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Excessive stomach inflation causing gut ischaemia
Resuscitation 80 (2009) 142–144
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letters to the editor Excessive stomach inflation causing gut ischaemia Sir,
Conflict of interest None.
An 18 years old male was found after a fall unconscious, but spontaneously breathing, 80 min−1 sinus rhythm, 125/73 mmHg arterial blood pressure, and an arterial oxygen saturation of 98%. The patient was anaesthetised and intubated, but became asystolic during hospital transfer. In the hospital an oesophageally placed tracheal tube was detected, and the position was corrected. Return of spontaneous circulation ensued after cardiopulmonary resuscitation with 1 mg epinephrine. A massively dilated abdomen was diagnosed (Figure 1). Multi-organ failure developed and CT scan revealed severe progressive cerebral oedema; intensive care support was withdrawn. The patient died ∼36 h after the fall, as previously reported.1 Excessive stomach inflation may occur with undetected oesophageal intubation, causing massive dilation of the abdomen, compromising ventilation even after tube position is corrected.2 Stomach inflation may also trigger intestinal rupture,3 or regurgitation and aspiration that may result in pneumonia. Recently, a stomach inflation-triggered abdominal compartment syndrome has been reported.4 In this patient autopsy revealed multiple tears in the oesophagus and extensive necrosis in the colon which may be indicative of stomach inflation-triggered (1) high intraluminal pressure, (2) intestinal hypo-perfusion, and (3) severe gut ischaemia. While ventilatory compromise, intestinal rupture, and pulmonary aspiration are well known complications of stomach inflation, gut ischaemia may have been insufficiently realised.
References 1. von Goedecke A, Keller C, Voelckel WG, et al. [Mask ventilation as an exit strategy of endotracheal intubation.]. Anaesthesist 2006;55:70–9. 2. Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Resuscitation 1998;36:71–3. 3. Reiger J, Eritscher C, Laubreiter K, et al. Gastric rupture-an uncommon complication after successful cardiopulmonary resuscitation: report of two cases. Resuscitation 1997;35:175–8. 4. Paal P, Neurauter A, Loedl M, et al. Effects of simulated stomach ventilation on hemodynamic and pulmonary function during CPR in pigs. Circulation 2007;116(Suppl. 927) [Abstract].
Peter Paal a,∗ Stefan Schmid b Holger Herff a Achim von Goedecke a Thomas Mitterlechner a Volker Wenzel a a Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria b Department of General and Surgical Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria ∗ Corresponding
author. Tel.: +43 512 504 80448. E-mail addresses: [email protected], [email protected] (P. Paal) 2 September 2008 doi:10.1016/j.resuscitation.2008.09.005
Crisis averted: Important and unexpected lessons learnt from a simulated case of ventricular fibrillation
Figure 1. Intra-luminal air in the massively dilated gut.
0300-9572/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.
Our Intensive Care Unit (ICU) recently assumed cardiopulmonary resuscitation (CPR) responsibilities for our tertiary-care hospital. While medical simulation has not yet been shown to directly save lives, evidence has shown its unique ability to accelerate CPR training and to increase adherence to guidelines.1,2 It has also been shown to enhance team performance and increase skill retention when compared to didactic instruction.1–5 Simulation is also risk-free for patients, and blame-free for participants.1,3 Therefore, we made the use of simulated cardiac arrests, using a High-Fidelity Computer Medical Simulator, a key strategy. Despite extensive resuscitation experience by our staff – and mandatory Advanced Cardiac Life Support (ACLS® ) training – it was only through simulation that sobering lessons were learnt. The Philips Heartstart MRx® (Koninklijhe Philips Electronics, N.V. Amsterdam) is one of the world’s most common devices for
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letters to the editor Excessive stomach inflation causing gut ischaemia Sir,
Conflict of interest None.
An 18 years old male was found after a fall unconscious, but spontaneously breathing, 80 min−1 sinus rhythm, 125/73 mmHg arterial blood pressure, and an arterial oxygen saturation of 98%. The patient was anaesthetised and intubated, but became asystolic during hospital transfer. In the hospital an oesophageally placed tracheal tube was detected, and the position was corrected. Return of spontaneous circulation ensued after cardiopulmonary resuscitation with 1 mg epinephrine. A massively dilated abdomen was diagnosed (Figure 1). Multi-organ failure developed and CT scan revealed severe progressive cerebral oedema; intensive care support was withdrawn. The patient died ∼36 h after the fall, as previously reported.1 Excessive stomach inflation may occur with undetected oesophageal intubation, causing massive dilation of the abdomen, compromising ventilation even after tube position is corrected.2 Stomach inflation may also trigger intestinal rupture,3 or regurgitation and aspiration that may result in pneumonia. Recently, a stomach inflation-triggered abdominal compartment syndrome has been reported.4 In this patient autopsy revealed multiple tears in the oesophagus and extensive necrosis in the colon which may be indicative of stomach inflation-triggered (1) high intraluminal pressure, (2) intestinal hypo-perfusion, and (3) severe gut ischaemia. While ventilatory compromise, intestinal rupture, and pulmonary aspiration are well known complications of stomach inflation, gut ischaemia may have been insufficiently realised.
References 1. von Goedecke A, Keller C, Voelckel WG, et al. [Mask ventilation as an exit strategy of endotracheal intubation.]. Anaesthesist 2006;55:70–9. 2. Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Resuscitation 1998;36:71–3. 3. Reiger J, Eritscher C, Laubreiter K, et al. Gastric rupture-an uncommon complication after successful cardiopulmonary resuscitation: report of two cases. Resuscitation 1997;35:175–8. 4. Paal P, Neurauter A, Loedl M, et al. Effects of simulated stomach ventilation on hemodynamic and pulmonary function during CPR in pigs. Circulation 2007;116(Suppl. 927) [Abstract].
Peter Paal a,∗ Stefan Schmid b Holger Herff a Achim von Goedecke a Thomas Mitterlechner a Volker Wenzel a a Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria b Department of General and Surgical Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria ∗ Corresponding
author. Tel.: +43 512 504 80448. E-mail addresses: [email protected], [email protected] (P. Paal) 2 September 2008 doi:10.1016/j.resuscitation.2008.09.005
Crisis averted: Important and unexpected lessons learnt from a simulated case of ventricular fibrillation
Figure 1. Intra-luminal air in the massively dilated gut.
0300-9572/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.
Our Intensive Care Unit (ICU) recently assumed cardiopulmonary resuscitation (CPR) responsibilities for our tertiary-care hospital. While medical simulation has not yet been shown to directly save lives, evidence has shown its unique ability to accelerate CPR training and to increase adherence to guidelines.1,2 It has also been shown to enhance team performance and increase skill retention when compared to didactic instruction.1–5 Simulation is also risk-free for patients, and blame-free for participants.1,3 Therefore, we made the use of simulated cardiac arrests, using a High-Fidelity Computer Medical Simulator, a key strategy. Despite extensive resuscitation experience by our staff – and mandatory Advanced Cardiac Life Support (ACLS® ) training – it was only through simulation that sobering lessons were learnt. The Philips Heartstart MRx® (Koninklijhe Philips Electronics, N.V. Amsterdam) is one of the world’s most common devices for