MALPOSITIONING of nasoenteric feeding tubes frequently is described in the medical literature and includes the tracheobronchial tree, the interpleural space, perforation of the esophagus and pneumothorax, and the ensuing complications, such as mediastinitis, pneumonia, and empyema. In addition, intracerebral placement via the intact, as well as the traumatically altered, base of the skull have been reported. [4,5]We report the intravascular malpositioning of a nasogastric tube. This case report shows that an acute and potentially life-threatening situation may arise after uneventful passage of such a tube.
The patient was a 56-yr-old woman after an emergency multiple coronary bypass graft procedure. She was extubated on day 4 after surgery but had several episodes of vomiting. Because of this and because enteral feeding was to be commenced, a nasogastric tube was necessary; the nasogastric tube that had been uneventfully placed at the time of surgery had been removed accidentally.
A lubricant containing a local anesthetic was therefore instilled into the right nasal cavity. An unrefridgerated 14-French polyurethane tube without a guide wire (Sherwood, Tullamore, Ireland) was easily passed downward via the right nostril after a slight initial resistance. A 50-ml syringe was then attached to the tube, and aspiration was attempted. Immediately, the syringe filled with dark red blood. Because a major gastrointestinal hemorrhage was assumed, a rapid-sequence intubation was performed to secure the airway. Eventually, 2.1 l of blood was drained through the tube during moderate suctioning. By this time, the patient became hypotensive; therefore, suctioning was discontinued. The hemodynamic situation was restored by the rapid infusion of 2000 ml hydroxylethyl starch solution (6%), 7 U packed erythrocytes, and 3 U fresh frozen plasma.
Fiberoptic esophagogastroscopy neither revealed the source of bleeding nor the location of the nasogastric tube in the upper gastrointestinal tract. Further testing for the location of the tube included plane chest radiography with and without contrast, transthoracic echocardiography, and computed tomography. The tests revealed that the nasogastric tube had penetrated the right internal jugular vein at the height of the soft palate and passed down the superior vena cava into the right atrium. (Figure 1and Figure 2).
The nasogastric tube was removed, and the site of entry was compressed with a nasopharyngeal tamponade. This tamponade could be removed the next day without any sign of bleeding. To prevent infection, imipenem/cilastin was administered intravenously for 6 days. Nine days after the incident, the patient was transferred back to the referring hospital without any sign of infection or other untoward sequelae.
Although reports exist describing nasogastric tubes that have eroded into major vessels, to our knowledge, this is the first report of the inadvertent, direct vascular placement of a nasogastric tube. When blood returned via the tube, our first assumption was that a major gastrointestinal tract hemorrhage had occurred. Only after hypotension resulted from our continued nasogastric suctioning did we consider an alternative diagnosis, and only after radiologic studies were completed was the actual location of the tube ascertained.
Anatomic variants of the nasopharynx facilitate mal-positioning of nasogastric tubes. Our patient had a deviation of the nasal septum to the left. The tube followed the concave contour of the septum, deviating to the right, and ultimately perforating the lateral oropharyngeal wall.
Various forms of perforation of the esophagus with a nasogastric tube have been described. Passage of soft nasogastric tubes often is facilitated by the use of reinforcing wire guides or by increasing the stiffness of the tube through previous refrigeration. Because our patient was awake and cooperative, she could assist in the placement by swallowing, making the use of any of these adjuncts unnecessary. No undue force was applied during the placement of the tube.
Various ways to verify correct placement of nasogastric tubes have been described. [10,11]The most common method is insufflation of air and auscultation for gurgling sounds over the upper left quadrant of the abdomen. This method does not allow reliable differentiation between gastric and endobronchial placement. In this case, insufflation of air before aspiration most likely would have led to a lethal outcome. Therefore, we believe that aspiration through the nasogastric tube should always be attempted before the injection of air.
If correct placement of the nasogastric tube cannot be confirmed by clinical means, radiologic verification is needed. [13,14]This may occasionally be the only way to define the anatomic route and the exact location of the tip of the nasogastric tube.