Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis

A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial

Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First-pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23-1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre.

Point-of-Care Ultrasound for Gastric Volume Measurement in a Pediatric Patient-Look Beyond the Antrum: A Case Report

Gastric ultrasound estimates stomach contents in perioperative patients. A 10-year-old boy with abdominal rhabdomyosarcoma, who received abdominal radiation, developed gastroparesis and was scheduled for endoscopic gastrointestinal pyloric dilation. Point-of-care gastric ultrasound revealed gastric antral cross-sectional area of 6.5 cm2 (estimated gastric content ~30 mL). However, dynamic right-to-left ultrasound revealed more hypoechoic material in the fundus of the stomach. On induction ~125 mL of stomach contents was suctioned. Antral measurements may not accurately predict the stomach contents in the setting of a stiff/fixed antrum. Scanning from antrum to fundus determined contents more accurately, especially with a prior history of abdominal radiation.

Ultrasound evaluation of gastric residual volume in fasting end-stage renal failure patients

STUDY OBJECTIVE

To evaluate the gastric contents and gastric residual volume in patient with end-stage renal failure by gastric ultrasound.

DESIGN

Prospective observational study.

SETTING

Tertiary care teaching hospital.

PATIENTS

Adults of either gender with BMI < 40 kg/m2 with end-stage renal failure scheduled to undergo arteriovenous graft or fistula.

INTERVENTIONS & MEASUREMENTS

The cross-sectional area of the gastric antrum was measured by gastric ultrasound with patient in both supine and right lateral decubitus positions. The volume of the gastric contents were calculated using suitable validated formula. In addition, the nature of the gastric contents was also determined by gastric ultrasound.

MAIN RESULTS

The incidence of delayed gastric emptying was found to be 57.7% in the population studied despite following the prescribed preoperative standard fasting guidelines.

CONCLUSIONS

There is a high incidence of delayed gastric emptying in patients with end-stage renal failure presenting for surgery which may predispose them to risk of pulmonary aspiration perioperatively.

Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia

Importance

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly increasing in the US, driven by its expanded approval for weight management in addition to hyperglycemia management in patients with type 2 diabetes. The perioperative safety of these medications, particularly with aspiration risk under anesthesia, is uncertain.

Objective

To assess the association between GLP-1 RA use and prevalence of increased residual gastric content (RGC), a major risk factor for aspiration under anesthesia, using gastric ultrasonography.

Design, Setting, and Participants

This cross-sectional study prospectively enrolled patients from a large, tertiary, university-affiliated hospital from June 6 through July 12, 2023. Participants followed preprocedural fasting guidelines before an elective procedure under anesthesia. Patients with altered gastric anatomy (eg, from previous gastric surgery), pregnancy, recent trauma (<1 month), or an inability to lie in the right lateral decubitus position for gastric ultrasonography were excluded.

Exposure

Use of a once-weekly GLP-1 RA.

Main Outcomes and Measures

The primary outcome was the presence of increased RGC, defined by the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids on gastric ultrasonography. Analysis was adjusted for confounders using augmented inverse probability of treatment weighting, a propensity score-based technique. Secondarily, the association between the duration of drug interruption and the prevalence of increased RGC was explored.

Results

Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group). After adjustment for confounding, GLP-1 RA use was associated with a 30.5% (95% CI, 9.9%-51.2%) higher prevalence of increased RGC (adjusted prevalence ratio, 2.48; 95% CI, 1.23-4.97). There was no association between the duration of GLP-1 RA interruption and the prevalence of increased RGC (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14).

Conclusions and Relevance

Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.

Gastric Volume and Antral Area in the Fasting State: A Meta-analysis of Individual Patient Data

BACKGROUND

Pulmonary aspiration of gastric content is a serious anesthetic complication. Gastric point-of-care ultrasound can determine the type and volume of gastric content when clinical information is equivocal. However, a cutoff value of either antral cross-sectional area or volume that may be considered as the upper limit of normal in fasting subjects is still controversial. The aim of this study is to characterize the distribution of baseline antral area and volume in fasting adult subjects and to identify an upper limit (95th percentile) of these distributions.

METHODS

The authors conducted a meta-analysis of individual participant data of primary studies from an academic research network of investigators collaborating in gastric ultrasound. Studies between January 2009 and December 2020 were included.

