Adel Ghuloom, MD
Ehsan A Haider, MBCH
Seventy year old female known to have hypertension and Diabetes Mellitus was seen in Accident and Emergency for sudden onset of abdominal pain. A perforated peptic ulcer was confirmed by computed tomography (CT).
The patient was operated for closure of the perforation, after which she was admitted to the ICU. A nasogastric tube was inserted for enteral feeding . Her general condition improved and she was transferred to a general ward.
In the general ward the patient became progressively dyspnoeic & on ascultation of her chest coarse crepitations mainly on the right side were detected . The patient was re-intubated and transferred again to ICU where a chest X-ray was taken.
Q1. What is the cause of deterioration of her condition?
Q2. How can you prevent such condition?
Answers to Medical Quiz
The feeding nasogastric tube was reinserted by the nurse at the bedside in the general ward,the position was only checked by auscultation test. However the tube has in fact been inadvertently introduced into the trachea and then forced into the right main bronchus. The patient was continuously fed through the nasogastric tube, which explains the deterioration in the patient’s condition.
The bedside auscultation test is not an accurate or reliable test in detecting the position of feeding nasogastric tube and even it can be misleading as in this patient1. However chest radiography can accurately detect nasogastric tube position and may prevent such complication2.
The signs and symptoms of the feeding nasogastric malpositioning in intensive care patients may be absent or misleading2, but a routine chest examination including chest x-ray can instantly detected such malpositioning of the nasogastric tube1. Feeding should not be started before nasogastric has been confirmed in position.
Finally this case supports the policy of obtaining routine chest radiographs in ICU patients, which is cost effective3.
REFERENCES
1. Lie JT. On the positioning (or mal positioning)
of a Nasogastric tube.
Am J Med 1988;85:282.
2. Bankier AA, Wiesmayr MN, et al. Radiographic
detection of
intrabroncial malpositions
of Nasogastric tube and subsequent
complication in intensive
care unit patients. Intensive care med
1997;23:406-10.
3. Brainsky A, Fletcher RH, et al. Routine portable
chest radiographs in
the medical intensive care
unit: effects and cost. Crit Care Med
1997;25:801-5.
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* Consultant
Intensive Care Unit
** Resident
Radiology Department
Salmaniya Medical Complex
State of Bahrain
