The feeding tube that was in the wrong place: Part2
Dr. B. Krishnamurthy
The feeding tube that was in the wrong place: Part2

The patient is a sixty year old diabetic and hypertensive female, who was admitted with acute subarachnoid hemorrhage due to a right middle cerebral artery aneurysm. She was stabilized in the Neuro ICU, and had an interventional clipping of the leaking aneurysm done. She continued to have a lowered level of consciousness and weaned off ventilator following a percutaneous tracheostomy. She was later transferred to the Neuro SDU. The neuro surgeon requested the ICU team to change the routine polyvinyl naso gastric tube to a softer polyurethane tube which can be retained for about a month. Read more about the case here:

In my opinion,

Q. What is the main cause of the event?
Answer: Wrong placement of the feed tube into the trachea.

Q. What are the additional factors that might have contributed to the event?
Answer: The inability of the consultant who placed the tube to confirm position, the non-availability of wet film and the neurosurgery consultant’s wish to restart feed as soon as possible all contributed to the event.

Q. What should be done to prevent recurrence and occurrence?
Answer: Feeding tube placements should be confirmed by the radiologist before feeds are started.

Q. Were there any error-producing conditions?
Answer: There seem to be multiple issues. The patient was not fully conscious. Hence could not cooperate in the NG tube insertion. The Task involved use of NG tube with a guide wire. Again tracheal placement is more common with these tubes. The consultant anaesthesiologist did not clinically recognize the wrong placement. The junior colleague could not seem to get the PACS system working. The Neurosurgeon missed the x-ray that showed wrong placement and very lightly took the decision to start feeds at the same level. There seems to be a lot of “production pressure” in the hospital. It is not known whether the nurse in charge noticed the issue of wrong placement but did not have the guts to tell the neurosurgeon suggesting hierarchal issues.

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Mar 14, 2019Like