Deaths associated with insertion of nasogastric tubes for enteral nutrition in the medical intensive care unit: Clinical and autopsy findings

Abstract

It is generally assumed that blind insertion of nasogastric tubes for enteral nutrition in patients admitted to medical intensive care units is safe; that is, does not result in life-threatening injury. If death occurs in temporal association with insertion of a nasogastric tube, caregivers typically attribute it to underlying diseases, with little or no consideration of iatrogenic death due to tube insertion. The clinical and autopsy results in three recent cases at Baylor University Medical Center challenge the validity of these notions.

Keywords: Enteral nutrition; iatrogenic death; nasogastric tube.

Figure 1.

(a) Autopsy findings in case 1. The segmental bronchus of the right lower lobe of the lung was perforated (white arrow) with an adjacent pleural perforation and hematoma (blue arrow). (b) Reference drawing, courtesy of Kenhub (https://www.kenhub.com), illustrator Yousin Koh. Accessed March 19, 2018.

Figure 2.

(a) Autopsy findings in case 2. Transverse section of the anterior cranial fossa (looking down into the skull) reveals the abnormal presence of blood clots within the upper nasal cavities (white arrow), indicating nasopharyngeal hemorrhage. (b) Reference drawing for orientation, courtesy of Basicmedical Key (https://basicmedicalkey.com/the-musculoskeletal-system/. Accessed March 19, 2018).

Figure 3.

(a) Autopsy findings in case 3. Transverse section of the anterior cranial fossa reveals extensive blood and clots throughout the upper nasal cavities indicating nasopharyngeal hemorrhage (white arrow). (b) Similar view of the anterior cranial fossa in a patient without nasopharyngeal hemorrhage, demonstrating the normal absence of blood within the sphenoid sinus.

Figure 4.

Case 3, microscopic examination. Upper nasal cavity mucosa adjacent to the sphenoid sinus was focally disrupted (black arrow) with submucosal hemorrhage (white arrow). Hematoxylin and eosin, original magnification ×100.

Figure 5.

Line drawing of the nasal and oral routes through which a feeding tube can be inserted into the stomach. The red dot denotes the sphenoid recess, and the blue dot denotes the sphenoid sinus. The green dot denotes the larynx. The black arrow denotes mucosa of the nasal cavity, and the red arrow denotes mucosa of the hypopharynx.

Figure 6.

Tissue samples obtained from patients undergoing autopsy who had not required enteral feeding tubes or endotracheal tubes prior to death. (a) From the upper nasal cavity, adjacent to the sphenoid sinus. The pseudo-stratified columnar epithelium is thin and delicate. (b) From the oropharynx. The stratified squamous epithelium is relatively much thicker than mucosa from the upper nasal cavity. Hematoxylin and eosin, original magnification ×100.