Anesth Analg 2008; 106:1592-
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e31816a3111
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Gastric Rupture and Pneumoperitoneum Caused by Oxygen Insufflation via a Fiberoptic Bronchoscope
Niels Chapman, MD
Department of Anesthesiology and Critical Care Medicine; University of New Mexico School of Medicine; 1 University of New Mexico; Albuquerque, New Mexico; nchapman{at}salud.unm.edu
To the Editor:
We report this event after having found only two other cases of gastric rupture after fiberoptic intubation with oxygen insufflation via the bronchoscope.1,2
An 81-yr-old man was scheduled for fusion of an unstable C-1 burst fracture. Awake fiberoptic intubation was chosen. After informed consent, the airway was topically anesthetized. Minimal systemic sedation was required as the patient was very cooperative. An Olympus BF-P160 videoscope, loaded with an 8-0 Mallincrodt endotracheal tube, was advanced through an oral airway conduit with intermittent 5 L/min oxygen insufflation via the working port. Visualization of airway structures was difficult; the esophagus was entered on two separate occasions with a combined maximum duration of approximately 30 s. After fiberoptic-assisted tracheal intubation was achieved, a neurological examination proved normal and general anesthesia was induced. A deterioration in the patient's hemodynamics required boluses of phenylephrine. On removal of the warming blankets, a very distended, tympanitic abdomen was discovered. Attempts to place an orogastric tube and gastroscopy failed and emergency laparotomy was performed. Findings included multiple gastric ruptures including a large perforation along the lesser curvature, which were surgically repaired. Subsequently, a fulminant coagulopathy evolved requiring temporary abdominal closure. Despite aggressive therapy, the coagulopathy remained uncontrollable, and care was withdrawn in consensus with the patient's guardian.
This incident illustrates the significant vulnerability of the esophagus and stomach to pressurized gases. In the two other reported cases of gastric rupture associated with oxygen insufflation during fiberoptic tracheal intubation, the oxygen flows were 3 and 5 L/min, respectively.1,2 Although Ovassapian and Mesnick discourage the use of oxygen insufflation via a bronchoscope,3 if supplemental oxygen is required, it might be safer to administer it via nasal prongs or via a separate catheter near the mouth rather than via the bronchoscope because of the danger of gastric distension should the tip of the bronchoscope enter the esophagus. In addition, the abdomen should remain uncovered during intubation, so that gastric distension, if present, can be immediately seen and treated.
REFERENCES
- Hershey MD, Hannenberg AA. Gastric distention and rupture from oxygen insufflation during fiberoptic intubation. Anesthesiology 1996;85:1479–80[Web of Science][Medline]
- Ho CM, Yin IW, Tsou KF, Chow LH, Tsai SK. Gastric rupture after awake fiberoptic intubation in a patient with laryngeal carcinoma. Br J Anaesth 2005;94:856–8[Abstract/Free Full Text]
- Ovaspassian A, Mesnick PS. Oxygen insufflation through the fiberscope to assist intubation is not recommended. Anesthesiology 1997;87:183–4[Web of Science][Medline]
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