Introduction: Small-bore nasoenteric tubes such as the Dobhoff are ubiquitous in the management of critical illness in the intensive care unit. They provide an effective means of providing enteral nutrition and medications to patients unable to safely swallow. While the reported mortality rate is well under 1%, complications can arise, such as pneumothorax, gastrointestinal perforation, and, very rarely, fracturing of the Dobhoff itself. We present a case series in which multiple patients presented with ruptured Dobhoff tubes and the proper steps to mitigate their recurrence.
Description: The patient is a 45-year-old male who presented for refractory hypoxemic respiratory failure secondary to alcohol induced interstitial pancreatitis. His PO2 levels were persistently low despite high PEEP, proning techniques, paralytics, and inhaled epoprostonol. He was then transferred for consideration of venovenous extracorporeal membrane oxygenation (VV-ECMO). His PO2 levels improved, and a Dobhoff was then placed for nutrition. A follow-up abdominal X-ray revealed that the feeding tube was broken at the level of the stomach. Gastroenterology was promptly consulted for endoscopic retrieval. In that same week, several other patients within the ICU presented with ruptured feeding tubes within the GI tract. A root cause analysis was initiated by a panel of intensive care physicians, pharmacists, healthcare administrators, and nursing leadership. Ultimately, it was determined that flushing the Dobhoff tube with an obstruction can lead to rupture. Regular assessment of tube position and function should be performed through routine evaluation and daily abdominal x-rays. Education regarding risk factors, troubleshooting techniques, and methods to avoid excessive flushing pressure is vital. Manufacturing defects must also be considered as an etiology. Developing standardized protocols regarding declogging can be utilized to maintain structural integrity. Minimizing the use of physical/chemical restraints can help reduce agitation and self-removal attempts.
Discussion: A series of ruptured enteric tubes necessitates the need for a multidisciplinary team to execute a root cause analysis. Ultimately, through education, standardized protocols, and close follow-up with the manufacturer, this complication can be avoided.
