Complications are numerous and vary from minor to severe. Mortality associated with NGT placement is about 0.3%. 35 Most severe complications occur when the tube is incorrectly placed.

Minor complications


Esophageal trauma


Pneumothorax


Aspiration


Intracranial trauma


Knotting of the tube

MINOR COMPLICATIONS

Minor complications include nasal irritation, epistaxis, and sinusitis.

ESOPHAGEAL TRAUMA

Mild irritation of the esophagus can occur with NGT placement. Esophageal perforation is uncommon, but can be life-threatening. 29 , 36 Risk factors for this serious complication include pre-existing esophageal abnormalities, altered mental status (inability to swallow during passage may result in more forceful attempts), cardiomegaly (causing esophageal distortion), multiple attempts at insertion, and general patient debilitation. 29 Signs of esophageal perforation include neck or chest pain, fever, subcutaneous emphysema, dyspnea, and dysphagia. 36 Treatment includes broad antimicrobial coverage and surgical consultation.

PNEUMOTHORAX

There are numerous reports of pneumothorax and other pleural injury resulting from NGT and feeding tube insertion. 26 , 37 , 38 , 39 , 40 ,  This complication arises when the tube inadvertently enters the trachea and travels distally in the pulmonary tree, eventually penetrating the visceral pleura and entering the pleural cavity. Several lessons can be extrapolated from these cases:

  • Inadvertent tracheal intubation is much more common in the elderly, in those with altered mental status, and in those who have recently been endotracheally intubated for an extended period. This is felt to be secondary to decreased airway reflexes in these patients.
  • Endotracheal placement of the NGT does not always result in immediate symptoms.
  • Pneumothorax can be avoided if misplaced tubes are identified promptly with proper confirmation techniques.

 

ASPIRATION

Aspiration pneumonia may result from gagging and vomiting that occurs during initial placement of the tube. Though NGTs are often placed to evacuate the gastric contents to prevent aspiration, some data suggests that NGTs may actually cause aspiration (and potentially pneumonia) by preventing the lower esophageal sphincter from completely closing. 41 , 42 There are several dramatic case reports of either charcoal or enteral feeding solutions infused directly into the lungs via a misplaced NGT. 26 , 27 , 28 , 32 Of note, no confirmatory radiograph was obtained in any of these cases prior to the infusion of the fluid. This should reinforce the fact that chest XRAYS should obtained before putting anything down the NGT.

***INSERT CT SCAN HERE***
INTRACRANIAL TRAUMA

Perhaps the most dramatic complication of NGT insertion is that of inadvertent intracranial placement. Numerous cases have been reported in the literature 43 , 44 , 45 , 46 , 47 , 48 The mortality associated with this complication has been reported as high as 64%. 43 In the great majority of these cases, the patient had suffered extensive traumatic maxillofacial injuries, and the most common site of entry into the cranial vault was through the cribriform plate. This structure is very thin and is easily disrupted by a basilar skull fracture. To avoid this disastrous complication, patients with maxillofacial injuries should not have blind insertion of NGTs. Alternative techniques in this situation include orogastric insertion, nasogastric insertion but with direct visualization, or fluoroscopically guided insertion.

KNOTTING OF THE TUBE

Another rare complication of NGT insertion is the knotting of the NGT around a pre-existing endotracheal tube. 35 , 49 , 50 , 51 This should be suspected when there is resistance to both insertion and removal of the NGT, or if the endotracheal tube moves in tandem with the NGT. Removal of a tightly knotted tube can be difficult, and may require cutting the NGT as it traverses the oropharynx, removal of the proximal half through the nose, and removal of the distal, knotted half en bloc with the endotracheal tube.

 

Back | Next