Patients whore ceived esophageal resection and gastroesophageal rebuild before was likely to occur stomach-ectopia to chest when years later. Patients who occurred gastric aspiration during anesthesia have very high risks proceeding to severe aspiration pneumoniaorMendelson’s syndrome.A67-year-old female patient had ahistoryofesophagealcarcinoma10yearsago,thenshereceived aradicalesophagealresectionandgastro-esophagealrebuild.Ina new operation with sufficient fasting period, the patient aspirated thegastriccontentsduringanesthesiainduction,atabouttwomin- ute later after a low tidal mask positive ventilation. The patient wasdiagnosedasgastricaspirationfromfiberopticbronchoscopy revealingyellowandgreengastriccontentsexistedinherairway. Visually intra-tracheobronchial suction and irrigation with sterile saline was performed through the fiberoptic bronchoscope to removethegastriccontents.ThoughreceivingFOBinterventionas late as nearly 5-hours after aspiration, the patient still recovered very well without secondary intubation or other complications. Careful and comprehensive pre-operative visit was vital to anesthesiologists.Patientswithahistoryofesophagealsurgeryshould avoid mask positive ventilation during anesthesia induction. Fiberoptic bronchoscopy guided suction and irrigation was a very effectiveandpowerfulmethodtotreatgastriccontents aspiration
2. IntroductionPerioperative airway management can be challenging in patients with a history of gastrointestinal surgery. Patients who received gastrointestinal or esophageal surgery before is vulnerable to aspiration especially during anesthesia intubation and extubation periods[1,2].Inparticular,theacidgastriccontentsaspiration is especially a disaster compared with other kinds of aspiration, knownasMendelson’ssyndrome[3].Theconventionaltreatment ofMendelson’ssyndromewereanti-infection,anti-fibrosis,hor- *Correspondingauthor: Zhongliang Dai, ZhongjunZhang,Departmentof Anesthesiology, Shenzhen People’s Hospital (The First Affiliated Hospital, Southern University of Science and Technology; The Second Clinical Medical College, Jinan University), Shenzhen EngineeringResearchCenterofAnesthesiology, Shenzhen, Guangdong 518020, P.R. China, Email:daizhongliang@jnu.edu.cn,lu ckydoczhang@163.com CaseReport ISSN2639-8109Volume7 Volume7Issue12-2021 CaseReport http://www.acmcasereports.com/ 2 monotherapy and ventilator support therapy [4]. Previously, the treatments to gastric aspiration were really limited and helpless, leadingtohighmortalityandbadoutcomes[5].ButafterFiberop- tic Bronchoscopy (FOB) was applied to aspiration related pneumonia,ithasbeenprovedveryeffectiveinemergencyward,ICU, and cerebral surgery departments [6,7,8]. But in anesthesiology, as far as we know, it still has not been suggested as a guidelineor the first choice to aspiration during anesthesia [9]. Here we re- ported this efficient treatment to Mendelson’s syndrome, and our case showed that even FOB was not applied immediately, it still hadbenefitcomparedwithothertraditionalmethods.Furthermore, wedigoutthelessonsfromthepreoperativevisittoanesthesiainduction,anditwarnedusthatthejuniorresidentanesthesiologists should be more cautious.
3. Case ReportA 67-year-old female patient had an esophageal carcinoma 10 yearsago,andshereceivedaradicalesophagealresectionand gastroesophagealrebuildthen.Sincethensherecoveredverywell, and only remained the impaired appetite and the weight lose. In lifetime she had no symptoms of reflux or flatulence. This time she suffered from a traffic crash and was submitted to hospital. She was diagnosed as multiple fractures, postoperative esophageal cancer, mild anemia, hyperglycemia, moderate malnutrition, hypoproteinemia.At first, she received a surgery on humerus and tibiofibularinER,andstepintoatemporarystablecondition.One weeklater,shewassubmittedtoORforafixationoffemoralneck fracture again. This time she had enough fasting period before operation. The day before the second surgery when the primary resident anesthetist executed the preoperative visit, the thoracic CT examination was not in her document and the resident only checked the thoracic X-ray, ECG assessment, CT examination around hip joint, and some other basic blood examinations. The thoracicX-rayreportwasbilateralpleuraleffusionandpulmonary infection, as shown in (Figure 1) On the morning of the second surgery, she was in good condition when came into OR.After enough sedation, the anesthetists