BACKGROUND
Microvillus inclusion disease (MVID) is a rare congenital intestinal epithelial cell disorder resulting in intestinal failure. Early small bowel and liver transplantation is the only effective treatment option. Impaired motility is common after bowel transplant, which might present with nausea, vomiting and consecutive aspiration. This, combined with heavy immunosuppression may lead to severe complication of aspiration pneumonia. A high index of suspicion for full stomach should be maintained, even if a patient meets standard fasting guidelines.
CASE DESCRIPTION
The patient was 4-year old, 13.7 kg male, with past medical history of MVID status post small bowel and liver transplant, splenectomy, hypertension, chronic immunosuppression, and global developmental delay, who presented to emergency department with a 1-day history of persistent emesis. After admission, abdominal x-ray demonstrated a paucity of small bowel gas with no evidence of bowel obstruction. He did have positive viral swab for influenza A and was treated with oseltamivir. The emesis was unresolved in spite of cessation of enteral feeding for 2 days, therefore patient was brought to the operating room (OR) to have peripherally inserted central catheter (PICC) placement for total parenteral nutrition (TPN) and fluid administration.
Before induction of general anesthesia, approximately 500ml of dark green liquid was suctioned via the nasogastric tube, in supine, right and left lateral decubitus positions. Modified rapid sequence induction (RSI) was performed with the patient in right lateral decubitus position, followed by uneventful tracheal intubation.
Two days later, the patient underwent esophagogastroduodenoscopy (EGD) for surveillance. 300ml similar liquid was suctioned out before induction. However, the stomach was found full during EGD, and another 200ml was suctioned by endoscope.
DISCUSSION
MVID is an extremely rare genetic disorder, caused by defective intestinal brush border. Early small bowel transplantation is the treatment of choice. Altered intestinal motility is common in transplant recipients, which presents as either hypomotility with persistent nausea and vomiting, or hypermotility with refractory diarrhea. Uncontrolled vomiting imposes significant challenges in airway management. Gastric suctioning via nasogastric or orogastric tube is used to further empty the stomach.
In this case we demonstrate that even thorough suctioning in supine, right and left lateral decubitus positions may not guarantee a completely empty stomach. Modified RSI was performed with the patient in right lateral decubitus position. This technique has also been reported by other authors as controlled RSI, during which stable hemodynamics were maintained with minimal patient stress. Induction in lateral position was successfully used by other anesthesiologists for patients at risk of aspiration. The overall risk of aspiration and associated complications has been estimated to be three times more common in children than adults. Appropriate strategies to minimize aspiration should be planned during anesthesia care in high risk pediatric patients.