RESULTS

Twelve primary studies met inclusion criteria and were included in the analysis with a sample size of 1,203 subjects. The 95th percentile of area values (measured in the right lateral decubitus) was 9.9 cm2 (95% CI, 9.4 to 10.4), and of volume, 2.3 ml/kg (95% CI, 2.3 to 2.4). In addition, an antrum grade 0 or 1 indicates a 98% probability of an antral area below the 95th percentile.

CONCLUSIONS

An area of 10 cm2 measured in the right lateral decubitus could be a simple, data-driven upper limit of antral area that could serve as a surrogate of upper limit of normal gastric volume values in fasting adults. These results are limited by the highly selected sampling of the studies included.

EDITOR’S PERSPECTIVE

Effects of Preoperative Oral Carbohydrate on Perioperative Maternal Outcomes Undergoing Cesarean Section: A Systematic Review and Meta-Analysis

Purpose

Preoperative oral carbohydrate (CHO) is a rapid postoperative rehabilitation protocol that improves perioperative outcomes and is widely used in adult surgical patients. However, pregnant women are excluded because of the possibility of aspiration due to delayed gastric emptying. This meta-analysis was conducted to evaluate the efficacy of preoperative oral CHO in elective cesarean section.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to July 2023. Randomized controlled trials were included. The risk of bias was assessed using the Cochrane tool. Risk ratios and 95% confidence intervals were calculated. Meta-analysis was performed using random-effects models to estimate risk ratios and mean differences (MDs) with 95% confidence intervals (CIs). The outcomes included thirst and hunger scores, incidence of vomiting and nausea, time to flatus, and homeostatic model assessment of insulin resistance (HOMA-IR).

Results

A total of nine studies with 1211 patients were included in the analysis. The levels of thirst and hunger were evaluated using a 10-point visual analog scale, with 0 representing the best and 10 representing the worst. The severity of hunger (weighted mean difference (WMD: -2.34, 95% CI: -3.13 to -1.54), time to flatus (WMD: -3.51 hours, 95% CI: -6.85 to -0.17), and HOMA-IR (WMD: -1.04, 95% CI: -1.31 to -0.77) were significantly lower in the CHO group compared to the control group. However, there were no significant differences in the severity of thirst or the incidence of vomiting and nausea between the CHO and control groups.

Conclusion

Preoperative oral CHO during cesarean section alleviates thirst and hunger, shortens the time of postoperative flatus, and reduces HOMA-IR. However, the available evidence is insufficient to reach a clear consensus on the benefits or harms of preoperative oral CHO during cesarean section. Therefore, it is premature to make a definitive recommendation for or against its routine use.

Gastric point-of-care ultrasonography in patients undergoing radical gastrointestinal surgery before anesthetic induction: an observational cohort study

BACKGROUND

Pulmonary aspiration of gastric contents is a serious perioperative complication. Patients with gastric cancer may experience delayed gastric emptying. However, the role of qualitative and quantitative gastric ultrasound assessments in this patient population before anesthesia induction has not yet been determined.

METHODS

Adult patients with gastrointestinal cancer were recruited and examined using gastric point-of-care ultrasound (POCUS) before anesthetic induction from March 2023 to August 2023 in a tertiary cancer center. Three hundred patients with gastric cancer were conducted with POCUS prior to induction, and three hundred patients with colorectal cancer were included as controls. The cross-sectional area (CSA) of the gastric antrum and gastric volumes (GV) were measured and calculated. We determined the nature of the gastric contents and classified the antrum using a 3-point grading system. A ratio of GV to body weight > 1.5mL/Kg was defined as a high risk of aspiration.

RESULTS

In patients with gastric cancer, 70 patients were classified as grade 2 (23%, including 6 patients with solid gastric contents) and 63 patients (21%) were identified as having a high risk of aspiration. Whereas in patients with colorectal cancer, only 11 patients were classified as grade 2 (3.7%), and 27 patients (9.7%) were identified as having a high risk of aspiration. A larger tumor size (OR:1.169, 95% CI 1.045-1.307, P = 0.006), tumor located in antrum (OR:2.304, 95% CI 1.169-4.539,P = 0.016), gastrointestinal obstruction (OR:21.633, 95% CI 4.199-111.443, P < 0.0001) and more lymph node metastasis (OR:2.261, 95% CI 1.062-4.812, P = 0.034) were found to be positively while tumor site at cardia (OR:0.096, 95% CI 0.019-0.464, P = 0.004) was negatively associated with high aspiration risk in patients with gastric cancer.

