Fatal Internal Jugular Vein Cannulation By A Misplaced Nasogastric Tube

A case report published involves a 79-year-old man with multiple comorbidities including depression, alcohol abuse, hypertension, CHF, and COPD who was admitted because of abdominal pain and distention which was found to be a perforation of the right colon.

He underwent a resection and did well until the seventh postoperative day when he became distended. A nasogastric tube was inserted. Its position was checked by injecting air through the tube and auscultating over the upper abdomen [a notoriously inaccurate method of locating an NG tube’s position].

A few hundred mL of dark blood came out. He was treated for a presumed upper gastrointestinal bleed. A chest x-ray showed the tube in good position but the tip was not seen.

When the patient’s vital signs deteriorated, a new NG tube was put in and drained 2 L of blood. The patient suffered a cardiac arrest and could not be resuscitated. At autopsy, the NG tube was found to have gone through the right pharyngeal wall and into the right internal jugular vein. The tip was in the superior vena cava.

Although I had never heard of this complication before, it has been reported in the literature at least one other time.

paper in Anesthesiology described a 56-year-old woman who underwent emergency coronary artery bypass graft surgery and developed vomiting on postoperative day 4. An NG tube was inserted with "slight initial resistance." When the tube was aspirated, 2 L of blood returned. She was thought to have an upper G.I. bleed and received large amounts of fluid, fresh frozen plasma, and packed red blood cells.

Endoscopy of the upper G.I. tract showed no sign of bleeding and the NG tube was not seen. A chest x-ray showed the NG tube had perforated the pharynx at the soft palate and entered the right internal jugular vein. The x-ray below shows the tip of the tube in the right atrium (white arrow).



The tube was removed, and the pharynx was packed. The packing was taken out on the next day. Nine days after the incident she was transferred back to the referring hospital.

Nasogastric tubes have been found in the cranial vault and even the spinal canal. See x-rays below.



Orogastric placement is recommended for patients with facial or skull base fractures. A history of trans-nasal cranial surgery calls for special care when NG or feeding tubes are to be inserted.

The authors of the 2017 paper recommend if gross blood is aspirated immediately after the insertion of an NG tube, an x-ray should be obtained to determine the tube's position. That seems like a good idea.




Source