High-flow nasal oxygen-assisted rapid sequence induction in a patient with intestinal obstruction: A case report

High-flow nasal oxygenation (HFNO) is used during induction of general anesthesia, particularly in patients with limited oxygen reserve. Although previous studies suggest a low risk of gastric insufflation with HFNO in healthy adults, the risk in high-risk patients remains uncertain. We report a case of HFNO-assisted rapid-sequence induction without clinically apparent gastric insufflation. A 27-year-old man with severe congenital motor and intellectual disabilities underwent emergency surgery for intestinal obstruction. He had a history of epilepsy, repeated aspiration pneumonia, percutaneous endoscopic gastrostomy, and two operations for gastroesophageal reflux disease. Computed tomography showed marked retention of gastric contents. Before induction, approximately 500 mL of gastric contents was aspirated through the gastrostomy. To detect clinically apparent gastric insufflation, a syringe without a plunger was connected to the gastrostomy opening and a glove was attached to its proximal end. A 16-Fr nasogastric tube remained in place. HFNO was delivered at an inspired oxygen fraction of 1.0 and a flow rate of 40 L/min during preoxygenation; the flow rate was increased to 70 L/min immediately after anesthetic induction for apneic oxygenation. Rapid-sequence induction was performed with fentanyl, propofol, and rocuronium under cricoid pressure in the head-up position, and the trachea was intubated uneventfully. During preoxygenation and apneic oxygenation, the glove did not inflate, and no regurgitation, clinically apparent aspiration, or desaturation was observed. Although gastric insufflation and microaspiration cannot be completely excluded, this case suggests that HFNO might be a feasible option in patients at increased risk of pulmonary aspiration.