By Matthew Newton, DNP, CRNA
Although aspiration is always on our minds, it isn’t something that we as Anesthesia providers encounter every day during outpatient gastrointestinal cases. However, when it does occur, it can lead to serious complications. Sedation-induced suppression of protective airway reflexes, an unsecured airway, gastrointestinal insufflation, and abdominal pressure may all create conditions in which aspiration becomes a real risk in ambulatory settings. It’s essential for providers to stay current on the recognition, prevention, and management of these events, especially since early intervention can dramatically influence outcomes.
Although GI procedures are routine in the outpatient setting, the risk of aspiration, while rare, cannot be ignored. Even in the PACU, where patients may appear awake and responsive, their reaction times and airway reflexes may remain impaired. If gastric contents enter the lower airway, they pose increased risks, such as pneumonitis, airway obstruction, infection, or a variety of undesirable outcomes. Severity is often determined by the volume, composition, and pH of the aspirate. A lower pH and larger volume are associated with the most serious complications, including ARDS and pulmonary edema.
Risk reduction begins well before the procedure with a thorough preoperative evaluation. With increasing production pressures and a sense of urgency, it can be tempting to rush through this vital step, but patient safety must remain our top priority. A careful preoperative screening should identify patients with GERD, obesity, diabetes, prior GI surgeries, or other comorbidities. Confirming appropriate NPO status (no clear liquids for at least 2 hours and no light solids for at least 6 hours) is critical. For higher-risk patients, premedication with prokinetics or antacids may be appropriate in certain situations.
If aspiration occurs intraoperatively, early recognition is vital. Signs may include coughing, emesis, sudden hypoxia, wheezing, tachypnea, or visible gastric contents in or around the mouth. Sometimes the indicators are more subtle, like a slight drop in SpO₂ or a sudden increase in respiratory effort without a clear cause. When aspiration is suspected, act immediately: consider placing the patient in Trendelenburg or lateral decubitus to limit further aspiration. Suction the oropharynx gently and administer 100% oxygen. If no signs of distress are present and oxygen saturation remains stable, monitor closely and conduct a thorough evaluation before considering discharge. If the aspiration is significant and the airway is unsecured, rapid sequence intubation may be required. Once intubated, suction through the endotracheal tube, auscultate for wheezes or crackles, and monitor SpO₂ and ETCO₂. Bronchodilators may be helpful if bronchospasm is present. Although corticosteroids are sometimes used, evidence on their effectiveness remains inconclusive. If oxygen saturation does not improve or clinical concerns persist, consider an ABG and a chest X-ray to assess for pneumonitis or other complications.
Postoperatively, close monitoring in the PACU is essential. Keep the patient upright and observe for respiratory distress, such as increased work of breathing, abnormal lung sounds, or declining oxygen levels. If aspiration pneumonitis is suspected, indicated by fever, hypoxia, or radiographic infiltrates, broad-spectrum antibiotics may be warranted, particularly when food or bile was involved. Continue frequent assessments until the patient’s respiratory status has clearly improved.
Prior to discharge, ensure the patient is truly stable, with a normal SpO₂ on room air, no respiratory distress, and full recovery from anesthesia. If a chest X-ray or clinical assessment suggests ongoing lung injury, always err on the side of caution. Once discharged, provide clear return precautions: symptoms like worsening cough, fever, chest pain, dyspnea, or fatigue should prompt immediate medical attention. Even if the event appears minor, scheduling a 24–48-hour follow-up can help identify any delayed complications.
Aspiration may be infrequent and sometimes unavoidable in outpatient practice, but preparation is key. By focusing on prevention, acting quickly when events occur, and delivering diligent postoperative care, we can mitigate risks and support better outcomes for our patients.
