Veterinary Hospital for evaluation and repair of a comminuted fracture of the second phalanx. The horse developed impaired arterial oxygenation during surgey and pulmonary edema post-operatively. We postulate that impaired arterial oxygenation resulted from atelectasis of the dependent lung during annesthesia, and the pulmonary edema occurred following re-expansion of the atelectatic of the initiating cause of the edema, removal of excess lung water from the alveoli, and restoration of normal arterial oxygenation. The horse was fully recovered within 12 hours of initiation of clinical signs of respiratory compromise. The horse was fully recovered within 12 hours of initiation of clinical signs of respiratory compromise. This report describes re-expansion pulmonary edema due to reperfusion injury in a horse, treatment of the condition, and a possible explanation of the pathogenesis of this pulmonary pathology.     

Removal of nasogastric tube fragments from three horses.

Three horses were admitted for retrieval of polyurethane nasogastric tube fragments. The fragments were removed from the esophagus or stomach of 2 horses by manipulation of a snare introduced through the biopsy port of an endoscope. The fragments were surgically removed from the stomach of the third horse.     

Successful conversion of equine atrial fibrillation using oral flecainide

Atrial fibrillation is the most common arrhythmia affecting performance in horses. Conversion to sinus rhythm carries a good prognosis if no significant underlying cardiac disease is present and horses commonly return to performance at the previous level or above. The drug most commonly used to convert equine atrial fibrillation is quinidine. However, quinidine has the potential for a number of adverse effects including colic, nasal mucosal edema, dyspnea and laminitis. Quinidine also requires administration through a nasogastric tube, as the drug is very bitter and acidic and may cause oral ulcerations if administered PO. Flecainide is an antiarrhythmic agent of Singh-Vaughan Williams class Ic, whereas quinidine belongs to class Ia. Intravenously administered flecainide has been reported to be a safe and effective drug for treatment of induced atrial fibrillation in the horse, with fewer adverse effects compared to quinidine, but has been less effective when administered to horses with naturally occurring atrial fibrillation. The pharmacokinetics of oral flecainide and the oral dosage required to treat equine atrial fibrillation have been determined. To the authors' knowledge, there are no reports describing treatment of equine atrial fibrillation with oral flecainide. This report describes the successful conversion of naturally occurring atrial fibrillation, by means of oral flecainide, in a horse.     

Use of a carbonated beverage to disintegrate a phytobezoar obstructing the intrathoracic portion of the oesophagus of a horse

This report describes the treatment of a 17-year-old American Quarter Horse gelding for an oesophageal obstruction of approximately 24 h’ duration. An intraluminal oesophageal mass resembling a phytobezoar and located close to the cardia, was observed during endoscopic examination of the oesophagus of a horse showing signs of oesophageal obstruction. An intrathoracic oesophageal diverticulum, filled with fluid, was observed about 40 cm proximal to the obstruction. The end of a nasogastric tube was guided beyond the diverticulum, using gastroscopic observation, so that its tip rested close to the obstruction. The obstruction failed to disintegrate or move into the stomach despite vigorous, prolonged lavage. With the nasogastric tube left in place, and the horse's head elevated, 0.5 L cola was administered adjacent to the obstruction through the nasogastric tube. The head was maintained in the elevated position for an hour, after which time the head was lowered and oesophageal lavage resumed. The nasogastric tube was passed into the stomach within 3 min of re-instituting lavage. The successful use of a carbonated beverage to treat human patients for oesophageal or gastrointestinal obstruction caused by a phytobezoar is well documented. Carbonated beverages have also been reported to be effective in treating horses for gastric and enteric impactions caused by persimmon seeds. Administering cola into the oesophagus may help resolve oesophageal obstruction of horses caused by a phytobezoar or impacted feed material when horses are refractory to other treatments.     

