Perioperative medical management of patients undergoing transsphenoidal pituitary surgery may represent a challenge and can require expert overall knowledge.1–3  The autonomous feeding and the oral assumption of drugs is not possible in the immediate postoperative period. Accordingly, an adequate correction of water imbalance and food deficit could be achieved by feeding via gastric probe.

Here, we present an image, from reconstructed tridimensional computed tomography scans, which shows a disastrous misadventure during postoperative management in a patient with neuroophthalmologic disorder. A 50-yr-old Caucasian woman was admitted to the hospital for visual impairment, headache, and vertigo. Examination disclosed a pituitary adenoma, and the transsphenoidal adenectomy was performed. Postoperatively, based on a gradual worsening of general status, the patient was transferred to the intensive care unit. During the night, at the shift change, a nasogastric tube was placed by a clinician who was not aware of the surgery performed.

The patient developed hemodynamic collapse and imaging demonstrated intracranial positioning of the nasogastric tube. The cause of death was considered to be pituitary apoplexy secondary to incorrect placement of the nasogastric tube.

In general, although nasal placement of gastric or tracheal tubes is considered a safe medical procedure, clinicians should consider the (very rare) risk associated with its practice.

Consequently, it is of crucial importance to evaluate the use of guidance systems (imaging or endoscopy) to verify the correct position of the tube during its insertion in these circumstances.

Acknowledgments

The authors would like to thank Ernesto d’Aloja, M.D., Ph.D., Maurizio Fossarello, M.D., and Gabriele Finco, M.D., of the University of Cagliari, Cagliari, Italy, for their help in critical manuscript revision.

Competing Interests

The authors declare no competing interests.

References

1.
Nemergut
EC
,
Dumont
AS
,
Barry
UT
,
Laws
ER
:
Perioperative management of patients undergoing transsphenoidal pituitary surgery.
Anesth Analg
2005
;
101
:
1170
81
2.
Ausiello
JC
,
Bruce
JN
,
Freda
PU
:
Postoperative assessment of the patient after transsphenoidal pituitary surgery.
Pituitary
2008
;
11
:
391
401
3.
Johnstone
JC
,
Leung
JS
,
Friedman
JN
:
Nasogastric tube misadventures.
Clin Pediatr (Phila)
2011
;
50
:
983
6