Discussion:
Critical patients are at risk of multiple complications owing to both
their illnesses and malnutrition. From having just a supportive role of
maintaining lean body mass and immunity, the view on the role of
nutrition has evolved into a more complicated one like minimizing
metabolic response to inflammation and evading disease-related
malnutrition 2, 4. As enteral feeding is more
physiological and associated with less frequency of complications than
parenteral feeding, in our center enteral feeding is preferred in cases
with no contradiction.
Nasogastric and orogastric tubes are the most commonly inserted feeding
tubes. In most cases, they are inserted blindly. Not only for feeding,
but they are also used for gastric and intestinal decompression in
intestinal obstructions, gastric lavage, and general anesthesia before
emergency surgical procedures. We counseled the patient’s party
regarding the alternative ways of enteral feeding like percutaneous
endoscopic gastrostomy, given the risk of aspiration in long-term
orogastric feeding. However, any surgical procedures were declined by
the patient party who chose to continue on the orogastric tube feeding.
In most cases, enteral feeding via a nasogastric or orogastric tube is a
safe procedure. Relative contraindications include conditions associated
with trauma like skull base fracture and facial bone fractures. In these
conditions, it is recommended to insert an orogastric tube under direct
vision in place of an orogastric tube.5 There have
been reported fatal incidents of insertion into the cranium itself in
patients with basilar skull fracture6. Esophageal
trauma or obstruction is another contraindication of orogastric tube
insertion. It can worsen the injury, cause perforation or even get
easily misplaced, especially in corrosive chemical
ingestions.7
Other more commonly encountered problems include discomfort, obstruction
of the tube, and trauma during insertion. Tube blockage occurs due to a
variety of causes among which coagulation of feeding formula, tube
kinking, medication fragments, and incompatible infusate precipitation
are the common ones.8 Gently flushing the tube after
each feed can help avoid the issue of feeding tube obstruction. In
another incident of a rare complication, a tube was blocked owing to
knotting in the stomach.9 It happened likely due to
leaving an excess length of the tube in the stomach, emphasizing the
need to avoid over inserting the tube. Long exposure to the harsh
gastric acid is a cause for the tube to break. Forceful flushing of an
obstructed tube can cause the distal end, usually a tip to
break.10 In our case though, the tube was fractured in
the middle and there was no issue in the earlier feed. The tube was
flushed regularly after feeding and no resistance was encountered in
doing so. It is not likely that acid or forceful flushing is the cause
of the tube fracture in our patient.
When a tube is fractured, it migrates distally owing to the peristalsis
in the gut tube. It is essentially managed as an ingested foreign body.
A study of endoscopic evaluation of foreign bodies shows that objects
longer than 6 cm are at risk of not passing the pylorus even after 48
hours after ingestion.11. Smaller pieces like the tip
of a feeding tube may be followed by a serial radiographic evaluation to
allow them to pass through the alimentary canal, but for larger foreign
bodies like in our case, it is not a wise idea to just follow the
passage tube as it carries the risk of intestinal obstruction and an
upper gastrointestinal endoscopy is the standard practice for the
removal of any ingested foreign body.12
Our patient had poor swallowing owing to the stroke and we relied on our
clinical judgment to do a laryngoscopic examination for the possibility
of the tube being in the throat. And luckily, the tube was still in the
esophagus with a proximal end in the laryngopharynx. It was retrieved
without difficulty in the same setting. Another reason for the tube
still being in an accessible position could have been the identification
of the fractured tube before it could migrate to the stomach.