Aspiration during anesthesia is a serious concern for anesthesiologists and surgical teams, due to its potentially life-threatening complications. Aspiration occurs when stomach contents enter the respiratory tract, leading to a range of outcomes from mild pneumonitis to severe acute respiratory distress syndrome (ARDS). It is important to understand the risk factors associated with aspiration during anesthesia, as well as treatment and relevant management strategies.
Patients who are at high risk for aspiration include those with a full stomach, gastrointestinal disorders, obesity, and pregnancy, and those undergoing emergency surgery. Additionally, conditions such as gastroesophageal reflux disease (GERD) and hiatal hernia can also increase the risk of aspiration, as they may compromise the esophageal sphincter’s ability to prevent regurgitation (1). Furthermore, individuals with neurological or muscular disorders that impair normal protective airway reflexes are also at risk of aspiration.
The use of GLP-1 agonists in the management of diabetic patients presents a novel consideration in the context of aspiration risk during anesthesia. GLP-1 agonists are primarily used to treat type 2 diabetes and enhance insulin secretion while lowering glucagon levels in a glucose-dependent manner. However, they also slow gastric emptying, which increases the risk of aspiration during anesthesia (2). The use of GLP-1 agonists and its implications on anesthesia preparation and management is an area of clinical interest. Anesthesiologists should consider the possibility of delayed gastric emptying in patients treated with these agents and plan accordingly to mitigate the additional risks of aspiration.
The management of aspiration risk should begin with a thorough assessment of the patient’s risk factors well before anesthesia and surgery occur. Fasting guidelines, such as those provided by the American Society of Anesthesiologists, should be followed rigorously to minimize the volume and acidity of gastric contents (2). In high-risk cases, pharmacological agents like antacids, H2 receptor antagonists, or proton pump inhibitors may be used to neutralize stomach acid and reduce the risk of pneumonitis if aspiration occurs (3).
During anesthesia induction, techniques such as rapid sequence induction are often used for patients at high risk of aspiration. This approach involves administering a potent, fast-acting sedative followed by a neuromuscular blocking agent, without manual ventilation, to minimize the chance of gastric content aspiration. Additionally, the head-up or reverse Trendelenburg position can reduce aspiration risk by leveraging gravity to keep gastric contents away from the esophagus (2).
Despite the implementation of preventive measures, aspiration can still occur. Immediate recognition and management are essential. The anesthesiologist must promptly clear the airway, potentially through suctioning, and administer 100% oxygen to mitigate hypoxia. Further treatment should be guided by the severity of the aspiration event. In cases of chemical pneumonitis, supportive care, including oxygen therapy, and in severe cases, mechanical ventilation, may be necessary. Antibiotic therapy is typically reserved for patients who develop bacterial pneumonia as a complication of aspiration (4).
Aspiration is a complex clinical issue that has significant implications for patient safety and outcomes. A multidisciplinary approach that involves risk assessment, preventive strategies, and prompt management of aspiration events is essential to minimize the risk and impact of this serious complication during anesthesia.
References
- Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology. 1993;78(1):56-62. doi:10.1097/00000542-199301000-00010
- Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393. doi:10.1097/ALN.0000000000001452
- Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis, MO: Saunders; 2014.
- Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020;58(12):1360-1541. doi:10.1080/15563650.2020.1834219
