Iatrogenic Oesophageal Perforation In A Newborn

Abstract

Endotracheal intubations and nasogastric tube (NG) insertions are common procedures in any neonatal intensive care unit. But complications secondary to these procedures are not commonly seen. Iatrogenic oesophageal perforation is a rare but known complication of these procedures. We would like to present two cases of preterm babies with iatrogenic oesophageal perforation. Both the babies had NG tube insertion and endotracheal intubation. Baby A had semi-elective and Baby B had an emergency intubation. Both babies were asymptomatic and were diagnosed incidentally on subsequent X rays. Baby A, born at 27 weeks gestation, was intubated at birth in view of prematurity and poor respiratory effort. The initial chest X-ray showed endotracheal tube in good position at T2 level and the NG tube in the stomach. Baby had two doses of surfactant and was extubated to CPAP at 24 hours of age. On day 5 of life due to clinical deterioration and increased oxygen requirement a decision was made to re-ventilate the baby. Semi-elective reintubation, done using intubation drugs, proved difficult and required multiple attempts. No evidence of any trauma or blood was noticed during the procedure. The subsequent X-ray showed the NG on the right side of the chest and a diagnosis of oesophageal perforation was made. There were no symptoms related to the perforation. Baby was managed conservatively. He was already on antibiotics before this episode in view of presumed sepsis which were continued.. Feeds were built up slowly and full feeds were established by day 18. The baby further went on to have chronic lung disease, but no complications secondary to oesophageal perforation. Figure 1 Figure 1 Figure 1: X ray chest and abdomen showing the nasogastric tube on the right side Baby B, born at 26 weeks gestation, had a difficult intubation at birth. A dose of surfactant was given soon after intubation. NG tube was inserted without any difficulty. Iatrogenic Oesophageal Perforation In A Newborn 2 of 4 Subsequent chest X-ray showed the NG tube deviating to the right side of chest with a small associated pneumothorax. Figure 2 . A second NG tube passed followed the same route. At this stage a diagnosis of situs inversus was considered as the NG tube was on the right side and there was no stomach bubble seen. Since the antenatal scans were normal, a differential diagnosis of oesophageal perforation was kept in mind. So after leaving the previous ectopic NG tube in situ, we successfully passed a second NG tube to the stomach. Figure 3. This confirmed the diagnosis of oesophageal perforation. There were no obvious signs or symptoms of perforation noticed.