4.6 Aspiration

Question 1

A 60-year-old man is having an elective knee arthroscopy and has just aspirated a significant amount of gastric fluid during anaesthesia.

He has a supraglottic airway device in place and is breathing spontaneously. His inspired oxygen fraction is 1.0 and the pulse oximeter shows an oxygen saturation of 91%.

a) Describe your immediate management of this patient. (4 marks)

Answer 1

AE
CFSH

Pause surgery if possible

Left lateral
head down

suction contents
Perform RSI w/ Cricoid

Suction trachea if feasible during intubation.
Abondon prcoedure

I+V withFIo2 1.0
Examine chest / rx bronchospasm

Filling + ensure haemodynamic stability

Perform early bronchoscopy
+ suction / aspirate particulate matter

Consider need to remain I+V and tranfer to ICU

This is an anaesthetic emergency. I would alert the theatre team, call for
help and adopt an ABC approach, assessing and managing the patient
simultaneously.

A:
» Head down tilt +/− lateral tilt.
» Remove SAD.
» Oropharyngeal suction.

B:
>> 100% oxygen.
>> RSI 
(with cricoid pressure and
 avoidance of stomach inflation).

> > Ideally, tracheal suction prior to ventilation but oxygenation is paramount.

> > Positive pressure ventilation with PEEP.

> > Symptomatic treatment with
bronchodilators if necessary.

C:
» Ensure cardiovascular stability;
manage as appropriate

Question 2

b) List the respiratory complications he could develop in the next 48 hours. (2 marks)

Answer 2

> > Sustained hypoxia.

> > Bronchospasm.

> > Pneumonitis.

> > Complications of barotrauma,
including pneumothorax due to ongoing
high airway pressures.

> > Lobar collapse.

> > Pulmonary infection.

> > ARDS.

Question 3

c) What are the possible preoperative risk factors for regurgitation and aspiration of gastric contents in
this case? (6 marks)

Answer 3

> > Obesity.

> > Failure of the lower oesophageal sphincter:
reflux, heartburn, hiatus hernia,
previous upper gastrointestinal surgery, gastro-oesophageal disease.

>> Drugs or conditions 
(recent opioid-based analgesia, 
recent pancreatitis,
diabetes mellitus, 
chronic kidney disease) 
affecting gastric emptying.

> > Failure to follow starvation advice preoperatively.

Question 4

d) Describe the strategies available to reduce the risk and impact of aspiration of gastric contents in any
patient. (8 marks)

Answer 4

> > Avoidance of general anaesthesia by
use of regional anaesthesia/local
anaesthesia/no surgery.

> > Routine preoperative starvation.

> > Naso- or orogastric tube insertion
and stomach drainage before or during
anaesthesia.

> > Premedication with prokinetic drugs, antacids,
H2 receptor blockers and
proton pump inhibitors.

> > Tracheal intubation instead of SAD use.

> > Second-generation supraglottic airway device use instead of first generation.