CONCLUSION

The Gastric POCUS prior to induction provides an assessment of the status of gastric emptying and can identify the patients at high risk of aspiration, especially those with gastric cancer.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( www.chictr.org.cn ) identifier: ChiCTR2300069242; registered 10 March 2023.

Pulmonary aspiration of gastric contents in two patients taking semaglutide for weight loss

Semaglutide is a new weight loss treatment that has received substantial media attention in recent years. Anaesthetists must be aware of a potentially dangerous side effect of the drug: decreased gastric emptying. This is caused by effects on gastric smooth muscle, mediated by the vagal afferent nerves. This is especially relevant in the peri-operative setting where pulmonary aspiration of gastric contents is a recognised complication. Here, we report two cases of peri-operative regurgitation of gastric contents in patients taking semaglutide. A patient taking semaglutide may have a full stomach despite compliance with routine pre-operative fasting guidelines. We consider how to manage patients receiving glucagon-like peptide-1 agonist therapy in the peri-operative period, including identifying those at high risk of regurgitation. Precautions such as rapid sequence induction and tracheal intubation can be used, but gastric ultrasound may also be useful in the pre-operative environment to help identify patients at high risk of aspiration.

Medical Malpractice Claims Related to Performance of Transesophageal Echocardiography by Anesthesiologists

More than 300,000 adults have cardiac surgery in the United States annually, and most undergo intraoperative transesophageal echocardiography (TEE). This patient population is often older with multiple comorbidities, increasing their risk for complications for even routine procedures. Major morbidity or mortality caused by TEE is rare, and it is unknown how often such complications lead to malpractice lawsuits. The authors identified 13 cases out of 2,564 in a closed claims database that involved TEE and reviewed their etiology. Esophageal injury accounted for most of the suits, and only 2 were related to diagnosis. Most expert reviews deemed the care provided by the anesthesiologist to be appropriate.

Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence

Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study

PURPOSE

Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada.

METHODS

We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24 hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables.

RESULTS

Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (β/SE[β], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors.

CONCLUSIONS

A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

Feasibility and Utility of Routine Point-of-Care Gastric Ultrasonography in Patients Undergoing Upper Gastrointestinal Endoscopy Procedures: A Prospective Cohort Study

OBJECTIVES

Previous studies have indicated that point-of-care ultrasonography (POCUS) of the gastric antrum can predict the adequacy of fasting before surgery and anesthesia. The aim of this study was to evaluate the utility of gastric POCUS in patients undergoing upper gastrointestinal (GI) endoscopy procedures.

METHODS

We performed a single-center cohort study in patients undergoing upper GI endoscopy. Consenting patient's gastric antrum was scanned before anesthetic care for endoscopy to determine the cross-sectional area (CSA) and qualitatively determine safe and unsafe contents. Further, an estimate of residual gastric volume was determined using the formula and the nomogram methods. Subsequently, gastric secretions aspirated during endoscopy were quantified and further correlated with nomogram and formula-based assessments. No patient required a change in the primary anesthetic plan except for using rapid sequence induction in those with unsafe contents on POCUS scans.

RESULTS

Qualitative ultrasound measurements consistently determined safe and unsafe gastric residual contents in 83 patients enrolled in the study. Unsafe contents were determined by qualitative scans in 4 out of 83 cases (5%) despite adequate fasting status. Quantitatively, only a moderate correlation was demonstrated between measured gastric volumes and nomogram (r = .40, 95% CI: 0.20, 0.57; P = .0002) or formula-based (r = .38, 95% CI: 0.17, 0.55; P = .0004) determinations of residual gastric volumes.

CONCLUSION

In daily clinical practice, qualitative POCUS determination of residual gastric content is a feasible and useful technique to identify patients at risk of aspiration before upper GI endoscopy procedures.

Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study

Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety.

Preprocedural fasting policies for patients receiving tube feeding: A national survey

BACKGROUND

Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures.

