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?
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