Respiratory insufficiency with pneumonia following improper gastric tube insertion into the right bronchus

Blind placement of gastric tubes is commonly done at the bedside, and is associated with significant risk. Inadvertent placement of gastric tubes into the lungs may lead to some dreaded and serious complications including intrapulmonary infusion of fluids, pneumothorax, pneumonitis, hydropneumothorax, bronchopleural fistula, empyema, and pulmonary hemorrhage. Although the reported frequency of inadvertent airway gastric tube placement varies from 1% to 15%, clinicians agree that the associated complications may result in increases in mortality, morbidity, cost and length of hospital stay, and are to be avoided [1]. In this report, we would like to present a case of respiratory insufficiency with pneumonia following improper gastric tube insertion into the right bronchus and active carbon administration. On the day of admittance, in the morning hours, the patient (a 43-yearold prisoner) was brought by ambulance to the local Emergency and Rescue (ER) Department from a prison, with suspected drug intoxication with an unknown substance. In the ER, the patient was unconscious but with both respiration and circulation fully sufficient, and a directional reaction to pain stimuli. On auscultation, numerous disseminated rhonchi, more pronounced on the left side, were heard. The patient was intubated (using thiopental and suxamethonium), and the gastric tube was placed, with subsequent gastric lavage. A pus-like fluid was extracted from the tracheal tube using suction; chest X-ray was performed to exclude pneumonia. As the patient’s general condition improved, he regained full consciousness, and with spontaneous breathing the tracheal tube proved unnecessary, which resulted in extubation (within approximately 30 min). The gastric tube was removed as well, but due to bronchial spasm, salbutamol nebulization was initiated, with further improvement of the general condition. Toxicological analyses were performed from urine and blood samples. At this stage, the patient was mentally labile, with pronounced anxiety and non-compliance with medical personnel requests, and was often verbally offensive. Two hours after admittance to the ER, toxicological analysis revealed high (toxic) levels of carbamazepine and phenothiazine, resulting in the introduction of treatment with activated carbon. A gastric tube (16 F) was placed again through the nasal cavity; however, this time the patient was fully conscious. Corresponding author: Joanna Solek-Pastuszka MD, PhD Clinic of Anesthesiology and Intensive Care Pomeranian Medical University 1 Unii Lubelskiej St 70-252 Szczecin, Poland Phone: +48 91 425 33 78 Fax: +48 91 425 33 84 E-mail: [email protected] 1Clinic of Anesthesiology and Intensive Care, Pomeranian Medical University, Szczecin, Poland 2Department of Clinical Anesthesiology and Intensive Care for Adults and Children, Pomeranian Medical University, Police, Poland