Esophageal Perforation and Pneumothorax after Routine Intraoperative Orogastric Tube Placement Ali A. Turabi, MD,* Ron J. Urton, MD,† Todd M. Anton, MD,* Robin Herrmann, CRNA,‡ and David Kwiatkowski, CRNA* Orogastric and nasogastric tubes are routinely inserted in anesthetized patients to both reduce the volume of stomach contents and decrease the incidence of postoperative nausea. We present a case of esophageal perforation and subsequent pneumothorax after insertion of an orogastric tube in a patient undergoing routine shoulder arthroscopy. (A&A Case Reports. 2014;2:122–4.)
R
outine intraoperative placement of orogastric (OG) and nasogastric tubes is common in anesthetized patients to reduce the volume of stomach contents and the incidence of postoperative nausea. In the following case, we describe a patient undergoing routine shoulder arthroscopy in whom “mild” resistance was noted during insertion of an OG tube, resulting in esophageal perforation and pneumothorax. The patient gave permission to submit this case study for publication.
CASE DESCRIPTION
A 39-year-old woman underwent right shoulder arthroscopy and distal clavicle excision under general anesthesia secondary to a 1-year history of right shoulder pain. Her medical history included asthma (well controlled with medication) and mitral valve prolapse (asymptomatic). Previous surgeries were uneventful except for postoperative nausea with a pilonidal cyst removal (2010). The patient received a right interscalene block for postoperative pain management. Both surgery and anesthesia (including tracheal intubation) were routine and uneventful. At the end of the case and before tracheal extubation, an attempt to pass a soft OG tube was performed. This was met with “mild resistance” early in insertion as is often the case when passing through the posterior oropharynx. The OG was then removed, the patient repositioned, and reinsertion attempted. Resistance was once again encountered, and again, the OG tube was removed. During removal after the second attempt, a significant amount of bright red blood, approximately 50 to 70 mL, was noted coming from the OG tube. Because the mild resistance was thought to be from the upper oropharynx, the thought was that possible trauma to the upper larynx or esophagus may have occurred. A glidescope was placed, and the tracheal tube
From the Department of Anesthesia, *U.S. Army Medical Corps, †U.S. Air Force Medical Corps, and ‡U.S. Navy, Landstuhl Regional Medical Center, Landstuhl, Germany. Accepted for publication December 23, 2013 Funding: No funding required. The authors declare no conflicts of interest. Address correspondence to Ali A. Turabi, MD, U.S. Army Medical Corps, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, Box 1107 APO, AE 09180. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000019
122 cases-anesthesia-analgesia.org
was noted to be in place without any obvious trauma to the upper airway. Laryngoscopy followed by esophagoscopy done by the ear-nose-throat specialist revealed blood coming from the esophagus below the upper esophageal sphincter and a small lesion just above the lower esophageal sphincter. Finally, esophagogastroduodenoscopy performed by a gastroenterologist revealed a single, linear, mucosal tear 39 cm from the teeth with no obvious sign of perforation or active bleeding (Fig. 1). A recommendation was made for conservative management with a soft diet and omeprazole. After tracheal extubation, the patient was brought to the postanesthesia care unit with stable vital signs, but over the next 30 minutes, her oxyhemoglobin saturation would not increase above 93% to 94%, despite a high flow of oxygen delivery via a nonrebreathing mask. Auscultation revealed decreased breath sounds over the left hemithorax and a portable chest radiograph revealed a left pneumothorax (Fig. 2) and intensive care unit (ICU) staff were informed. While in the postanesthesia care unit, the patient had a chest tube placed and was then transferred to the ICU. In the ICU, an esophagram (Fig. 3) was ordered that revealed an esophageal perforation. The patient was then transferred to a different hospital for possible thoracic repair of this injury. An esophageal stent was placed and removed 2.5 weeks later. No persistent leak was noted, and appropriate follow-up revealed no additional complications.
