What is the management protocol after an aspiration event on induction?

From the Guidelines

The management protocol after an aspiration event on induction involves immediate intervention to minimize lung damage and prevent complications, with a focus on securing the airway, suctioning the aspirated material, and providing supportive care. The first step is to position the patient in a head-down, left lateral position to contain the aspiration to the right lung. Suction the oropharynx and trachea immediately to remove as much aspirated material as possible, as seen in cases where patients were taking glucagon-like peptide-1 receptor agonists and experienced regurgitation or pulmonary aspiration during general anesthesia 1. Intubate the patient if not already done to secure the airway and provide 100% oxygen. Perform bronchoscopy if large particle aspiration is suspected or if the patient doesn't improve. Administer bronchodilators such as albuterol (2.5-5 mg nebulized) for bronchospasm. Consider a single dose of prophylactic antibiotics only if the aspirated material was particularly contaminated, though routine antibiotic use is not recommended. Corticosteroids are generally not indicated unless there is significant bronchospasm. Some key points to consider in the management of aspiration pneumonia include:

• Monitoring the patient closely with pulse oximetry, arterial blood gases, and chest X-rays to assess for development of aspiration pneumonitis or ARDS
• Providing supportive care including mechanical ventilation with lung-protective strategies if respiratory failure develops
• The severity of lung injury depends on the volume and pH of aspirated material, with acidic gastric contents (pH < 2.5) causing more severe chemical pneumonitis, as reported in cases of patients taking GLP-1 receptor agonists who experienced pulmonary aspiration despite appropriate fasting 1. Most patients with minor aspiration recover within 24-48 hours with supportive care, while severe cases may require ICU management. It is essential to note that the use of GLP-1 receptor agonists has been associated with an increased risk of pulmonary aspiration under anesthesia, even with prolonged pre-operative fasting times 1.

From the Research

Management Protocol After Aspiration Event on Induction

The management protocol after an aspiration event on induction involves several key steps:

• Intensive medical monitoring and fiber-optic bronchoscopy should be performed, depending on the degree of severity 2
• An X-ray thorax image or a CT scan should be performed if symptoms arise 2
• Treatment of aspiration pneumonitis should focus on aggressive pulmonary care to enhance lung volume and clear secretions, with intubation used selectively 3
• Treatment of aspiration pneumonia requires diligent surveillance for clinical signs of pneumonia, with treatment decisions based on factors such as clinical diagnostic certainty, time of onset, and host factors 3

Prevention of Aspiration

Prevention of aspiration is crucial, and several measures can be taken:

• Patients at risk of aspiration should be examined and explained prior to rapid sequence induction (RSI) according to the recommendations of the National German Society of Anesthesiology for preoperative evaluation 2
• Optimal drug pre-treatment with antacids, proton pump inhibitors, or H2 blockers should be used the evening before induction 2
• Consistent pre-oxygenation with an FIO2 of 1.0 and an oxygen flow > 10 l/min using a completely sealing respiratory mask with capnography should take 3-5 minutes 2
• A nasogastric tube placement followed by rapid sequence induction or conscious intubation may be recommended for patients after esophagectomy 4

Airway Management

Airway management is critical in patients at risk of aspiration:

• A gastric tube (GT) should not be withdrawn and should be connected to suction during induction 5
• The use of GTs and airway management should be individualized based on factors such as the procedure, type and severity of underlying pathology, state of consciousness, and likelihood of difficult airway 5
• An algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents has been proposed, taking into account various factors and procedures 5