The feeding tube that was in the wrong place

The feeding tube that was in the wrong place: Part1


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.

The Consultant anesthesiologist placed the tube and asked for an X - ray to be taken to confirm the tip placement below the diaphragm. However, he was not able to see the X -ray himself and requested a team member to do the same. The resident visited the unit but was told that the wet film was not ready but he can check it on the PACS. He attempted to do it but could not succeed. Mean while he was called to attend a code blue call and had to rush out of the HDU. 

The neurosurgeon visited the patient and was concerned that the feedings were not resumed. He cursorily looked at the PACS and removed the guide wire and checked the tube position by injecting air into the feed inlet and auscultating the abdomen. After confirming the position, he requested feeding to be resumed. The feeding was resumed at the original 100 mL per hour at 1230 hrs.  

The afternoon nurse noticed that the patient was becoming increasingly tachypnoeic and was showing evidence of desaturation. The JR on call stopped the feeds and increased oxygen to 100% and called the Rapid response team (RRT). The RRT who came in found that the patient’s trachea was full of the naso-gastric feeds and sucked out as much as possible. They re -initiated ventilation and transferred the patient back to the ICU. The ICU team did a direct laryngoscopy and found that the feed tube was entering the larynx. Review of the X ray taken confirmed that the tube tip was not located below the diaphragm and was seen to go to the right main bronchus.

The patient underwent a brochospy and tracheo – bronchial toilet was done and as much of the left over feed was aspirated.  A new feed tube was sited under vision and feeding started after radiological confirmation. Patient improved after this and was weaned of the next day. Thankfully there were no signs of a chest infection.

In your opinion,

• What is the main cause of the event?
• What are the additional factors that might have contributed to the event?
• What should be done to prevent recurrence and occurrence?

If you have anything to add please feel free to share your views in the comments section below! The answers can be accessed here:

About Author
Though i am an anesthesiologist and intensivist by training I consult for health care quality and safety management now
About PlexusMD MedicoLegal Desk
PlexusMD Medicolegal Desk brings out key facts and learnings from cases involving Doctors and Hospitals across the country to update Doctors with the latest regulations, avoid common mistakes and stay safe while discharging their duties.
Dr. V●●●k B●●●y J●●●n and 16 others like this8 shares
Dr. V●●●n D●●●●●●h
Dr. V●●●n D●●●●●●h Critical Care Medicine
This event is scary but very much can happen. Patient was obtunded after a CNS event and not cooperative and hence a doctor can have difficulty inserting feeding tube correctly. Important points no note : 1, indication for inserting a feeding tube. 2. Technique of insertion 3. Follow up and confirmation of position 4. Handing off complication if any. In this case the indication was not right. If the patient already had a pvc tube, inserting a softer tube was not necessary in the first place. Secondly, the technique involves injecting MCT oil in the lumen of tube before passing into a patient. This will help easily remove the guide wire. Thirdly, if the position was not confirmed on PACS, and code blue happened in another place, it was duty of the nurses to inform that the position is not checked and also the duty of anesthesia registrar to follow up on that. As per the history, the neurosurgeon had checked on PACS and removed the wire, so he is the doctor to be held responsible for the mishap. These is a possibility that he tube may be seen properly in PACS and while removal of huids wire the position may have changed if proper lubricant was not used as explained above. The complication was handled promptly but this must be a traumatic experience for the family and they may file a complaint. ... Read more
Dec 4, 2018Like4
Dr. S●●●●●v S●●●●●1
Dr. S●●●●●v S●●●●●1 Obstetrics and Gynaecology
When the resident came to check the position whether below the diaphragm or not but hurriedly left for some more important work he should have left a verbal gesture to the duty nurse that things are not 100\% safe yet to start feeding. The neurosurgeon is right in changing over to a softer polyurethane tube which shows his greater concern for the patient, but he committed a mistake of ensuring the position of the catheter perhaps in a hurry and belief that it must be in right position. He took this small mistake lightly that caused the terrible scenario which could be properly tackled by the Rapid response team. I don' t think the patient' s attendants have anything to complain at this stage because the hospital' s mistake or may be by any chance the patient' s natural condition if deteriorates it has been successfully managed at nick of time for which actually the hospital should score more.There are mistakes means the hospital is functioning. Mistakes rectified in time means hospital is functioning very well. ... Read more
Dec 4, 2018Like3
Dr. K●●●●●a R●●a
Dr. K●●●●●a R●●a Test
Dec 7, 2018Like