Wandering Nasogastric Tube

nasogastric tube misplacement

After a road traffic accident, doctors inserted a nasogastric tube in a 33-year-old male patient. However, the NG tube entered the pleural space despite a conventional verification of correct placement!

A 33-year-old male patient presented to the emergency department after a road traffic accident. On presentation, he had a dilated pupil and a C2 spine fracture which subsequently led to paraplegia. Moreover, he had localized pain on his right upper extremity with an extension on his left upper extremity. He required intensive care unit admission and nasogastric tube placement.

In the ICU, the doctors intubated the patient as he required mechanical ventilation. His Glasgow coma scale (GCS) was 7. The doctors also passed a nasogastric tube uneventfully. His physical examination was normal. Moreover, the serological investigations were also normal.

On the 30th day of hospital admission, his nasogastric tube was changed. There are several ways of confirming the position of the NG tube after insertion. These include clinical observation for signs of respiratory problems, auscultating for gurgling sound while insufflating air, aspiration of gastric content from the tube, chest X-ray, ultrasonography, etc.

In this patient, they confirmed the placement clinically by auscultating for a gurgling-like sound upon air insufflation. 50 mL of air was insufflated and a low gurgling-like sound was heard over the epigastric region by auscultation.

Moreover, the patient had no respiratory problem during NGT insertion.

However, on the 1st day of NG tube insertion, respiratory sounds decreased on the right hemithorax. Additionally, his tidal volume decreased and airway pressures increased.

Immediate chest radiography revealed that the tip of the NG tube was lying in the right pleural space. CXR confirmed the diagnosis of right-sided pneumothorax.

The doctors inserted a chest tube on the right side.

During serial follow-ups, the pneumothorax gradually resolved.

Although, nasogastric tube insertion is a simple procedure, there are chances of its misplacements. The risk increases in unconscious patients. Other risk factors include supine position, absent gag reflex, trauma, pre-existing lung disease, agitated patients, and mechanical ventilated patients.

The conventional clinical signs to verify tube placement include the absence of respiratory distress, auscultation while insufflation, and aspiration of gastric contents. However, most misplacements remain undetected despite using these methods accurately.

This patient’s NG tube placement was confirmed on auscultation. However, auscultation cannot distinguish between oesophagal, gastric, bowel, and respiratory tract placement. Therefore, it is not uncommon to hear a gurgling sound on auscultation, yet end up with a misplaced NG tube. Chest X-ray is the gold standard for verifying correct NG tube placement, however, CXR is not a quick method to confirm.

Having said that, it is imperative to verify the NG placement in high-risk patients. Therefore, in such patients, radiological verification of correct NG tube placement is a method of choice as compared to the conventional techniques.

SOURCEEastern Journal of Medicine
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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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