Nasogastric tube ending in the right pleura of an intubated patient
Paparoupa, M., Yan, Y., Möller, M. et al.
Intensive Care Med (2018). https://doi.org/10.1007/s00134-018-5460-x
- An 89-year-old woman was treated in our intensive care unit with Escherichia coli urosepsis. The patient developed multiple organ failure and became intubated and mechanically ventilated. On the third intensive care day, a new 16Fr. type “Levin” nasogastric tube was inserted for enteral feeding. As no anatomical abnormalities were described, we followed a blind insertion technique, encountering no resistance while advancing the tube towards the stomach, and final position was confirmed by auscultation of a gurgling noise over the epigastrium. Enteral nutrition was started, according to ICU feeding protocol. However, 48 h later, acute hemodynamic instability was observed and invasive mechanical ventilation became difficult. A bed-side ultrasonography showed a pleural effusion on the right side, and a puncture for pleural-catheter placement revealed nutrition in the pleural space. 3D-reconstructed images of a chest computed tomography (Fig. 1a, arrow) demonstrated the endpoint of the nasogastric tube into the right pleura, confirming the perforation of the right lower lobe bronchus and massive lung parenchyma damage (Fig. 1b), despite the patient having an endotracheal tube in situ and giving no signal of cuff insufficiency. We suggest that radiological control remains the standard procedure to confirm the correct position of a nasogastric tube, even by invasive ventilated patients.
- 一名89岁女性患者因大肠杆菌泌尿系感染导致sepsis在ICU接受治疗。患者出现多器官功能衰竭，接受气管插管和机械通气。入住ICU的第三天，置入16 F的Levin型鼻胃管进行肠内营养。由于未发现任何解剖学异常，我们采用盲法置入，将鼻胃管送入胃内时未遇到任何阻力，置管结束后在上腹部听诊到气过水声确认导管位置。根据ICU喂养方案开始肠内营养。然而，48小时后，患者出现血流动力学不稳定，有创机械通气难以维持。床旁超声检查显示右侧胸腔积液，置入胸腔引流管发现胸腔积液为营养液。胸部CT检查三维重建（图1a，箭头）显示鼻胃管末端位于右侧胸腔内，确诊右下叶支气管穿孔及大面积肺实质损害（图1b）（尽管患者有气管插管且没有套囊漏气的表现）。我们建议，即使对于接受有创机械通气的患者，影像学检查仍然是确认鼻胃管位置正确与否的标准措施。