METHODS

The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated.

RESULTS

The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed.

CONCLUSIONS

Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

Retained Gastric Contents After Adequate Fasting Associated with GLP-1 Receptor Agonist Use: A Report of 3 Cases

CASES

Three patients presented for orthopaedic surgery on glucagon-like peptide receptor agonist (GLP-1 RA) medications with a minimum fasting time of 10 hours. Gastric ultrasound confirmed the presence of retained solids in the stomach; all 3 cases were postponed.

CONCLUSION

There is growing concern for increased perioperative aspiration risk related to delayed gastric emptying associated with GLP-1 RA and a paucity of literature to guide perioperative management. This may cause case cancellation over safety concerns for elective procedures. The presented cases illustrate the association of GLP-1 RA drugs and delayed gastric emptying causing case postponement.

Diagnostic accuracy of a simple qualitative ultrasound assessment for the diagnosis of empty stomach in the adult: A supplementary analysis of a prospective observer-blind randomized crossover study

BACKGROUND

It has been reported that qualitative ultrasound assessment performed in the semi-upright position had high sensitivity to detect gastric fluid volume >1.5 mL.kg-1 . Nevertheless, the diagnostic accuracy of qualitative assessment for the diagnosis of empty stomach (fluid volume <0.8 mL.kg-1 ) has not been assessed. We aimed to assess the diagnostic accuracy of simple qualitative ultrasound assessment with and without head-of-bed elevation to 45° for the diagnosis of an empty stomach. We also aimed to determine the diagnostic accuracy of a composite ultrasound scale and clinical algorithm.

METHODS

We performed a supplementary analysis of a prospective observer-blind randomized crossover trial in which adult fasting volunteers attended two distinct sessions, with the head-of-bed angled either at 0° or 45°, in a randomized order. Three tests were performed within each session, each corresponding to a different (either 0, 50, 100, 150 or 200 mL) and randomized volume of water; the same volumes were ingested in both sessions, in a randomized order. Ultrasounds were performed 3 min after water ingestion, blindly to the volume ingested.

RESULTS

We included 20 volunteers in whom 120 measurements were analyzed. The sensitivity and specificity of the qualitative assessment in the semirecumbent position were 93% (95% CI: 68-100) and 89% (95% CI: 76-96), respectively. The composite scale and clinical algorithm did not have better diagnostic accuracy than the qualitative assessment performed with head-of-bed elevation. Without head-of-bed elevation, the clinical algorithm had significantly higher specificity (98% [95% CI: 88-100]) than qualitative assessment (67% [95% CI: 51-80]; p < 0.05).

CONCLUSION

These results suggest that qualitative assessment in the semirecumbent position had high diagnostic accuracy for the diagnosis of fluid volume <0.8 mL.kg-1 ; this method can be used in clinical practice for reliable diagnosis of empty stomach.

Clinical Utility of Pepsin and Bile Acid in Tracheal Secretions for Accurate Diagnosis of Aspiration in ICU Patients

BACKGROUND

Aspiration of stomach content or saliva in critical conditions-e.g., shock, intoxication, or resuscitation-can lead to acute lung injury. While various biomarkers in bronchoalveolar lavage fluids have been studied for diagnosing aspiration, none have been conclusively established as early indicators of lung damage. This study aims to evaluate the diagnostic value of pepsin, bile acid, and other biomarkers for detecting aspiration in an intensive care unit (ICU).

MATERIALS AND METHODS

In this study, 50 ICU patients were enrolled and underwent intubation before admission. The evaluation of aspiration was based on clinical suspicion or documented instances of observed events. Tracheal secretion (TS) samples were collected within 6 h after intubation using sterile suction catheters. Additional parameters, including IL-6, pepsin, and bile acid, were determined for analysis. Pepsin levels were measured with an ELISA kit, while bile acid, uric acid, glucose, IL-6, and pH value in the tracheal secretion were analyzed using standardized lab methods.

