Anesthetic management of Boerhaave's syndrome

Boerhaave's syndrome or spontaneous esophageal perforation is a life threatening condition which demands early diagnosis and urgent management. Although very selective patients can be treated nonoperatively, in most patients, better overall results can only be attained with early aggressive surgery. Clinical data and accounts of anesthetic management of this condition scarely appear in medical literature. Managing these patients for surgery is among the most challenging tasks facing the anesthesiologist because they may develop septic syndrome with shock. A rapid-sequence induction is mandatory, and the procedures that may aggravate the injury to esophagus should be avoided. Inotropic support and close attention to fluid balance may be required during operation. Because Boerhaave's syndrome is rare, we report here two cases to illustrate possible anesthetic implications of this disease. Both patients underwent thoracotomy to relieve empyema of mediastinum under general anesthesia. The first patient recovered completely after operation due to early diagnosis and treatment, but the second patient developed multiple organ failure and died after operation due to delayed diagnosis of esophageal rupture and severe sepsis. Because survival is directly related to the time to diagnosis and treatment, all clinicians need to be aware of this lethal disease.