IATROGENIC PNEUMOTHORAX AFTER NASOGASTRIC TUBE PLACEMENT

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Nasogastric tubes (NGT) are frequently used in the Intensive Care Unit (ICU). They have multiple indications and is a common procedure that usually goes without complication. However, adverse reaction rates can vary from 0.3% to 15% which are usually seen after chest trauma or mechanical ventilation. CASE PRESENTATION: 64-year old male, with no past medical history was admitted to the ICU, intubated, mechanically ventilated due to altered mental status secondary to intracerebral hemorrhage (ICH). Non-surgical management and strict blood pressure control was achieved, and patient was extubated after six days. Nevertheless, patient failed swallow evaluation test, and insertion of Dobhuff tube for enteral nutrition was performed. Immediately after insertion, patient became agitated, tachycardic, tachypneic, hypoxic with O2 saturation of 89% on 80% FiO2 on high flow nasal cannula. Emergent chest X-Ray (CXR) showed a large right sided pneumothorax, and chest tube placement was placed. Follow up CXR showed slight improvement of pneumothorax, but subjacent emphysema and severe diffuse saphenous emphysema were noticed. Due to patient’s acute hypoxic respiratory failure, emergent reintubation was required complicating his ICU stay by extensive subcutaneous emphysema and pneumomediastinum. DISCUSSION: Nasogastric tube has a key role in the management of hospitalized patients, particularly the critically ill. It is a common procedure done and its use is both diagnostic and therapeutic. Significant complications include pneumonia, pneumothorax, subcutaneous emphysema, and respiratory failure. Risk factors for complications include altered mental status, absence of a gag reflex, presence of an endotracheal tube, supine position, and head and neck surgery. Our patient developed an iatrogenic pneumothorax secondary to misplaced NGT that prolonged his ICU stay. Given the compromise of patient’s airway reflexes, swallowing mechanism, and neurologic state, he was unable to report shortness of breath or chest discomfort after NGT placement. Other predisposing factors such as multiple attempts and blind insertion along with stylet-stiffened feeding tube also play a role. There are several techniques to confirm proper placement of NGT and should be enforced after every placement. Although, air insufflation and epigastric auscultation are commonly used, there are not 100% reliable and misinterpretation can occur. CXR post NGT insertion is the gold standard confirmatory test. It must be done right after the procedure to rule out life-threatening complications such as pneumothorax and extensive subcutaneous emphysema. CONCLUSIONS: Misplaced NGT pose a serious threat to patient safety which can complicate patient’s hospital course and increase length of stay. Although it is a simple procedure, it can have serious complications that warrants careful assessment with CXR to assure adequate placement. Reference #1: Agha R, Siddiqui MR. Pneumothorax after nasogastric tube insertion. JRSM Short Rep. 2011;2(4):28. Published 2011 Apr 6. doi:10.1258/shorts.2011.010142 Reference #2: Pejin E, Bee S, Yuh S. Nasogastric tube placement confirmation: where we are and where we should be heading. Proceedings of Singapore Healthcare. Volume: 26 issue: 3, page(s): 189-195. Published 2017 Sept 1. Reference #3: Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and Mediastinal Emphysema: Pathophysiology, Diagnosis, and Management. Arch Intern Med. 1984;144(7):1447–1453. doi:10.1001/archinte.1984.00350190143024 DISCLOSURES: No relevant relationships by Adriana Briceno Bierwirth, source=Web Response No relevant relationships by ahmad hamdan, source=Web Response No relevant relationships by Gabriela Orellana, source=Web Response No relevant relationships by Carlos Perez, source=Web Response