DISCUSSION
OG tubes are frequently used in anesthesia practice, most commonly for gastric decompression and potential reduction of postoperative nausea and volume of postoperative emesis. In this patient, it was deemed appropriate because the patient had a history of postoperative nausea and vomiting. OG tube placement carries certain known risks including tracheobronchopleural penetrations,1–3 intravascular penetration,4 gastroesophageal rupture,5 and intracranial entry.6 Rassis et al.2 reported a 2% incident of tracheopulmonary complications among 740 tube insertions associated with a 0.3% mortality rate. Pneumothoraces accounted for approximately 60% of these complications, requiring chest tube placement 50% of the time.1,2 The risk is greater in anesthetized, tracheally intubated patients who cannot give verbal feedback while attempting OG or nasogastric tube placement.7 In our patient, early involvement of appropriate consultants and the culture of supporting complete May 15, 2014 • Volume 2 • Number 10
Figure 1. Single linear 10 mm tear in esophagus found on esophagogastroduodenoscopy.
Figure 2. Chest radiograph taken in the postanesthesia care unit, showing large pneumothorax.
patient care limited a potentially life-threatening complication. Although these complications are rare, they can have devastating outcomes if not identified early. Patients should be identified as having high risk for increased stomach contents before placement of an OG tube to avoid unnecessary complications, and if blood is noted in the OG tube, this complication should be considered. E
Figure 3. Esophagram showing contrast above the diaphragm and extravasation. REFERENCES 1. Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429–33 2. Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2:25–8
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3. Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardiovasc Surg 2010;58:476–80 4. Düthorn L, Schulte Steinberg H, Häuser H, Neeser G, Pracki P. Accidental intravascular placement of a feeding tube. Anesthesiology 1998;89:251–3 5. Wu PY, Kang TJ, Hui CK, Hung MH, Sun WZ, Chan WH. Fatal massive hemorrhage caused by nasogastric tube misplacement
124 cases-anesthesia-analgesia.org
in a patient with mediastinitis. J Formos Med Assoc 2006; 105:80–5 6. Gregory JA, Turner PT, Reynolds AF. A complication of nasogastric intubation: intracranial penetration. J Trauma 1978;18: 823–4 7. Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med 1989;149:184–8
A & A case reports
R
outine intraoperative placement of orogastric (OG) and nasogastric tubes is common in anesthetized patients to reduce the volume of stomach contents and the incidence of postoperative nausea. In the following case, we describe a patient undergoing routine shoulder arthroscopy in whom “mild” resistance was noted during insertion of an OG tube, resulting in esophageal perforation and pneumothorax. The patient gave permission to submit this case study for publication.
CASE DESCRIPTION
A 39-year-old woman underwent right shoulder arthroscopy and distal clavicle excision under general anesthesia secondary to a 1-year history of right shoulder pain. Her medical history included asthma (well controlled with medication) and mitral valve prolapse (asymptomatic). Previous surgeries were uneventful except for postoperative nausea with a pilonidal cyst removal (2010). The patient received a right interscalene block for postoperative pain management. Both surgery and anesthesia (including tracheal intubation) were routine and uneventful. At the end of the case and before tracheal extubation, an attempt to pass a soft OG tube was performed. This was met with “mild resistance” early in insertion as is often the case when passing through the posterior oropharynx. The OG was then removed, the patient repositioned, and reinsertion attempted. Resistance was once again encountered, and again, the OG tube was removed. During removal after the second attempt, a significant amount of bright red blood, approximately 50 to 70 mL, was noted coming from the OG tube. Because the mild resistance was thought to be from the upper oropharynx, the thought was that possible trauma to the upper larynx or esophagus may have occurred. A glidescope was placed, and the tracheal tube
