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
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ISSN: 2155-6148
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