Gastric perforation caused by oxygen insufflations through a nasopharyngeal Nelaton catheter

SIR—Several methods of oxygen enrichment have been described to support oxygenation in variety of clinical situations. Low flow oxygen insufflation through a nasopharyngeal tube is one of the accepted techniques (1,2). Oxygen insufflation may sustain oxygenation in apnea periods and support patient’s ventilation during sedation and anesthesia; however, gastric distention and rarely perforation should be kept in mind as a possible complication. An eleven-year-old boy was presented with a periodontal abscess for tooth extraction and abscess drainage. His preanesthetic evaluation, medical history, and physical examination were unremarkable. He was premedicated with midazolam. Anesthesia was induced with 1 mg kg 1 boluses of propofol. After a short period of a bag-mask assisted ventilation with 100% oxygen, he had adequate spontaneous ventilation. A number 10 Nelaton catheter was inserted through his nostril into the pharynx to a distance of about 10 cm and was secured with a tape. The catheter was connected to three liters per minute oxygen flow. About 5 min later, abdominal distention was noticed. The nasopharyngeal catheter was withdrawn. A nasogastric tube was inserted to decompress the stomach, but the abdominal tense distention did not improve. Fluoroscopic image confirmed the clinical suspicion of pneumoperitoneum (Figure 1). The child was intubated. Laparoscopic exploration located the gastric perforation at the posterior wall lesser curvature and was correct primarily with double layer sutures. The tooth extraction and abscess drainage was completed, and the child was extubated shortly thereafter. His remaining hospital course was uneventful, and he was discharged at postoperative day 8. Low flow oxygen insufflation is a well-accepted practice. We do not know whether the catheter was dislodged distally or into the esophagus during head positioning. Even in that scenario, gastric perforation is not common. Most of the times, gas escapes throw the open mouth, and the stomach decompresses distally through the pylorus. Rupture of the normal stomach associated with oxygen administration has been reported in adults (3) and in a case of accidentally connected oxygen flow to the nasogastric tube (4). Barichello et al. (5) suggested that the mechanism of the rupture is primarily because of increased pressure. Anesthesia reduces normal muscle tone. The abnormal relaxed upper esophageal sphincter enables large quantity of air to enter the stomach when increased negative pressure occurs during the inspiratory phase. One-way valve mechanism may occur as a result of the increased Table 1 Relationship of Age, Weight, and Height to PICC length