RESULTS

The 50 patients admitted to the ICU with various diagnoses. The median survival time for the entire cohort was 52 days, and there was no significant difference in survival between patients with aspiration pneumonia (AP) and those with other diagnoses (p = 0.69). Among the AP group, the average survival time was 50.51 days (±8.1 SD; 95% CI 34.63-66.39), while patients with other diagnoses had a mean survival time of 32.86 days (±5.1 SD; 95% CI 22.9-42.81); the survival group comparison did not yield statistically significant results. The presence of pepsin or bile acid in TS patients did not significantly impact survival or the diagnosis of aspiration. The p-values for the correlations between pepsin and bile acid with the aspiration diagnosis were p = 0.53 and p > 0.99, respectively; thus, pepsin and bile acid measurements did not significantly affect survival outcomes or enhance the accuracy of diagnosing aspiration pneumonia.

CONCLUSIONS

The early and accurate diagnosis of aspiration is crucial for optimal patient care. However, based on this study, pepsin concentration alone may not reliably indicate aspiration, and bile acid levels also show limited association with the diagnosis. Further validation studies are needed to assess the clinical usefulness and reliability of gastric biomarkers in diagnosing aspiration-related conditions. Such future studies would provide valuable insights for improving aspiration diagnosis and enhancing patient care.

Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report

PURPOSE

We report a case in which the use of semaglutide for weight loss was associated with delayed gastric emptying and intraoperative pulmonary aspiration of gastric contents.

CLINICAL FEATURES

A 42-yr-old patient with Barrett's esophagus underwent repeat upper gastrointestinal endoscopy and ablation of dysplastic mucosa. Two months earlier, the patient had started weekly injections of semaglutide for weight loss. Despite having fasted for 18 hr, and differing from the findings of prior procedures, endoscopy revealed substantial gastric content, which was suctioned before endotracheal intubation. Food remains were removed from the trachea and bronchi using bronchoscopy. The patient was extubated four hours later and remained asymptomatic.

CONCLUSION

Patients using semaglutide and other glucagon-like peptide 1 agonists for weight management may require specific precautions during induction of anesthesia to prevent pulmonary aspiration of gastric contents.

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Evolving Use of Regional versus General Anesthesia for the Surgical Repair of Open Globe Injuries

PURPOSE

The purpose of the current study is to report outcomes with the evolving use of regional anesthesia with monitored anesthesia care (RA-MAC) vs general anesthesia (GA) in the repair of open globe injuries.

DESIGN

Retrospective, consecutive, comparative, nonrandomized clinical study.

METHODS

The study includes 507 eyes of 507 patients with open globe injuries treated with either RA-MAC or GA at a tertiary referral center between 2015 and 2020. There was no predetermined protocol for selection of anesthesia method. However, based on experience and findings of prior research by this group, regional anesthesia with monitored anesthesia care was typically selected initially and changed to general anesthesia if warranted after evaluation of the patient and discussion with the surgeon. The main outcome measure was visual acuity at last follow-up. Results were compared to previously published study groups between 1995 and 2014.

RESULTS

Primary closure of open globe injury was performed under RA-MAC anesthesia in 462 patients (91%) and under GA in 45 patients (9%). Zone 1, 2, and 3 injuries were recorded in 251, 170, and 86 patients, respectively. Zone 1 (96%, 240 of 251 patients) or zone 2 (92%, 156 of 170 patients) (P < .001) were more likely to be repaired under RA-MAC vs zone 3 injuries (76%, 65 of 86 patients). The improvement from presenting visual acuity was similar for the 2 anesthesia groups, 0.52 logMAR and 0.46 logMAR for RA-MAC and GA, respectively (P = .68, CI -0.3 to 0.2). The use of RA-MAC anesthesia for open globe injuries has increased at our institution from 64% in 1995-1999 to 91% in the present study, 2015-2020 (P < .00001).

CONCLUSION

The current study demonstrates that with anesthesiologists experienced in ophthalmic regional anesthesia techniques, and appropriate case selection, RA-MAC can be safely used as an alternative to general anesthesia for open globe repair. Considerations when employing RA-MAC include a patient's ability to cooperate, position, and communicate for the duration of the globe repair.

