ASPIRATION

Risk Factors of Aspiration

Patient:

Inadequate fasting

Delayed gastric emptying

Incompetent Lower Oesophageal Sphincter

(Emergency, Pregnancy, Diabetes,

Obesity, Hiatus Hernia, GORD)

Surgery:

Upper GI tract

Lithotomy

Head down

Laparoscopy

Cholecystectomy

Anaesthetic:

Light anaesthesia

Supraglottic airways

Positive-pressure ventilation

Difficult airway

Long surgery

Management of Aspiration:

1 Call for help, communicate and delegate.

2 Place head down and consider left lateral position.

3 Remove the airway and suction the pharynx.

4 Intubate and suction the bronchial tree.

5 Ventilate with 100% O2 then titrate to normal SpO2.

6 If severe aspiration, proceed only with emergencies.

7 Empty stomach before emergence.

8 Consider ICU/HDU admission.

How much assistance required depends on the severity and circumstances. Mild regurgitation in a fasted patient may be managed simply with suction only, but more significant aspiration needs immediate aggressive management.

Immediate communication with the surgeons and delegation of tasks (e.g. turning the patient) may limit the amount of aspiration. Positioning the patient will depend on the type of surgery and practical limitations.

Steps 1 to 4 should be achieved before step 5 if SpO2 permits.

Cricoid pressure (Sellick's manouvre) can be used during intubation but not during active vomiting or regurgitation.

Mild aspiration often resolves without specific treatment, and at 2 hours post aspiration if the patient is not symptomatic, the chest X-ray is clear and the SpO2 is normal, ICU can be avoided.

However, if there is particulate matter, indicative of more severe aspiration, ICU will be required for post-op management.

Steroid and antibiotic therapy are not indicated in the short term management of aspiration. Antibiotics are used only if pneumonia develops. Steroids have shown no effect on outcome or mortality.

Some evidence suggests that residual neuromuscular block significantly reduces upper oesophageal sphincter tone for a significant time after emergence, increasing the risk of aspiration during the recovery phase.

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