gave heraconventionalinduction,thatis,sequentiallyinjectionofetomidate, propofol, cisatracurium, sufentanil, and then gave her a lowtidalandhighfrequencypositivemaskventilation(300mlvolume,16timesperminute.Height:153cm,weight:40kg).About3 minutes later after drug administration, the doctor started to intubate. But immediately after opening her mouth, some yellow and green liquid flowed out. Urgent suction was executed in mouth and then intubation was finished immediately. Before connecting to ventilator, bronchial suction through tracheal catheter was also executedseriously.Duringtheinductionperiodandthefirst1hour afterinduction,SpO2was100%with50%FiO2,andthebilateral pulmonary auscultation was normal. Butinthefollowingtime,abnormalsymptomsstartedtorise.We need to rise FiO2 gradually to reach the 100% SpO2.The wheezingralestartedtoappear,slightatfirst,andthenbecamemoreand more obvious in the following 2 hours. The surgery lasted about3 hours.At the end of the surgery, increasing FIO2 to 70% could maintain the patient’s vital signs to normal including heart rate, SpO2andbloodpressure.Methylprednisoloneandaminophylline wereadministeredduringthesurgery.Aftershewastransferredto PACU,theheartratestartedtoincreasegradually.20minuteslater inPACU,sherevivedwellwithahighheartbeatabout110bpm. After extubation, she had very obvious difficulty and shortnessin breath and couldn’t get rid of the high-flow oxygen supply (6- 8L/min) through the mask, and her thoracic movement was very fierce. The lung wheezing rale became more and more obvious. ThenshewastransferedtorespiratorydepartmentforaFiberoptic Bronchoscopy examination (FOB). When she arrived the respiratory department, 5 hours had passed sincetheaspiration.BeforeFOBexamination,therespiratorydoc- tor searched the patient’s thoracic CT examination from the hospital network, founding that the patient’s stomach was absolutely stayed in chest and had expanded a lot, as shown in (Figure 2). Fentanyl and midazolam were given and a good cooperation was achieved. Then FOB was inserted into the bronchus and bronchi. Some green and yellow purulent secretion were found covering thebronchusandbronchi,asshowninFigure3.ThenFOBguided suctionandirrigationineverysegmentalbronchuswere performed carefully to remove the mucus and residue. Immediately after the operation,thepatientsaidshefeelbetter,withherthoracicupsand downs,respiratoryrate,andheartratewerealldecreasedtonormal obviously.Then she was transferred to ICU for further treatment. During her stay in ICU for 2 days, she received the conventional treatmentsincludinghormonotherapy,aminophylline,salbutamol and arterial blood gas analysis and so on. Her arterial blood gas analysis was always below the standard of mechanical assistant ventilation (as shown in Table 1), so she just received the nasal oxygen supply(2-4L/min) without intubation. At the third day in ICU,sherefusedtoreceiveinvasivearterialbloodgasanalysisand demanded returning to the general ward, so the orthopedist took heroutofICU.Ingeneralward,shereceivedsomeantibioticsand recoveredverywell,10dayslatershewasdischargedfromhospi- tal without any complications.
4. DiscussionForthosepatientswhohaveoccurredaspiration,nomattertheaspirationcontentswereblood,gastricjuice,bileordisinfectant,the fiberopticbronchoscopysuctionandirrigationtreatmentisalways effective[6,7,8].ThishasbeendemonstratedinERandneurolog- ical ICU where there were high risks of aspiration. But in MORDERNanesthesiology(versionIV),itadvocatedthatifgastricaspirationwasplenty,bronchusirrigationmayleadtoacidcorrosion spreading, so FOB guided irrigation and suction was not suggested as the first aid. We thought this proposition should be thought twice.AblindirrigationwithoutFOBguidethroughtrachealtube may cause corrosion or infection spreading, because without in- stant and thorough suction, the acid fluid may flow around. But the new developed respiratory FOB apparatus can switch irriga- tion and suction promptly, so the spreading fluid can be limited very well. So we suggest that FOB guided suction and irrigation therapy could be the first choice for aspiration, even for the acid aspiration. Forthosepatientswhohadgastrointestinalsurgerybefore,it shouldbecautiousthattheywereveryvulnerabletoaspirationespeciallyduringinductioninanesthesiology.AccordingtotheA&E Clinical Guidelines No. 14 Guidelines on Rapid Sequence Intubation (RSI), it is strongly suggested that these kinds of patients