Gastric Rupture after Bag Mask Ventilation: A Review Under a Case Report Marta Carvalho 1 , Pedro Godinho 2 , Andreia Moura 3 , Carla Silva 3 , Isabel Tourais 3 , Margarida Marques 3 and Humberto S Machado 1* 1 Department of Anesthesiology, Intensive Care and Emergency, Centro Hospitalar do Porto, Portugal 2 Department of Anesthesiology, Centro Hospitalar de Leiria, Portugal 3 Department of Anesthesiology and Burn Unit, Centro Hospitalar de Universitário de Coimbra, Portugal * Corresponding author: Humberto S Machado, Department of Anesthesiology, Centro Hospitalar do Porto, 4099-001 Porto, Portugal, Tel: 00351935848475; E-mail: hjs.machado@gmail.com Received date: March 24, 2016; Accepted date: May 02, 2016; Published date: May 09, 2016 Copyright: © 2016 Carvalho M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Introduction: Bag mask ventilation is considered a safe and effective ventilation method. Despite the high frequency of gastric distension, few cases of gastric rupture are reported in literature. Case report: A 50-year-old female firefighter, ASA 2, was admitted in to the Burn Unit due to 2nd/3rd grade burns (34% of body surface). On the 22nd day after admission, she underwent balneotherapy, under sedation and analgesia and in spontaneous ventilation. During the procedure, desaturation (SpO 2 65%) and paradoxical respiratory abdominal movements were noticed. Very high pressures were immediately required for bag-mask ventilation and the bag was difficult to compress. A remarkable increase in abdominal perimeter was evident, leading to the compromise of lower limb circulation. The patient was intubated and a noradrenaline infusion started due to marked hypotension, unresponsive to fluids. Imaging studies revealed a left pulmonary atelectasis and a massive pneumoperitoneum. Emergent exploratory laparotomy demonstrated a gastric laceration in an ischemic mucosa area, which was corrected. The patient was extubated on the first post-operative day, with no further complications. Conclusion: Although bag mask ventilation is a routine practice, it is associated with several complications. Gastric rupture is an extreme rare complication of this technique. The higher incidence of curling ulcers in burned patients may have contributed to gastric rupture and this case stresses the need to consider this potentially lethal complication. Keywords: Gastric rupture; Bag mask ventilation; Burned patient Introduction Bag-valve-mask ventilation (BMV) is a safe and efective method of ventilation. Common complications such as aspiration, difcult ventilation or gastric dilatation are usually promptly recognized, but not always easily corrected [1]. Gastric distension, despite fairly common, rarely leads to gastric perforation and very few cases are reported in literature [2]. Although local ischemia and structural wall defects may predispose to acute gastric rupture (GR), some cases may occur in normal tissue [2-4]. Complications of acute GR include gross peritonitis, sepsis, and cardiopulmonary dysfunction, with mortality rates as high as 80% [5,6]. We report a case of acute GR, during BMV, leading to tension pneumoperitoneum. Case Report A 50-year-old frefghter, with controlled arterial hypertension (ASA 2) was admitted into the Burn Unit due to second and third- degree burns (34% of total body area, caused by fre). She was under pantoprazol 40 mg once daily and morphine (patient- controlled analgesia system), since admission. Tere was no record of hemodynamic instability and the patient was kept under spontaneous ventilation without ventilatory support. Previous balneotherapies and surgical escharotomies underwent with no complications. She was scheduled for a new balneotherapy on the 22nd day afer admission and the procedure started under sedation and analgesia (midazolam 2 mg, fentanyl 0.1 mg, propofol 50 mg and ketamine 25 mg) in spontaneous ventilation, with supplementary oxygen by nasal cannula (FiO 2 28%). Sedation was followed by an episode of desaturation (SpO 2 80%), with total recovery afer oropharyngeal tube placement. A few minutes later, she developed a new episode of desaturation (SpO 2 65%) and bag mask ventilation with 100% oxygen was promptly started, only with partial recovery. Very high pressures were required for BMV and it was difcult to compress the bag. A progressive and signifcant increase in abdominal perimeter was evident, leading to the compromise of lower limb circulation. Te patient was intubated (uneventfully, with visualization of tube passage between vocal cords) with subsequent nasogastric tube and rectal probe placement. Correct tube placement was confrmed by means of end-expiratory CO 2 measurements. Substantial inspiratory peak and plateau pressures (50-60 mmHg) were required to raise the oxygen saturation above 90% (measured by plethysmography) and thoracic expansion was perceived asymmetric, with absent lef respiratory sounds. Fluid unresponsive hypotension led to the start of a noradrenaline infusion. Pulmonary X-ray disclosed a lef pulmonary atelectasis. Pneumoperitoneum was evident on abdominal x-ray and ultrasound (Figures 1 and 2). Emergent exploratory laparotomy revealed a gastric laceration in an ischemic mucosa area in the lesser curvature, which was surgically repaired. Afer peritoneal cavity opening, ventilator pressures decreased to 20-30 cm H 2 O and the patient became Carvalho, et al., J Anesth Clin Res 2016, 7:5 DOI: 10.4172/2155-6148.1000617 Case Report Open Access J Anesth Clin Res ISSN:2155-6148 JACR, an open access journal Volume 7 • Issue 5 • 1000617 J o u r n a l o f A n e s t h e s i a & C l i n i c a l R e s e a r c h ISSN: 2155-6148 Journal of Anesthesia & Clinical Research