From the Department of Anesthesia, *U.S. Army Medical Corps, †U.S. Air Force Medical Corps, and ‡U.S. Navy, Landstuhl Regional Medical Center, Landstuhl, Germany. Accepted for publication December 23, 2013 Funding: No funding required. The authors declare no conflicts of interest. Address correspondence to Ali A. Turabi, MD, U.S. Army Medical Corps, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, Box 1107 APO, AE 09180. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000019
122 cases-anesthesia-analgesia.org
was noted to be in place without any obvious trauma to the upper airway. Laryngoscopy followed by esophagoscopy done by the ear-nose-throat specialist revealed blood coming from the esophagus below the upper esophageal sphincter and a small lesion just above the lower esophageal sphincter. Finally, esophagogastroduodenoscopy performed by a gastroenterologist revealed a single, linear, mucosal tear 39 cm from the teeth with no obvious sign of perforation or active bleeding (Fig. 1). A recommendation was made for conservative management with a soft diet and omeprazole. After tracheal extubation, the patient was brought to the postanesthesia care unit with stable vital signs, but over the next 30 minutes, her oxyhemoglobin saturation would not increase above 93% to 94%, despite a high flow of oxygen delivery via a nonrebreathing mask. Auscultation revealed decreased breath sounds over the left hemithorax and a portable chest radiograph revealed a left pneumothorax (Fig. 2) and intensive care unit (ICU) staff were informed. While in the postanesthesia care unit, the patient had a chest tube placed and was then transferred to the ICU. In the ICU, an esophagram (Fig. 3) was ordered that revealed an esophageal perforation. The patient was then transferred to a different hospital for possible thoracic repair of this injury. An esophageal stent was placed and removed 2.5 weeks later. No persistent leak was noted, and appropriate follow-up revealed no additional complications.
DISCUSSION
OG tubes are frequently used in anesthesia practice, most commonly for gastric decompression and potential reduction of postoperative nausea and volume of postoperative emesis. In this patient, it was deemed appropriate because the patient had a history of postoperative nausea and vomiting. OG tube placement carries certain known risks including tracheobronchopleural penetrations,1–3 intravascular penetration,4 gastroesophageal rupture,5 and intracranial entry.6 Rassis et al.2 reported a 2% incident of tracheopulmonary complications among 740 tube insertions associated with a 0.3% mortality rate. Pneumothoraces accounted for approximately 60% of these complications, requiring chest tube placement 50% of the time.1,2 The risk is greater in anesthetized, tracheally intubated patients who cannot give verbal feedback while attempting OG or nasogastric tube placement.7 In our patient, early involvement of appropriate consultants and the culture of supporting complete May 15, 2014 • Volume 2 • Number 10
Figure 1. Single linear 10 mm tear in esophagus found on esophagogastroduodenoscopy.
Figure 2. Chest radiograph taken in the postanesthesia care unit, showing large pneumothorax.
patient care limited a potentially life-threatening complication. Although these complications are rare, they can have devastating outcomes if not identified early. Patients should be identified as having high risk for increased stomach contents before placement of an OG tube to avoid unnecessary complications, and if blood is noted in the OG tube, this complication should be considered. E
Figure 3. Esophagram showing contrast above the diaphragm and extravasation. REFERENCES 1. Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429–33 2. Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2:25–8
May 15, 2014 • Volume 2 • Number 10 cases-anesthesia-analgesia.org 123
Esophageal Perforation and Pneumothorax
3. Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardiovasc Surg 2010;58:476–80 4. Düthorn L, Schulte Steinberg H, Häuser H, Neeser G, Pracki P. Accidental intravascular placement of a feeding tube. Anesthesiology 1998;89:251–3 5. Wu PY, Kang TJ, Hui CK, Hung MH, Sun WZ, Chan WH. Fatal massive hemorrhage caused by nasogastric tube misplacement
124 cases-anesthesia-analgesia.org
in a patient with mediastinitis. J Formos Med Assoc 2006; 105:80–5 6. Gregory JA, Turner PT, Reynolds AF. A complication of nasogastric intubation: intracranial penetration. J Trauma 1978;18: 823–4 7. Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med 1989;149:184–8
A & A case reports
