Immediate gastric decompression during rapid sequence induction enabled by high-flow nasal oxygenation: A case report

Regurgitation during rapid sequence induction (RSI) remains a major concern, particularly in patients at high risk of aspiration. Although gastric tube insertion after airway securement is commonly performed to achieve gastric decompression, it is often delayed because of the need to prioritize rapid airway management and avoid hypoxemia. High-flow nasal oxygenation (HFNO) has been shown to prolong safe apnea time by providing effective apneic oxygenation, thereby offering a critical time margin during airway management. We report a case in which immediate gastric decompression was achieved during HFNO-assisted RSI using a double insertion technique under direct visualization with a video laryngoscope. A 34-year-old obese pregnant woman with a presumed full stomach underwent emergency surgery under general anesthesia. HFNO enabled stable oxygenation during a short period of apnea, allowing both tracheal intubation and gastric tube insertion to be completed without desaturation. Gastric contents were promptly aspirated through the tube immediately after insertion. This case highlights the feasibility of immediate gastric decompression during RSI when supported by HFNO. This approach may reduce the risk of occult regurgitation and microaspiration and suggests a potential shift in RSI workflow from delayed to immediate gastric decompression under selected conditions.