Wednesday, August 16, 2017

Fatal internal jugular vein cannulation by a misplaced NG tube

A case report published last month involves a 79-year-old man with multiple comorbidities including depression, alcohol abuse, hypertension, CHF, and COPD who was admitted because of abdominal pain and distention which was found to be a perforation of the right colon. 

He underwent a resection and did well until the seventh postoperative day when he became distended. A nasogastric tube was inserted. Its position was checked by injecting air through the tube and auscultating over the upper abdomen [a notoriously inaccurate method of locating an NG tube’s position].

A few hundred mL of dark blood came out. He was treated for a presumed upper gastrointestinal bleed. A chest x-ray showed the tube in good position but the tip was not seen.

When the patient’s vital signs deteriorated, a new NG tube was put in and drained 2 L of blood. The patient suffered a cardiac arrest and could not be resuscitated. At autopsy, the NG tube was found to have gone through the right pharyngeal wall and into the right internal jugular vein. The tip was in the superior vena cava.

Although I had never heard of this complication before, it has been reported in the literature at least one other time.

A 1998 paper in Anesthesiology described a 56-year-old woman who underwent emergency coronary artery bypass graft surgery and developed vomiting on postoperative day 4. An NG tube was inserted with "slight initial resistance." When the tube was aspirated, 2 L of blood returned. She was thought to have an upper G.I. bleed and received large amounts of fluid, fresh frozen plasma, and packed red blood cells.

Endoscopy of the upper G.I. tract showed no sign of bleeding and the NG tube was not seen. A chest x-ray showed the NG tube had perforated the pharynx at the soft palate and entered the right internal jugular vein. The x-ray below shows the tip of the tube in the right atrium (white arrow).

The tube was removed, and the pharynx was packed. The packing was taken out on the next day. Nine days after the incident she was transferred back to the referring hospital.

Nasogastric tubes have been found in the cranial vault and even the spinal canal. See x-rays below.

Orogastric placement is recommended for patients with facial or skull base fractures. A history of trans-nasal cranial surgery calls for special care when NG or feeding tubes are to be inserted.

The authors of the 2017 paper recommend if gross blood is aspirated immediately after the insertion of an NG tube, an x-ray should be obtained to determine the tube's position. That seems like a good idea.


Anonymous said...

One thing I've always found annoying with portable CXRs is there is never a reliable way to know what lines/tubes are supposed to be there. You obviously learn what all the lines/tubes look like radiographically, but I always thought it would be a good double check to know which devices I should be seeing. If it's an initial CXR after line placement, I don't know what line or lines are supposed to be there. Ok, so I see the right IJ Central line, but I don't see the OG that's listed as being present -- is that in the cranium, out of the field of view?

These are rare occurrences, but it makes everyone look incompetent when it happens. If I saw a central line 2 days ago but not today, I have no idea if it was pulled out purposely or accidentally, or malpositioned such that I don't see it at all, and the EMR and stated indication are useless between copied notes and repeated orders for some ICD-10 code. All I can say is it's no longer present. If I call the ordering MD every time they pull a central line without thoroughly documenting it in the EMR/orders, I'm going to waste a lot of my time and their time.

Skeptical Scalpel said...

Anon, good points. I agree clinicians often don't give enough history and that trying to check what's going on in the EMR is difficult to impossible. I have seen records that don't mention why a patient was intubated or even that he was intubated. You only know something happened since the day before because the notes now refer to the presence of an ET tube and a ventilator.

William Reichert said...

I was frequently amused to read an xray report indicating
that a ventilated patient's pulmonary edema had improved when actually the clearer image was the result of increasing the patient's total lung volume by manipulating the ventilator's settings. The best practice is to always over read the Xray yourself. Knowledge about the patient puts you in a better position to care for your patient.

Anonymous said...

Even worse when techs, aides, orderlies or others with limited knowledge of anatomy are ordered to place the NG tubes, urinary caths, or even IVs

Skeptical Scalpel said...

I agree completely that clinicians should look at their patient's imaging studies.

I have seen some problems with procedures done by inexperienced and unsupervised people.

helsayes said...

Passing a NG tube is a procedure that ought not be taken lightly and immediate postprocedural XR is a must. Thank you

William Reichert said...

Speaking of NG tubes, a few years ago I ordered a dobhoff tube be placed to initiate feedings. The next day I noted that the tube was in the stomach ( on x ray) but the feedings had not been started.
The nurse told me that this was because on that floor the nurses have "been trained to advance the tube into the jejunum".prior to feeding. I said that this was unnecessary
( also impossible to do without fluoro??) but the nurse and even ( get ready to be terrified) the HEAD NURSE told me that this was the protocol on that floor and the nurses "knew how to do it" . Except they didn't. For three days I waited and yet no advancement had been accomplished. No feedings had begun.I spoke to the HEAD nurse and pointed out that for a long time people had been feeding themselves by ingesting food that first went into the stomach. Why not just leave the tube in the stomach and feed the patient;. Episodes like these made it less traumatic to retire. I began to understand that where I worked it was more important for the nurses to feel empowered and than for a physician to practice according to his understanding of what is the right thing to do. So I was, really, no longer needed.

