Fatal pneumoperitoneum caused by nasopharyngeal oxygen delivery after transoesophageal echocardiography for cardiac surgery

Abstract

We report a case of fatal post-operative pneumoperitoneum in a patient who had undergone urgent mitral valve surgery. In the absence of a proven cause of the pneumoperitoneum (refusal by the family of an autopsy), we can only propose a hypothesis for its origin. The most probable one is that forceful or sustained retrograde flexion of the transoesophageal echocardiographic probe created a lower oesophagus or gastric rupture and that oxygen flow administered by the nasal cannula went straight to the abdominal cavity, leading to tension pneumoperitoneum.

Gastric Rupture following Nasopharyngeal Catheter Oxygen Delivery—A Report of Two Cases

“…Searching the English literature on PubMed, we identified 17 additional cases of gastric perforation following nasal 25,[27][28][29][30]32,34 or nasopharyngeal 23,24,26,31,33 catheter use (Table 1). Gastric distension and rupture following the use of these devices occurred across all ages (range 35 to 89 years old).…”

“…The most common symptoms and signs of gastric perforation in this series are the abrupt onset of abdominal pain and distension. Delay in diagnosis and management frequently leads to rapid deterioration, with cardiorespiratory compromise and ensuing death 23,27,28,[32][33][34] . Immediate needle decompression can be performed 23,24,28 and is usually done in dire circumstances to allow survival until definitive laparotomy.…”

“…Delay in diagnosis and management frequently leads to rapid deterioration, with cardiorespiratory compromise and ensuing death 23,27,28,[32][33][34] . Immediate needle decompression can be performed 23,24,28 and is usually done in dire circumstances to allow survival until definitive laparotomy. In this series, needle decompression was attempted in only three patients, of whom two died before a definitive laparotomy could be performed.…”

“…There is also a clear association between gastric rupture and direct chest or abdominal trauma [6][7][8][9][10][11][12][13][14] . Even without application of external force, sufficient gastric distension can result in gastric rupture and this has been described following a variety of oxygen delivery methods in many patients [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] . Direct insufflation of the stomach is clearly the cause of gastric distension and rupture in cases of unrecognised insertion of airway devices into the oesophagus 22,[35][36][37][38][39][40] or inadvertent administration of oxygen into nasogastric tubes 41,42 .…”

The authors reply

“…Low flows (4-6 L/min) are recommended for nasopharyngeal catheters, and despite these low flows, numerous-sometimes fatal-hazards have been reported (6)(7)(8). Regarding their last one, the whole point of high-flow nasal cannula oxygen is that it enables the delivery of high-flow, heated, and humidified oxygen, which conventional oxygen cannot, whatever the device used.…”