What is the risk of aspiration in a patient with hiatal hernia and Gastroesophageal Reflux Disease (GERD) who is nil per os (NPO) prior to sedation for Esophagogastroduodenoscopy (EGD)?

From the Guidelines

The risk of aspiration in a patient with hiatal hernia and Gastroesophageal Reflux Disease (GERD) who is nil per os (NPO) prior to sedation for Esophagogastroduodenoscopy (EGD) is low, as long as the patient has strictly followed NPO guidelines. For most elective procedures, patients should be NPO for at least:

• 6 hours for solid foods
• 4 hours for non-clear liquids
• 2 hours for clear liquids Adhering to these guidelines significantly reduces gastric volume and acidity, minimizing aspiration risk, as supported by the international multidisciplinary consensus statement on fasting before procedural sedation in adults and children 1. However, some precautions should still be taken:

1. Position the patient with the head slightly elevated during sedation.
2. Have suction readily available.
3. Consider rapid sequence intubation if there's high concern for aspiration. The low risk is due to the empty stomach achieved through NPO status, which limits the volume of potential aspirate. Additionally, the fasting state reduces gastric acid production, making any potential aspirate less harmful to the lungs. Despite these precautions, the anesthesiologist should still be aware of the patient's GERD and hiatal hernia, as these conditions can potentially increase the risk of regurgitation. Close monitoring during the procedure is essential, as the risk of pulmonary aspiration is a rare but potentially life-threatening complication of procedural sedation 1. It is also important to note that procedural sedation intentionally targets a state in which protective airway reflexes are retained, which reduces the aspiration risk compared to general anaesthesia, as discussed in the consensus statement 1.

From the Research

Aspiration Risk in Patients with Hiatal Hernia and GERD

The risk of aspiration in a patient with hiatal hernia and Gastroesophageal Reflux Disease (GERD) who is nil per os (NPO) prior to sedation for Esophagogastroduodenoscopy (EGD) is a concern.

• The current guidelines support a reduced fasting duration before procedures necessitating anesthesia or sedation 2.
• Studies have shown that aspiration risk is quite low, and the use of NPO past midnight can be reduced without increasing the risk of aspiration 2, 3.
• The relationship between NPO duration and the risk of aspiration is still a topic of controversy, and there is no clear evidence to support specific fasting periods for either liquids or solids prior to procedural sedation 3, 4.
• Factors that might influence the development of aspiration pneumonia include the position of the patient's body, method of feeding, and size of the feeding tube 5.
• In patients with certain conditions, such as congenital insensitivity to pain with anhidrosis, the risk of aspiration may be higher due to coexisting autonomic nervous system abnormalities, and rapid-sequence induction with an endotracheal tube should be utilized for the anesthetic management 6.

Specific Considerations for Hiatal Hernia and GERD

• Patients with hiatal hernia and GERD may be at increased risk of aspiration due to the potential for gastric reflux and delayed gastric emptying.
• However, the evidence suggests that the risk of aspiration is still relatively low, and the use of NPO past midnight may not be necessary for all patients undergoing EGD 2, 3.
• The decision to use NPO or to allow clear liquids before the procedure should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.