Oldfoolrn said...

Rigid authoritarian nurses especially those in administrative positions have been causing mayhem for decades. If you want something done in an effective, patient centered fashion see a bedside nurse with a couple of decades experience.

I was at a critical care equipment demo when an office sitting supervisory nurse identified QRS complexes on an arterial line waveform. These folks have a combination of arrogance and ignorance that is dangerous around patients.

Anonymous said...

While I agree with your sentiment, I can tell you, RNs are indeed trained to place jejunal (dobhoff) feeding tubes post-pylorically. Typically NG tubes aren't as far as I know ever placed post-pyloric even under flouro. What you experienced is however typical in that those tubes often will not migrate past the pylorum even though they have a weighted tip and will needed interventional radiology consult if feeding the stomach is not an option.
That said, if it is safe to do so we shouldn't be delaying nutrition and while yes it's often policy to get feeding tubes post-pyloric before initiating tube feeds, typically all it takes is an md order clearing the nurses to feed the stomach via the tube or getting IR to place one for you.

It is unfortunate to hear a medical provider leaving practice feeling they are not needed. Good, caring doctored are always needed and appreciated by us nurses.

Skeptical Scalpel said...

helsayes, I think if you get what is obviously gastric contents when you aspirate the tube, an x-ray may not be necessary. When in doubt, get an x-ray.

William and Anon, there is no question that some nursing policies are arbitrary and non-evidence-based [see my posts about surgical caps]. In my experience, no amount of logic or science can change them.

Old, that's a great story about a nurse mistaking QRS complexes as an arterial waveform. I would love to have been present for that.

Cory Beevers said...

That looks nastyyyy...

Went straight to my spine looking at that.

Anonymous said...

In Australia all NGT placements are initially checked with Litmus paper, then a CXR that is checked by the Registrar.

Skeptical Scalpel said...

If you are going to get a chest x-ray on every patient, why bother with the litmus paper?

Unknown said...

Skeptical, litmus paper is at the bedside when you place the tube. A stat portable xray may be two hours and three phone calls by the attending surgeon away. A lot can happen in two hours if the tube is misplaced, I have seen a transbronchial pleural tube placed when an NG was intended. What really irritates me about the confirmation of NG placement is nurses who want confirmation before connecting the tube to suction, although with the case report above I am for the first time aware of a situation where connecting the misplaced tube to suction could be a problem.

Skeptical Scalpel said...

I understand litmus paper can be at the bedside. The commenter said they use it and then get a chest x-ray anyway. If you are going to get a chest x-ray on every patient, why bother with the litmus paper?

I agree the case I wrote about makes one think about getting an x-ray on every patient.

Harold said...

"If you want something done in an effective, patient centered fashion see a bedside nurse with a couple of decades experience."

You don't sound foolish to me.

Anonymous said...

The images posted here are the most amazing complications of an NG/OG tube I've ever seen. In the cranial vault? Spinal canal? OMG!

The comment above about the office-sitting-nurse/secretary reminded me of the time, as a 4th-year medical student, I went to the Surgery Chairman's office to inquire as to the progress of my "Chairman's Letter of Recommendation" as required by some surgery programs I was applying to. (The year was 1988/89). As I walked in, I was met by his personal "secretary" wearing a long, white coat--who promptly SCREAMED at me for having asked for multiple copies of the letter to be sent to the various programs I'd applied to. She said, "Don't you know how long it takes me to type each of those addresses?!!" I replied, "I'm sorry, but all you need to do is create a mail-merge in WordPerfect--typing the addresses only ONE TIME for each and any student that asks for a letter. It literally will take you 10 seconds to compile 100 letters." To which she answered, "I don't have WordPerfect, I have a WANG computer." I laughed under my breath. A secretary, wearing a long-white coat, who knows nothing of word processing or has no computer literacy (back in the days of DOS), yelling at me. I think this is exactly like the clip-board carrying nurse crating havoc...same thing...just in reverse: the secretary's incompetence creating havoc. If only Dr. Aufses knew how incompetent she was.

Skeptical Scalpel said...

Great story. I always thought Arthur Aufses was a nice guy and a real gentleman. I think he would have been supportive and understanding.

your opinions matter said...

I was doing a BV ICD implant a few years ago when an anesthetist left on break and was replaced by an anesthesiologist. He decided he did not like the pt's snoring and placed an nasopharyngeal airway after which the pt began to hemorrhage. This event occurred two days after a mandatory lecture on avoiding blood transfusion.
My part of the procedure was delayed for an hour while the pt was treated with intubation and packing and "stabilized" enough for me to finish the case.
Unfortunately he developed severe anemia, encephalopathy, and eventually sepsis and did not recover.

I thought he may have had varices, but this brings up another possibility.

Skeptical Scalpel said...

As the case I blogged about illustrates anything can happen. An autopsy might have clarified things.

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