Corresponding author: Tümay Umuroğlu Address: Kalfa Çeşme sok. Validebag sitesi 7/ 5 Üsküdar- Istanbul / TURKEY 81020
Tel: +90 216 325 4356 Fax: +90 216 339 9989 e-mail address: tans6@ hotmail.com
Marmara Medical Journal 2004;17(2);78-80
CASE REPORTS
MISPLACEMENT OF A NASOGASTRIC TUBE INTO THE
POSTPNEUMONECTOMY SPACE
Tümay Umuroğlu, İ. Varlık Doğan, Abdurrahman Yaycı
Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
ABSTRACT
Nasogastric tubes cause complications related to traumatic insertion. We reported a case of misplacement of a nasogastric tube into the postpneumonectomy space. A sixty-three-year old male patient was admitted to intensive care unit with the diagnosis of broncho and esophagopleural fistula 3 months after a pneumonectomy. A nasogastric tube had to be inserted immediately for the maintenance therapy of atrial fibrillation by the enteral route, by listening to the sound of air over the abdomen to minimize the risk of misplacement, but gastroscopy revealed that it was in the postpneumonectomy space. We concluded that it is important to verify the exact place of a nasogastric tube radiologically in patients with undiagnosed esophageal pathologies.
Keywords: Post-pneumonectomy, Nasogastric misplacement
NAZOGASTRİK SONDANIN POSTPNÖMONEKTOMİ ARALIĞINA
YANLIŞ YERLEŞİMİ
ÖZET
Nazogastrik sondaların travmatik olarak takılmaları sonrasında komplikasyonlar gelişebilmektedir. Burada postpnömonektomi bölgesine yanlışlıkla yerleştirilen bir vakayı tartıştık. Hasta pnömonektomi operasyonu geçirdikten 3 ay sonra bronko ve özofageal fistül tanısıyla yoğun bakım ünitesine kabul edildi. Atrial fibrilasyon tedavisinin idamesini sağlayabilmek amacıyla acil olarak nazogastrik sonda takılması planlandı. Sondanın yanlış yere yönlenmesini önlemek amacıyla batın duvarından sonda ucundan verilen hava sesi steteskop aracılığıyla dinlendi. Ancak daha sonra uygulanan gastroskopide nazogastrik sondanın postpnömonektomi bölgesine ilerlemiş olduğu saptandı. Sonuç olarak, bilinmeyen özofageal patolojisi bulunan hastalarda, nazogastrik sondaların yerlerinin doğruluğunun radyolojik olarak saptanmasının gerekli olduğu sonucuna vardık.
Anahtar Kelimeler: Postpnömonektomi, yanlış yerleşimli nazogastrik sonda
INTRODUCTION
Nasogastric tubes (NG) are commonly used for stomach lavage, stomach decompression, administration of oral medications and enteral
nutrition in critically ill patients 1, however they
may lead to many complications such as pulmonary or intracranial intubation, esophageal
perforation and pneumothorax 2-5. We report a
case of an unusual placement of a nasogastric tube into the postpneumonectomy space in the absence of trauma.
CASE REPORT
A 63-year-old man with hypertension and coronary artery disease was admitted to the
intensive care unit with hypotension (50/30 mmHg), hyperventilation (respiratory rate: 24/min), tachycardia (160/min) and hypothermia(35 C axillary). 10 months previously he had been diagnosed with lung squamous cell carcinoma and a right lower lobectomy was performed. 7 months later, he underwent right pneumonectomy for a recurrence. On admission, his arterial blood gases, obtained while breathing 5L/min oxygen with a face mask,were as pH 7.40, PaO2 67.2mmHg, PaCO2 38mmHg, HCO3 23.1mmol/L, BE –1.3 and SaO2 93%. The electrocardiogram showed an atrial fibrillation with a rate of 160/min. A chest radiograph indicated fluid collection on the right side, clear
Marmara Medical Journal 2004;17(21);78-80 Tümay Umuroğlu, et al.
Misplacement of a nasogastric tube into the postpneumonectomy space left lung field and a normal-sized heart, consistent with the diagnosis of bronchopleural fistula. A
right chest tube was inserted for the drainage of fluid. After fluid resuscitation, 15µg/kg/min
dopamine hydrochloride infusion, piperacillin/ tazobactam and aminoglycoside were administered to the patient. Digitalization was performed but a sinus rhythm was obtained only after administration of 10mg metoprolol tartarate, i.v. An echocardiogram showed normal left ventricular function. The patient’s hypoxemia improved after administration of 8L/min oxygen with a face mask. Blood cultures obtained on admission were positive for group F streptococcus and thoracal drainage fluid culture was positive for E. Coli. Antibiotic therapy was continued.