Abdominal Crisis in the Horse: A Comparison of Pre-Surgical Evaluation With Surgical Findings and Results

The results of preoperative examination, surgical intervention and the outcome of 50 cases of acute abdominal crisis in the horse are presented. Pre-surgical parameters discussed in this correlative study include duration of the condition prior to sergery, pulse rate, packed cell volume (PCV), abdominal distention, intestinal motility and tympany, rectal findings, reflux of fluid after passage of a nasogastric tube, and abdominal paracentesis. A retrospective study was performed to evaluate the usefulness of each clinical parameter in deciding that a case was surgical, arriving at a specific pre-surgical diagnosis, and in giving a prognosis. Rectal examination was the single most useful diagnostic tool. Reflux of gastric fluid through the nasogastric tube usually indicated obstruction of the small intestine.     

Broken nasotracheal tube aspiration in a horse during anaesthetic recovery

A horse was presented for soft palate thermocautery and surgical advancement of the larynx under general anaesthesia, following a history of respiratory noise and poor athletic performance. Physical examination prior to surgery was unremarkable. The horse was anaesthetised and a 20 mm cuffed endotracheal tube (ETT) used to intubate the trachea via the right nostril. The cuff was deflated at the end of the procedure and the tube secured in place around the head of the horse for the recovery. The horse was assisted to standing and during this process the end of the nasotracheal tube broke and was observed hanging from the head collar. The remainder of the tube was aspirated into the trachea of the horse. The remaining length of endotracheal tube was removed using a modified endoscopic technique. The horse recovered with no further problems. An unusual complication of a nasotracheal tube left in situ for recovery in a horse is reported and possible reasons for this complication are discussed.     

Fragments of nasogastric tubes as esophageal foreign bodies in two horses

Two horses were referred with fragments of nasogastric tubes as esophageal foreign bodies. Radiography and endoscopy were used to identify the location of the fragments. Portions of the tubes were retrieved by esophagotomy in 1 horse and by manual examination of the oral cavity in the other. Both tubes were friable in focal areas, but were quite pliable over most of the length of the tube.     

The duodenum: An uncommon site of surgical lesions

It is fortunate for the horse that duodenal lesions requiring surgical correction occur infrequently. Despite being an uncommon site of obstruction, palpation of the duodenum should be part of a complete surgical abdominal exploration. Horses with proximal obstruction typically have large volumes of reflux following passage of a nasogastric tube. Biochemistry abnormalities may include hypochloraemia and hyperglycaemia particularly with a complete or strangulating obstruction. Early surgical treatment of a duodenal volvulus may result in a favourable outcome.     

Complications of nasogastric intubation in horses: nine cases (1987-1989).

Pharyngeal or esophageal trauma was diagnosed in 9 horses after nasogastric intubation. Evidence of trauma (edema or ulceration) was detected in the pharynx of 3 horses and in the esophagus of 6 horses. Complications associated with nasogastric intubation were first observed in 5 horses while they were intubated and in 4 horses after extubation. Clinical signs of pharyngeal or esophageal trauma were similar, and included salivation, bruxism, coughing, and nasal discharge. Treatment, including extubation, enteral feeding through a small nasogastric tube, or esophagostomy distal to the affected site, was attempted in 6 horses. Three of 6 treated horses survived, but 4 of 5 horses with perforated esophagus were euthanatized.     

Diagnostic radiology and nuclear cardiology. Their use in assessment of equine cardiovascular disease

Survey thoracic radiography, although limited by physical considerations in the adult horse, can supply clinically useful information about changes in cardiac size and function. The radiographic features of cardiomegaly, altered pulmonary circulation, pulmonary edema, and pleural effusion as manifested in the horse are discussed. Nuclear cardiology can be performed in the standing horse. The initial transit of a radioactive tracer through the central circulation provides information about cardiac chamber size, efficiency of ventricular contraction, valvular competence, and presence of intracardiac or extracardiac shunts. Computer analysis of similar studies allows quantitation of several useful cardiac parameters including ventricular ejection fraction and shunt size (QP/QS). Gated blood pool nuclear studies are better suited to evaluate cardiac response to stress but are difficult to perform in the conscious horse with standard imaging equipment.