To the Editor:—
We recently had a case that we would like to bring to the attention of the anesthesia community. A 52-yr-old woman was admitted to our hospital as an outpatient to have a right breast mass excised. Her American Society of Anesthesiologists physical status was II; her Mallampati airway score was also II. She reported ingesting nothing by mouth (NPO) for more than 6 h. Her preoperative examination was unremarkable, other than hypertension. The importance of being NPO was explained previously by the surgeon's office, and it was reconfirmed during our preoperative examination the morning of surgery. The patient volunteered that she had not even drank water since midnight.
After a slow induction by propofol (2.5 mg/kg) and fentanyl (100 μg), the patient was intubated with a #4 disposable Laryngeal Mask Airway ™ (LMA North America, Inc., San Diego, CA) on the first attempt with no difficulties. The cuff of the Laryngeal Mask Airway ™ was inflated with 30 ml of air. After the intubation, a leak test was performed, and leak pressure was recorded as 30 cm H2O. Anesthesia was maintained with 1 minimum alveolar concentration (MAC) desflurane for about 140 min in the supine position with maximum of 23 cm H2O peak airway pressure to provide approximately 700 ml tidal volume with assisted spontaneous breathing. Flawless emergence of the patient was followed by the extubation of the Laryngeal Mask Airway ™. At that time, we discovered a green gummy mass at the tip of the Laryngeal Mask Airway ™. Other than a slight dirty appearance on the inner surface of the Laryngeal Mask Airway™ , nothing was out of the ordinary.
The patient was followed in the recovery room for an hour; she was fully awake and oriented. She didn't complain of sore throat, nausea, dysphagia, or dysphonia. When asked, she said that she was chewing a gum on the way to the hospital, but couldn't remember whether she threw it away before going into surgery. None of the holding-area nurses, the nurse-anesthetist, nor the attending anesthesiologist (myself) realized that the patient had been chewing gum preoperatively.
It appears that some patients do not consider chewing gum as a part of their NPO status; therefore, it would be wise to question patients specifically for nonnutritious products such as chewing gum.