Orogastric Tube Fracture and Ingestion in a Patient With Hyperacute Delirium: A Unique and Potentially Catastrophic Complication.

Orogastric tubes (OGTs) are frequently used to administer feeds and medications to critically ill patients. They are inserted blindly, with a low first-pass success rate and frequent benign complications. OGT fractures and ingestion are exceedingly rare, with only two cases reported to date. Herein, we describe a rare case of OGT transection and ingestion in a male patient admitted for hyperacute delirium and complicated pneumonia. The OGT remnant was retrieved using an endoscope without any complications. Clinicians must be aware of this rare but potentially catastrophic complication of OGT use. OGTs must be inspected in the same manner as endotracheal tubes to ensure patient safety.