Yuan You, Zhong Wei, Gao Huiming, Zhang Xia, Chen Junxi, Qing Yuanqin, Hu Rujun
Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, People's Republic of China.
Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, People's Republic of China.
Medicine (Baltimore). 2025 Jan 10;104(2):e41101. doi: 10.1097/MD.0000000000041101.
Enteral nutrition is a critical component of care for critically ill patients. However, the blind insertion of a nasoenteric tube, despite being a simple procedure, carries inherent risks that necessitate a reevaluation of the technique.
A case of a 60-year-old female experienced the rare yet critical complication of a misplaced nasoenteric tube entering the thoracic cavity during a blind insertion procedure for enteral nutrition following a liver transplant.
Following liver transplantation, the patient was diagnosed with severe pneumonia, a right-sided hydropneumothorax, and severe malnutrition.
After the misplacement of the nasoenteric tube into the pleural cavity was detected from the chest X-ray, the tube was immediately removed, and the pneumothorax was actively managed. Subsequently, with the support of contrast radiography, the nasoenteric tube was successfully reinserted to provide the patient with nutritional support and promote rehabilitation.
The patient responded well to the intervention and was discharged in stable condition following complete recovery.
The case prompts a reevaluation of blind placement techniques and calls for the adoption of more reliable technologies to prevent similar incidents and ensure patient safety, such as electromagnetic and visualized guided placement technique.
肠内营养是重症患者护理的关键组成部分。然而，鼻肠管的盲目插入尽管是一个简单的操作，但存在内在风险，需要对该技术进行重新评估。
一名60岁女性患者在肝移植后进行肠内营养盲目插入操作时，发生了罕见但严重的并发症，即鼻肠管误插入胸腔。
肝移植后，该患者被诊断为严重肺炎、右侧血气胸和严重营养不良。
胸部X光检查发现鼻肠管误插入胸腔后，立即将导管取出，并对气胸进行积极处理。随后，在造影检查的支持下，成功重新插入鼻肠管，为患者提供营养支持并促进康复。
患者对干预措施反应良好，完全康复后病情稳定出院。
该病例促使人们重新评估盲目放置技术，并呼吁采用更可靠的技术来预防类似事件，确保患者安全，如电磁和可视化引导放置技术。
