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.