74 year old man from nursing home presented to the Emergency Department for replacement of feeding tube. The resident places the feeding tube and “burp” auscultated without any material aspirated from tube. Confident the tube was in place the patient was sent back to the nursing home but noted to be complaining of belly pain with abdominal distention on exam. The patient was then sent back to ER where he was noted to have acute abdomen. Diagnostic CT showed the feeding tube misplaced into the peritoneum. Patient was then emergently taken to OR where feeding tube and large amount of feeding material noted to be in peritoneum.
Issue: No date of placement of feeding tube noted. Feeding tubes are not mature for at least 4 weeks. Because the feeding tube tract may not have matured adequately before 4 weeks, the gastric wall and the abdominal wall may separate leaving a rent in the gastric wall. The blind placement of a feeding tube at the bedside may result in the tube being placed in the peritoneal cavity. Therefore, if it has been less than 4 weeks since placement of the feeding tube, the site is immature and feeding tube replacement should be referred to GI. The problem may be that information on the date of placement of the tube may not be available
Issue: Is auscultation of “burp” adequate for confirmation of tube? If feeding material returns on placement of tube and you hear a burp, this may be sufficient. However, verification with contrast x-ray of abdomen is prudent if any doubt. In fact up-to-date declares contrast x-ray verification as the standard of care for verification of feeding tube placement.
Issue: As an attending you do not know what the resident does not know. You can’t assume anything. This requires eternal vigilance as one easily goes into the default mode of assuming the resident may know “basic” stuff. With EMR, there should be a template specifically asking date of placement of tube and if it is less than 4 weeks a recommended referral to GI. After pt is discharged, call the patient back if you find that the tube placement wasnt adequately verified.
– Dr. Peter Gruber