鼻胃管之置放為急重症病人治療上極為重要之步驟,尤其對於意識不清患者更為提供餵食之重要途徑,而錯誤的置放更可能造成致命性的併發症。我們報告一例鼻胃管錯置之病例。病人因呼吸衰竭而置放氣管內管及鼻胃管置入餵食。初時以聽診胃區確認鼻胃管位置,隨後並照胸部X光片但誤認為是氣管內管置放過深而置入右支氣管中。後雖經過再次評估發現是鼻胃管誤入右支氣管,因此拔除鼻胃再重新置入胃內,但病人仍因敗血症於兩週後死亡。文獻報告指出,即使已放入氣管內管或氣切管後,仍有可能將鼻胃管錯置入氣管或支氣管內。因此鼻胃管置入後,X光的確認及正確的判讀仍是重要且關鍵性的步驟,而這往往是為醫療人員所輕忽的。
Nasogastric tube is a replacement method of food providing for unconscious patient. The misplacement of nasogastric tube may associate with some lethal complications. We report a case of right bronchus misplacement of nasogastric tube in a respiratory failure patient. After Chest X-ray confirmation and reinserted the nasogastric tube into the stomach carefully. But patient expired 2 weeks later unfortunately. Careful nasogastric tube insertion and chest X-ray confirmation the location of nasogastric tube are suggested.