ICU拔管后通气诱导的胃破裂：一例病例报告

文献信息

中文摘要

背景： 胃破裂是一种罕见但可能致命的并发症，曾在心肺复苏（CPR）期间被报道。这通常归因于胸外按压联合正压通气引起的急性胃过度膨胀。在重症监护病房（ICU）计划性拔管后发生通气诱导的胃破裂较为罕见。
病例介绍： 一名80岁男性在腰椎手术后于ICU计划性拔管后不久发生急性胃破裂。拔管前未进行定量神经肌肉监测。拔管后4分钟，在成功重新插管前，进行了反复的球囊面罩通气和喉罩辅助通气。在抢救通气期间观察到进行性腹部膨胀。影像学显示大量气腹，而急诊手术发现胃小弯侧有一处5厘米长的纵向穿孔，无缺血性变色证据。未进行CPR。患者需要长时间机械通气，并于2个月后死于进行性医院获得性肺炎。
结论： ICU拔管后反复正压通气可能导致胃破裂，即使没有进行CPR。对进行性腹部膨胀的认识、拔管前的客观神经肌肉评估以及仔细控制吸气压力可能提高高危患者的气道安全性。

英文摘要

BACKGROUND: Gastric rupture is a rare yet potentially fatal complication that has been reported during cardiopulmonary resuscitation (CPR). This is generally attributed to acute gastric overdistension caused by chest compressions combined with positive-pressure ventilation. Ventilation-induced gastric rupture after planned extubation in the intensive care unit (ICU) is rare.
CASE PRESENTATION: An 80-year-old man developed acute gastric rupture shortly after planned ICU extubation following lumbar spinal surgery. Quantitative neuromuscular monitoring was not performed prior to extubation. Four minutes after extubation, repeated bag-mask ventilation and laryngeal mask airway-assisted ventilation were administered prior to successful reintubation. Progressive abdominal distension was observed during rescue ventilation. Imaging demonstrated massive pneumoperitoneum, while emergency surgery identified a 5-cm longitudinal perforation along the lesser curvature of the stomach without evidence of ischemic discoloration. No CPR was conducted. The patient required prolonged mechanical ventilation and died 2 months later from progressive nosocomial pneumonia.
CONCLUSIONS: Repeated positive-pressure ventilation after ICU extubation may result in gastric rupture even in the absence of CPR. Awareness of progressive abdominal distension, objective neuromuscular assessments before extubation and careful control of inspiratory pressure may improve airway safety in high-risk patients.