shouldapplyRSI[10,11].ThemainpointsofRSIincludeenough preoxygen,rapidsequentialdrugadministration,pressingcricoid cartilage, and avoid positive pressure ventilation before capsule inflation. Our junior resident had two mistakes: firstly he didn’t realizethatthewomanhadahistoryofesophagusresectionwhich may lead to high risks of aspiration during induction; secondlyhe gave the woman a mask positive pressure ventilation, which should be avoided according to RSI inA&E Clinical Guidelines. The positive mask ventilation may inflate the woman’s residual stomach and increase the aspiration risks. Fortheanesthesiologists,itshouldbecautiouswhenexecutingthe preoperationvisit.Carefulandcomprehensivehistory-takingand examinations-screeningareveryimportant.Forthosepatientswho received a history of esophagus excision and stomach-esophagus reconstruction,itworthnotingthattherebuildstomachinchest wouldexpandastimegoeson[12].ThethoracicCTexamination isvitaltothiskindofpatientsandsuperiortoX-rays.Justasinour case, thoracic X-ray was not sensitive to recognize the stomach expanding, only diagnosing the bilateral pleural effusion. But in thelaterthoracicCTexaminations,thediagnosewasanexpanded residual stomach absolutely stayed in chest, which should have indicatedaveryhighriskofaspirationtous.Inthedepartmentdiscussion after surgery, with a more careful observation, we found an image of expanded residual stomach beside the aorta in the thoracic X-ray, as shown in Figure 1. Our junior anesthesiologist missed the thoracic CT examination and only checked the X-ray, so he missed a very important point during history-taking. For the chairmen of anesthesiology department, we suggest that they build a strong relationship with the respiratory department.Inourhospital,afterthiscase,thechairmeninanesthesiolo gyand respiratory department built a green channel of aspiration related FOB treatment, aiming at the aspiration cases during anesthesia. Thanksforthiscooperation,recentlywehadsavedanotherobstet- ric aspiration during induction. In conclusion, we suggest the FOB guided irrigation and suction recommended for those who has occurred aspiration during anesthesia.Patientswhohadahistoryofesophagusreconstructionsurgery or other gastrointestinal surgery should apply RSI induction andavoidmaskpositiveventilation.Duringhistory-takingprocedure,itshouldbemorecarefulandcautious.Ourpatienthadavery good prognosis due to a timely and efficient intervention, which may be a useful case for other anesthesiologists. 5. Funding ThisstudywassupportedbytheShenzhenKeyMedicalDiscipline ConstructionFund(grantno.SZXK044)andShenzhen’sSanming Project of Medicine (grant no. SZSM202011021)
References 1. RobinsonM,DavidsonA.Aspirationunderanaesthesia:riskassessment and decision-making[J]. Continuing Education inAnaesthesiaCritical Care & Pain. 2014; 14: 171-5.
2. Olsson GL, Hallen B, Hambraeus-Jonzon K.Aspiration during anaesthesia:acomputer-aidedstudyof185,358anaesthetics.ActaAnaesthesiol Scand. 1986; 30: 84-92.
3. Mendelson CL. The aspiration of stomach contents into the lungsduring obstetric anesthesia. Am J Obstet Gynecol. 1946; 52: 191-205.
4. Gibbs CP, Modell JH. Pulmonary aspiration of gastric contents: pathophysiology, prevention, and management. In: Miller RD, editor. Miller’sAnesthesia. 4th ed. NewYork: Churchill Livingstone; 1994;1437-64.
5. Abdulla S. Pulmonary aspiration in perioperative medicine. ActaAnaesthesiol Belg. 2013; 64: 1-3.
6. RyuT,KimDH,ByunSH.Fiberopticbronchoscopictreatmentof 7. AnTH,AhnBR.Pneumoniaduetoaspirationofpovidineiodineafterinductionofgeneralanesthesia-Acasereport-[J].KoreanJournal of Anesthesiology. 2011; 6.
8. Choi SH, Lee SJ, Yoon KB, Han S, Kim JH. Fiberoptic bronchoscopictreatmentofpulmonaryaspirationoccurringinachildduring induction of anesthesia -Acase report. Korean JAnesthesiol. 2005; 49: 744-7.
9. Gal TJ. Airway management. In: Miller RD, editor. Miller’s Anesthesia. 6th ed. New York: Elsevier Churchill Livingstone; 2005; 1617-52.
10. Smith, Charles E. Rapid-Sequence Intubation inAdults: Indicationsand Concerns[J]. Clinical Pulmonary Medicine. 2001; 8:147-65.
11. CBLo,TWWong.A&EClinicalGuidelinesNo.14Guidelineson Rapid Sequence Intubation (RSI)
12. KonradssonM,NilssonM.Delayedemptyingofthegastricconduitafter esophagectomy. J Thorac Dis. 2019; 11:, S835-44.
WangL.FiberopticBronchoscopicTreatmentofGastricAspirationinaPatientwithChest Stomach Ectopia a Case Report . Annals of Clinical and Medical Case Reports 2021