In addition to reports of feeding tubes misplaced in the lungs, there have been reports of perforated esophagus and insertion into the brain.
Intracranial feeding tube placement have been mentioned in medical literature.
- Isik A, Firat D, Peker K, Sayar I, Idiz O, Soyt ¨urkM. A case report of esophageal perforation: complication of nasogastric tube placement. Am J Case Rep. 2014;15:168-171.
- Lord, L.M. Enteral Access Devices: Types, Function, Care, and Challenges. Nutrition in Clinical Practice, 2016; 33(1):16-38. doi: 10.1002/ncp.10019
- Hassan A. The inadvertent intracranial introduction of nasogastric tube: The lesson learned the hard way. Saudi J Health Sci 2016;5:145-7
New York State Public Health Law requires that nasogastric tubes for patient feeding must be the smallest possible and not exceed 12 Fr in diameter unless medically indicated.*
In addition, the feeding tube must be made of a soft, flexible material and specifically manufactured for nasogastric feeding.*
In the United Kingdom, administering enteral therapy into a misplaced feeding tube is considered a Never Event.*
Never events are defined as ‘serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic barriers are available at a national level and should have been implicated by all healthcare providers’.*
|NHS England Patient Safety Domain. Revised never events policy and framework; 2015. https://www.england.nhs.uk/wp-content/uploads/2015/04/never-evnts-pol-framwrkapr.pdf. Accessed 20 May 2019.|
Of the 1.2 million small bore feeding tubes placed, about 0.1-0.3% of patients die as a result of blind misplacement.*
About 1.2–2 percent of small bore feeding tubes that are placed blindly at the bedside enter the airway undetected. *
* Krenitsky, J. Blind Bedside Placement of Feeding Tubes: Treatment or Threat? Practical Gastroenterology. 2011; March, 32-42.|
There are nearly 249,000 adult patients who rely on home enteral nutrition.*
This accounts for 60% of home care patients with enteral access devices. *
Mundi, M. S., Pattinson, A. , McMahon, M. T., Davidson, J. and Hurt, R.
T. (2017), Prevalence of Home Parenteral and Enteral Nutrition in the
United States. Home Nutrition Support, 32: 799-805.
Approximately 50% of patients with head and neck cancer will require enteral nutrition.*
It is estimated that 13,000 new cases of head and neck cancer were diagnosed in 2017. *
Greaves, J.R. (2018). Head and Neck Cancer Tumor Seeding at the
Percutaneous Endoscopic Gastrostomy Site. Nutrition in Clinical
Practice, 33(1), 73-80.