|Year : 2016 | Volume
| Issue : 3 | Page : 145-147
The inadvertent intracranial introduction of nasogastric tube: The lesson learned the hard way
Department of Neurology, Faculty of Medicine, College of Medicine, University of Dammam, Dammam; Department of Neurology, King Fahd Hospital of University, Al Khobar, Kingdom of Saudi Arabia
|Date of Web Publication||14-Dec-2016|
Department of Neurology, King Fahd Hospital of Dammam University, AlAqrabiyah, Al Khobar
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Misdirection of nasogastric tube (NGT) into the cranial cavity is a well-documented complication, usually seen in patients with fracture of skull base. However, there are very few nontrauma cases have been described in the literature with this complication in nontrauma cases. Approximately 39 cases of inadvertent insertion of NGT into the cranial cavity have been reported in the literature. We are reporting accidental malpositioning of NGT into the brain of an elderly lady who was admitted with medical illness. Her computed axial tomography scan of the head showed the intracranial placement of tube. The NGT was retrieved, but after 48 h of tube insertion, the patient expired. The aim to present this rare case is to create awareness about this potential and dreaded complication associated with NGT intubation.
Keywords: Fatal inadvertent, intracranial malpositioning, nasogastric tube in the brain
|How to cite this article:|
Hassan A. The inadvertent intracranial introduction of nasogastric tube: The lesson learned the hard way. Saudi J Health Sci 2016;5:145-7
| Introduction|| |
Insertion of nasogastric tube (NGT) is one of the most common and well-established bedside procedures in patients with altered mental status. This procedure, although simple, is not risk free. Many complications with NGT insertion have been reported, especially in patients with basal skull fracture. These complications include laryngeal injuries, nasopharyngeal, esophageal, gastric, and duodenal perforation, bronchopleural fistula, pneumothorax, pneumomediastinum, pulmonary hemorrhage, and even death. ,, The first catastrophic complication of misdirected NGT into the brain was described in early 1970s; and since then, approximately 39 cases have been mentioned in the medical literature. ,, Most of these instances have been documented in patients with trauma, whereas only few cases have been reported in nontrauma settings. We are reporting a rare incident of accidental malpositioning of NGT in the brain of a patient with medical illness. Although the NGT was manually removed immediately, the patient subsequently died within 48 h. Our aim to present this case is to create awareness regarding this potential, but dreaded complication as well as to highlight the lesson learned from this case.
| Case Report|| |
A 70-year-old, known female patient of hypertension and osteoporosis, presented with 1 week history of cough and fever followed by altered mental status. On examination, she was pyrexial (38.8°C), and her blood pressure was 100/60 mmHg, and Glasgow Coma Scale (GCS) score was 12 (E = 3, V = 4, and M = 5). She was moving all four limbs (localizing) on painful stimuli with flexor plantars. The chest examination revealed decreased air entry to the right lung. Her chest X-ray (CXR) from the emergency department revealed right upper zone consolidation. She was admitted with the diagnosis of community-acquired pneumonia and sepsis. Prompt appropriate treatment was started. To avoid aspiration pneumonia, NGT was inserted for her oral medications which she was taking for her chronic illnesses. The physician observed all precautions and performed the procedure of NGT insertion as per established protocol. Two attempts at insertion were made, each ended in aspiration of blood-stained fluid. The tube was left in the position, assuming it to be blood-stained nasal secretions from traumatic insertion or probably blood-stained gastric aspirate from stress ulcers. CXR was ordered to see the position of NGT in the stomach as per protocol. The patient did not receive any medication or feeding through NGT. After 2-3 h of the NGT insertion, while CXR was not yet done, her GCS dropped to 8 (E = 2, V = 3, and M = 3). She was immediately intubated and shifted to the medical intensive care unit. Neurology service was involved at that time; computed axial tomography (CAT) scan of the head was done which revealed coiled NGT in the brain [Figure 1]. The patient was immediately seen by a neurosurgeon by that time patient became deeply comatose with seven GCS. Inotropic support was started, and NGT removed through the nose. However, the patient could not survive, and brain death was declared after 48 h of the event.
