Nasogastric tube malposition: a case report

Abstract

Enteral nutrition is an alternative method for patients who cannot be fed by mouth. However in these patients complications of enteral feeding tubes should always be taken into consideration. Among the possible complications, tube misplacement is particularly important because it may lead to mortal consequences. Before starting to feed, the position of the tube should be confirmed. There are various methods other than auscultation that can be used for this purpose; such as pH evaluation of gastric aspirate or capnography. However, the gold standard method is radiologic imaging. Therefore replacement of the tubes by the home care services should be performed very cautiously and the position should be confirmed effectively. Misplacement of feeding tubes can have mortal consequences as in our case. Eighty four years old male patient who had developed shortness of breath after feeding by nasogastric tube admitted to hospital. It was learned that his nasogastric tube had been changed at home the day before the symptoms had started. Pneumonia was suspected clinically with physical examination and laboratory results. Chest X-ray revealed diffuse pneumonia on the right side and the nasogastric tube was also observed at the right bronchus. The patient did not respond the treatment and died due to septic shock related with aspiration pneumonia.