A Novel Case of Acute Respiratory Distress Syndrome Following Radiofrequency Ablation for Atrial Fibrillation

Radiofrequency ablation (RFA) is a minimally invasive cardiac catheterization procedure employed in patients whose atrial fibrillation (AF) is not well-controlled on medical therapy. While serious complications after the RFA are uncommon, we present the unique case of a 71-year-old male who suffered from acute respiratory distress syndrome (ARDS) and pneumomediastinum post-procedure. He presented to the ED with dyspnea, non-massive hemoptysis, and fever three days following RFA. Admission CT thorax demonstrated patchy ground glass opacities (GGOs) and stable fibrotic changes. He was admitted for suspected pneumonia, however, he failed to significantly improve on broad-spectrum antibiotics. Bronchoscopy found blood in proximal airways, however, lavage with serial aliquots were without worsening hemorrhage, ruling out suspected diffuse alveolar hemorrhage. Cytology resulted in rare iron polymorphonuclear neutrophils and no malignant cells. With worsening clinical status, the patient was eventually intubated. Repeat CT thorax showed new moderate pneumopericardium, small pneumomediastinum, and progressed GGOs. The respiratory course continued to worsen, and the patient passed away approximately one month after admission. We also present a brief literature review with the aim of identifying prognostic risk factors regarding post-RFA ARDS development. Additionally, this case identifies a novel complication of RFA, as post-procedural pneumomediastinum has not been previously described.

Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study

Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg^-1 (mean ± SD 3.08 ± 1.67, range 1.51-5.01 mL kg^-1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration.

2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting

These practice guidelines are a modular update of the "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." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

Ultrasonographic assessment of preoperative gastric volume in patients with dyspepsia: a prospective observational study

Background

Patients undergoing gastroenteroscopy during sedation are prone to aspiration, and most patients with dyspepsia have delayed gastric emptying. This study aimed to investigate the feasibility of measuring the gastric antrum cross-sectional area (CSA) to supply a novel clinical diagnostic reference value in patients with dyspepsia.

Methods

Patients with dyspepsia undergoing elective gastroscopy were included. The Perlas qualitative 0–2 grading scale score was determined before the operation. The anteroposterior diameter (D1) and craniocaudal diameter (D2) between gastric antrum serosal surfaces were measured perpendicular to each other in the supine and right lateral decubitus (RLD) positions. CSA values in the supine position and RLD position were determined. Gastric contents were endoscopically suctioned with the volumes measured and noted as actual gastric volume. Multiple regression analysis was used to fit a mathematical model for estimating the gastric volume. Receiver operating characteristic (ROC) curves were constructed to determine the accuracy of RLD CSA to detect gastric volumes of > 0.8 ml/kg.

Results

A total of 117 patients were enrolled and divided into a functional dyspepsia (FD) group and an organic dyspepsia group according to gastroscopy findings. For a gastric volume of > 0.8 ml/kg, cut-off values for FD and organic dyspepsia were 6.7 cm² and 10.0 cm², respectively. Two new modified mathematical models were derived to predict an estimated gastric volume for FD and organic dyspepsia: volume = 3.93 × RLD CSA - 0.47 × age; and volume = 6.15 × RLD CSA - 0.61 × age.

Conclusion

We used the cut-off value of the antral area for the fast diagnosis of gastric volumes in patients with dyspepsia, which may assist clinicians in identifying patients at risk of aspiration.

Trial registration

www.chictr.org.cn (CHICTR-DDD-17010871); registered 15 March 2017.

A New Scope of Practice: Adult Pulmonary Aspiration Managed With a Pediatric Gastroscope: A Case Report

Pulmonary aspiration continues to be a major cause of anesthesia-related mortality. Anesthesiologists are encouraged to perform bronchoscopy to manage aspiration of particulate matter; however, they have limited training and experience in clearing luminal obstructions endoscopically. In our report, an adult with achalasia aspirated during induction for a per-oral endoscopic myotomy (POEM), resulting in desaturation and high airway pressures. Bronchoscopy by the anesthesiologist was ineffective. However, bronchoscopy by the gastroenterologist using a pediatric gastroscope cleared the bronchi of debris and led to immediate clinical improvement. Anesthesiologists, faced with particulate matter aspiration, could consider assistance from a gastrointestinal endoscopist.

Utilization and Outcomes of Extracorporeal Membrane Oxygenation in Obstetric Patients in the United States, 1999-2014: A Retrospective Cross-Sectional Study

BACKGROUND

Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States.

METHODS

Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models.

RESULTS

During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74).

CONCLUSIONS

During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.