|Figure 1: Non-contrast-enhanced axial images of CAT scanillustrating intracranial loops of nasogastric tube visible in both hemispheres more on theleft side, associated with brain swellingand subarachnoid hemorrhage|
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| Discussion|| |
NGT insertion, a simple and routine procedure, most oftenly performed by the junior physicians. The instances of inadvertent intracranial insertions have been well-documented and seen in cases with craniofacial trauma associated with cribriform plate (CP) fracture. Only four cases in nontrauma setting have been published in English literature. , The possible gateways for misdirection of NGT into the cranial cavity are abnormally thin CP, congenitally absent CP, fracture of the base of skull spreading across the CP, and floor of the anterior cranial fossa.  Whereas in a nontrauma case, this complication can occur either due to insertion of NGT through a CP with congenital defect or as a result of rigid tube that can penetrate through a thin but uninjured CP.  High-grade paranasal sinus pneumatization, significant deviation of nasal septum, and poor development of nasal turbinates are few important factors that may favor the false passage of NGT. 
In our case, it is postulated that the CP was thin and perforated by a rigid NGT. The consequences of intracranial placement of NGT are serious, and reported mortality is as high as 64% while morbidity is seen in the form of hemiparesis, visual loss, anosmia, cerebral hemorrhage, and persistent cerebrospinal fluid fistula.  Although our patient was in sepsis, which itself has high mortality rate; in addition, the intracranial placement of the NGT resulted in serious iatrogenic damage and adversely affected the outcome.
The best way to avoid this lethal complication is to prevent it in the first place. There are two clinical maneuvers of evaluation of NGT placement, either by auscultation of the gurgling sounds of insufflating air over the epigastrium or by aspiration of gastric fluid. Both may yield false-positive results, and considered as poor predictor of NGT misplacement, particularly in patients with altered mental status. ,
To reduce the chances of this dreaded complication especially in patients with head trauma, who are at a higher risk of NGT malpositioning, many measures have been described in the literature such as fluoroscopic- or endoscopic-guided nasogastric or orogastric intubation. , CXR is commonly used to verify the proper location of the NGT, and it is a strongly recommended to perform CXR before the NGT is used to administer any medicine or to feed the patients to minimize the hazard associated with malpositioned NG tube.  In our case, CXR was ordered as per protocol, medications or feeding was not yet started through NGT. The tube was left in the position, assuming it is either blood-stained nasal secretions from traumatic insertion or blood-stained gastric aspirate from stress ulcer of serious illness.
In most cases, the misplaced NGT is coiled in the cranial vault rather than within the brain parenchyma, and an urgent CAT scan of the head is always essential in all cases once such misplacement of tube is suspected. 
There is no clear agreement in the medical literature about a better approach to remove the intracranial placed NGT. The recommended options are retrieval of NGT under direct visualization either by craniotomy or by careful removal through the nose. ,, Currently, no scientific evidence is available to comment on the prognostic advantage of either technique. In our case, CAT scan of the head was performed after observing the drop in the conscious level, and finally, NGT was retrieved through the nose by neurosurgery.
| Conclusion|| |
This case highlights an extremely rare complication and a potential risk of intracranial misplacement of NGT in a medical patient with obtunded mental status. An important lesson for our young physicians, who in the emergency rooms and medical wards are first to see and manage such patients is, that this dreaded complication may lead to serious iatrogenic damage. Extra care must be taken, especially in elderly patients and patients with known history of osteoporosis or having a risk of osteoporosis such as postmenopausal women. CXR must be done immediately after passing NGT to confirm its correct position. In cases where insertion of NGT is difficult to perform, recurrent attempts must be avoided. Fluoroscopic- or endoscopic-guided nasogastric or orogastric intubation should be considered in such difficult cases. Moreover, performing this procedure as per the standard guidelines will be helpful to minimize the chance of this catastrophic complication.
Thank you for your consideration Dr. Ali Hassan MBBS, FCPS, FEBN Assistant Professor and Consultant Neurologist College of Medicine, University of Dammam Department of Neurology King Fahd Hospital of University Al Khobar, Kingdom of Saudi Arabia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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