Case Presentation
A 58-year male developed a sudden onset of weakness in the right half of
the body along with slurring of speech and difficulty in swallowing. For
the same, the patient went to a local center where he was diagnosed to
have a posterior circulation stroke. He was referred to a tertiary care
center where he underwent Digital Subtraction Angiography and a
thrombectomy. The procedure was uneventful and the patient stayed there
at the ICU, intubated for five days before coming to our center against
medical advice for financial constraints. On presentation to our ICU,
the patient also had a fever and he was started on
piperacillin-tazobactam after sending for pan-culture. According to the
ICU protocol, he was started on enteral nutrition via an orogastric
tube. The patient tolerated the feeds well and he was continued on the
same. Gastric aspirate volume was less than 150 ml throughout the ICU
stay.
On the third day of admission, the patient also developed septic shock
and required noradrenaline support for two days. The culture report
returned positive for Klebsiella pneumoniae in the sputum which
was sensitive to the started antibiotics. However, the fever did not
subside and a repeat culture on the fourth day of admission returned
positive for methicillin-resistant Staphylococcus aureus,sensitive to amikacin.
Multiple attempts to wean the patient off the ventilator were
unsuccessful and anticipating a prolonged requirement of mechanical
ventilation, the endotracheal tube was changed to a tracheostomy tube
via a percutaneous approach on the 10th day of
admission and the 17th day of intubation. The patient
was continued on feed via an orogastric tube.
We tried to wean the patient off the ventilator after tracheostomy but
the patient developed tachypnea and desaturation every time we
de-escalated mechanical ventilation. The orogastric tube was changed
once after 20 days in the ICU. After the 25th day of
his stay in our ICU, antibiotics were stopped as the patient became
afebrile for 48 hours. However, only 4 days after stopping the
antibiotics, he developed a fever again and he was started on meropenem
and vancomycin. His urine routine and culture showed infection withEnterococcus faecalis, sensitive to polymyxin B and the
antibiotics were replaced accordingly. The patient’s party was counseled
regarding the option of Percutaneous Endoscopic Gastrostomy for the
likelihood of long-term requirement of a feeding tube, but they refused
the escalation of care and also signed a do not resuscitate order.
On the 40th day of admission, the nasogastric tube was
changed for obstruction. The 16 Fr tube was replaced by another of the
same size. Its position was confirmed clinically by listening to the
gush of airflow into the stomach using a 50 ml syringe and a
stethoscope. Feeding attempts after insertion of the tube were
uneventful.
On the 45th day of ICU admission, during regular
feeding, the proximal end of the orogastric tube was found broken by the
caring nurse. The distal end was nowhere to be seen in the oral cavity.
The patient was immediately sedated and paralyzed on the suspicion of a
fractured, orogastric tube. A laryngoscopic examination of the patient
revealed that the proximal end of the distal part in the proximal
esophagus and the distal part was retrieved using Magill forceps.
(Figure 1) Another orogastric tube was inserted two hours after the
event and the patient was started on oral feed immediately. The patient
tolerated the feed and was continued on the same.