On the 10th hour after admission, the patient’s
hemodynamic status improved, dopamin hydrochloride infusion was discontinued and he was allowed to take oral nutrition. After 26 hours, with a total oral intake of 3075cc, gastric contents were observed in the thoracic drainage tube. Esophagopleural fistula was suspected. Oral nutrition was discontinued.
On the 3rd day after admission, the patient again
had atrial fibrillation with a rate of 156/min. 15mg diltizem i.v. bolus followed by 10mg/h infusion and magnesium replacement were ineffective. Subsequent i.v. bolus of 10mg metoprolol tartarate resolved atrial fibrillation and the heart rate decreased to 80/min. Since administration of a ß-blocker infusion is inappropriate for maintenance therapy, a nasogastric tube had to be inserted in order to give it enterally. A 16 French polyvinylchloride nasogastric tube was inserted, listening to the sound of air over the abdomen as well as to the right hemithorax, keeping in mind the possibility of tube misplacement into postpneumonectomy space. Air was heard strongly over the epigastrium but weakly over the hemithorax and since drainage material from the tube looked like a gastric juice, the tube was accepted as properly placed. Metoprolol tartarate 50mg four times daily was started orally. The patient again had tachycardic attacks only resolved with the administration of propafenon hydrochloride 150mg i.v. Propafenon hydrochloride tablet 150mg three times daily was administered from NG tube but tachycardial episodes continued. Endoscopy revealed a 5x6 cm
fistula on the wall of the esophagus at 28thcm, a
tumor at 23rdcm from mouth, and it was observed
that the nasogastric tube was installed in postpneumonectomy space through this fistula. It was removed. The patient was accepted to be inoperative. Application of a stent to esofageal
fistula was unsuccesful because of the fragile wall of the esophagus. Gastrostomy was performed, atrial fibrillation was controlled and he was
discharged on the 15thday after admission.
DISCUSSION
Gastrointestinal access for critically ill patients is mandatory for administration of oral medications, enteral nutrition, gastric decompression and
lavage 1. Nasogastric and nasoduodenal tube
placements are the most common preferred accesses. Nasogastric tube placement is an easy and simple method. Hearing the sound of air injected into the tube over epigastrium and demonstration of gastrointestinal contents in
syringe aspirate are methods to verify its place 6.
It does not require radiographic confirmation. Nasoduodenal tube is made of radiopaque material and has the advantage of radiologic confirmation for proper placement but it is an
expensive and time consuming procedure 7.
Besides the incidence of tube displacement increases with the use age of small-bore
nasoduodenal tubes 8,9. We used a large-bore
nasogastric tube in order to minimize this risk, however, the defect on the esophageal wall was big enough to cause misplacement.
There are many complications related to nasogastric placement, such as bleeding, intracranial intubation, pneumothorax and
esophageal perforation 2-5. Review of the relevant
literature suggests that trauma is usually the
predisposing factor in such complications 5,10. In
our case report, we discussed an unusual misplacement of a nasogastric tube to postpneumonectomy space through a pathological defect in the esophageal wall in the absence of trauma. Although we knew that there was an esophagopleural fistula, placement of a nasogastric tube was vital for the administration of oral medication for the maintenance treatment of atrial fibrillation. To minimize the possibility of inserting the nasogastric tube into postpneumonectomy space, we listened to the sound of air over the whole right hemithorax as well as the epigastrium. Although the tube was placed in postpneumonectomy space, the sound was less pronounced over the right hemithorax than over the upper abdomen. The reason for that could be the thicker thoracic wall or the leak of air from the thoracic drainage tube. The presence of gastric juice in the nasogastric tube may be the
Marmara Medical Journal 2004;17(21);78-80 Tümay Umuroğlu, et al.
Misplacement of a nasogastric tube into the postpneumonectomy space result of the back flow of gastric contents into the thoracal cavity through the fistula located very close to the esophagogastric opening. It was not a surprise that atrial fibrillation was uncontrollable, despite many medical interventions as the drugs administered were into the postpneumonectomy space and had drained from the existant thoracic tube without being absorbed.
It is suggested that in high risk patients a nasogastric tube should only be inserted under direct vision and a subsequent X-ray is mandatory for confirming proper positioning 8.
Regarding our case report, we concluded that it is important to verify the exact place of a nasogastric tube either radiologically or fluoroscopically with an injection of a contrast dye, in patients with undiagnosed esophageal pathologies; or insertion of radiopaque tubes may be an appropriate approach to prevent the complications due to misplacements.
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