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Perioperative Pulmonary Aspiration (10Cs)

This page is part of the Safetots Crisis SOPs, a framework for prevention and treatment of the most relevant crisis situations in pediatric anaesthesia.

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Summary

Perioperative pulmonary aspiration is a rare event provided that the airway technique and device has been selected according to the patient risk factors.

Background

Peri-operative pulmonary aspiration is rare in pediatric anesthesia and usually has a good outcome.

Prevention

  • strict adherence to fasting instructions and recognition of patients with delayed gastric emptying or with a full stomach
  • patients with intestinal obstruction require a naso-gastric tube
  • choice of appropriate induction technique and airway device
  • controlled Rapid Sequence Induction and Intubation (RSII) requires rapid induction of anesthesia, deep muscle relaxation and gentle face mask ventilation to maintain oxygenation, ventilation and anesthesia
  • ensure sufficient depth of anesthesia (+/- muscle relaxation) to avoid coughing, bucking, straining resulting in regurgitation of gastric content and pulmonary aspiration

Treatment

  • call for assistance and help
  • place patient in lateral and head down position
  • suction clearance of airway content and secure airway with tracheal intubation
  • no broncho-alveolar lavage
  • solid foreign body aspiration may require bronchoscopy and extraction
  • lung recruitment maneuver if required
  • postpone non-emergency surgery if severe aspiration suspected
  • chest x-ray, steroids or prophylactic antibiotics are not routinely required unless symptoms persist
  • attempt early extubation

Post Care

  • hospital discharge is possible if asymptomatic after 2 hours

References

  1. Frykholm P, Schindler E, Sümpelmann R, Walker R, Weiss M. Preoperative fasting in children: review of existing guidelines and recent developments. Br J Anaesth. 2018; 120: 469-74.
  2. Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth. 2018; 28: 411-4.
  3. Disma N, Thomas M, Afshari A, Veyckemans F, De Hert S. Clear fluids fasting for elective paediatric anaesthesia: The European Society of Anaesthesiology consensus statement. Eur J Anaesthesiol. 2019; 36: 173-174.
  4. Kelly CJ, Walker RW. Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice. Paediatr Anaesth. 2015; 25: 36-43.
  5. Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia.Br J Anaesth 1999; 83: 453-60. Weiss M, Gerber AC. [Induction of anaesthesia and intubation in children with a full stomach. Time to rethink!].  Anaesthesist. 2007; 56: 1210-6.
  6. Weiss M, Gerber A. Rapid sequence induction in children – it’s not a matter of time! Paediatr Anaesth. 2008; 18: 97-9.
  7. Eich C, Timmermann A, Russo SG, Cremer S, Nickut A, Strack M, Weiss M, Müller MP. A controlled rapid-sequence induction technique for infants may reduce unsafe actions and stress. Acta Anaesthesiol Scand. 2009; 53: 1167-72.
  8. Schmidt J, Strauß JM, Becke K, J Giest J, Schmitz B. Handlungsempfehlung zur Rapid-Sequence-Induction im Kindesalter. Anästhesie & Intensivmedizin 2007; 48: S86-S93.
  9. Engelhardt T. Rapid sequence induction has no use in pediatric anesthesia. Paediatr Anaesth. 2015; 25: 5-8.

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