Department of Anaesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
* Corresponding author: Department of Anaesthesiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd, Taipei 112, Taiwan. E-mail: cmho{at}vghtpe.gov.tw
Accepted for publication February 11, 2005.
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Abstract |
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Keywords: complications, gastric rupture ; complications, intraoperative ; complications, stomach rupture ; intubation, fibreoptic ; intubation, tracheal
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Introduction |
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Case report |
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In the operating room, electrocardiography, pulse oximetry, non-invasive arterial blood pressure monitoring, and several minutes of preoxygenation were begun before intravenous glycopyrrolate 0.2 mg, midazolam 2 mg and fentanyl 50 µg were administered. After cotton-tipped application of 4% cocaine on the nasal mucosa and spraying with 10% lidocaine in the upper airway, the distal end of a fibrescope (FI-10RBS, diameter 3.5 mm; Pentax, Tokyo, Japan) was advanced into the pharynx through the right nostril. Oxygen (5 litre min1) was delivered via an auxiliary supply from the anaesthesia machine (Narkomed GS; North American Dräger, Telford, PA, USA) and insufflated intermittently through the fibrescope suction channel. After two attempts, the narrowed glottic opening was visualized and the tip of the fibrescope was advanced into the trachea. Subsequently, the lubricated 7-mm cuffed tracheal tube (Hi-Contour; Mallinckrodt Medical, Athlone, Ireland) was threaded into the trachea via the shaft of the fibrescope after identification of the carina. Because of difficulties in withdrawing the fibrescope, the fibrescope with the tracheal tube was withdrawn. At the same time, the patient became agitated and bucked suddenly. Five minutes later, another attempt was made, and thiamylal 180 mg, fentanyl 100 µg and atracurium 25 mg were administered for induction of general anaesthesia. Although three attempts at intubation took about 20 min, we estimated that the total cumulative time during which the fibrescope was in the pharynx with oxygen delivered was approximately 3 min. A distended, tense and tympanic abdomen was noted. Immediate insertion of a nasogastric tube did not produce any improvement. The surgery was uneventful and finished within 2 h. The patient's trachea was not extubated because of abdominal distension. He was sent to a postanaesthesia care unit for observation.
In the unit, the patient became irritable and severe abdominal pain was noted. A semi-erect chest X-ray (Fig. 1) revealed a massive pneumoperitoneum. Emergency laparotomy was performed for suspected perforated hollow viscus. When the abdominal cavity was opened, large volumes of gas escaped and the stomach and small intestine collapsed. A 4-cm full-thickness longitudinal tear along the lesser curvature of the stomach close to the cardia was identified and repaired in two layers. Ten days later, wound disruption and a suspicious leakage were found. Emergency laparotomy revealed leakage of the previous primary closure with many localized abscesses, and total gastrectomy and Roux-en-Y oesophagojejunostomy were done. In the surgical intensive care unit, prolonged, assisted ventilation was required because of deteriorating pulmonary function. The patient died from multiple organ failure after 58 days of hospitalization.
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Discussion |
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Possible aetiologies for iatrogenic gastric rupture may be classified into two major categories: inadvertent oxygen administration and external compression. Inadvertent oxygen administration includes mouth-to-mouth resuscitation,4 bag-mask resuscitation,5 nasal catheter insertion6 and inadvertent oesophageal intubation.7
An inflation pressure of 1525 cm H2O is needed to open the lower oesophageal sphincter and to force oxygen into the stomach.8 A flow of oxygen at 5 litre min1 in combination with glycopyrrolate and fentanyl, which both decrease the oesophageal sphincter tone,9 may have been sufficient to blow oxygen into the stomach. Although the cardia and pylorus are sites of potential decompression because of fixation by the hepatogastric ligament,10 different degrees of gastric distension (along the lesser and major curvatures) may change the anatomy and configuration of the stomach to prevent outlet of oxygen.3 4 7
External cardiac massage10 and the Heimlich manoeuvre11 are possible sources of external compression. Intragastric pressure of roughly 50100 cm H2O is required for gastric rupture in a post-mortem cadaver.4 Thus, forcing oxygen into the stomach and compressing the abdominal wall both play important roles. In our patient, oxygen insufflation from the suction channel of the fibrescope coupled with an agitated and bucking patient could have caused increased intra-abdominal pressure and a critical intragastric pressure, leading to gastric rupture. As in the previously reported case,3 nasogastric suctioning was not helpful because the stomach on rupture decompressed itself into the peritoneal cavity.
Because the upper part of the lesser curvature contains fewer mucosal folds and becomes less elastic,7 10 it is the most common gastric rupture site.6 11 McDonnell and colleagues12 presented the catenoidal configuration model and Barker and Karagianes5 employed LaPlace's law to explain why wall tension in the stomach during gas inflation is greatest along the lesser curvature. Increased intragastric tension elevates intraluminal tension more here, dragging the mucosa of the lesser curve over the catenoidal segment.
Fibreoptic intubation, retrograde intubation and transtracheal jet ventilation are all established techniques for the management of the difficult airway.1 Among these, fibreoptic intubation is the preferable management for an anticipated difficult airway.13 14 Retrograde intubation is performed blindly and is an alternative when fibreoptic intubation is precluded or fails, or is unavailable.15 Transtracheal jet ventilation is relatively contraindicated in patients with an obstructed upper airway and may cause barotraumas.16 However, transtracheal jet ventilation is considered an alternative when conventional methods are unsuccessful.17 Therefore, fibreoptic intubation was adopted as the approach in our patient.
In conclusion, although oxygen insufflation to assist fibreoptic intubation is commonly recommended for directing secretions, defogging the lens and oxygenating the patient,18 19 we present this unusual case to emphasize that gastric rupture is a potential complication of fibreoptic intubation in the awake patient with partial upper airway obstruction.
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References |
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