**6. Management of aspiration**

The first step in aspiration management is to be vigilant for any signs and symptoms of aspiration in patients especially in those who are known to have full stomach. Any witnessed gastric or oropharyngeal contents into the trachea during induction, maintenance or emergence from anesthesia, witnessed vomitus through the nose or mouth or sudden elevation of peak airway pressures during ventilation or cough, persistent hypoxia, bronchospasm or abnormal breath sounds following intubation, sore throat, dyspnea at recovery may suggest that a patient has aspirated (**Table 4**). Management in the intensive care unit includes monitoring and supportive therapy and broad-spectrum antibiotics.

#### **Immediate steps in clinically significant aspiration**

1.Call for **help** for **senior** anesthesiologist.


#### **Table 4.**

*Summary for immediate steps in aspiration prophylaxis.*

#### **6.1 Chemical pneumonitis**

The main stay of treatment in chemical pneumonitis includes immediate tracheal suctioning to remove the aspirated material followed by pulmonary support. Use of antibiotics must be revaluated by the team after 48–72 h and its use discontinued if there are no signs of infection [41].

#### **6.2 Bacterial pneumonia**

The antibiotic regimen should include aerobic and anaerobic coverage, especially against gram-negative bacilli and *Staphylococcus aureus*. **Carbapenem** (Imipenem, Meropenem) or Piperacillin Tazobactam in resistant Gram-negative bacilli or in patients who have received intravenous antibiotic coverage in the past 90 days. If anaerobic bacteria are suspected, parenteral antibiotic of Ampicillin-Sulbactam 1.5–3 g intravenous every 6 h or **Amoxicillin Clavulanate** (immediate release 875 mg orally twice daily or extended release 2 g orally twice daily) is an appropriate alternative.

Other alternative regimens include **Metronidazole** 500 mg orally or intravenous three times daily plus either amoxicillin 500 mg orally three times daily or Penicillin G intravenous 1–2 million units intravenous every 4 to 6 hours. In penicillin allergy Clindamycin 600 mg intravenous every 8 h or **Ceftriaxone** 1–2 g intravenous daily or **Cefotaxime** 1–2 g intravenous every 8 h in combination with Metronidazole. Oral antibiotics switch from parenteral antibiotics is based on clinical improvement, hemodynamic stability, tolerance for oral medications [41, 42].

#### **7. Full stomach in special populations**

#### **7.1 Difficult airway management in full-stomach patient**

If a difficult airway is predicted, the risk of aspiration may be weighed against the risk of difficult or failed airway management. In such a case, modified rapid sequence

**117**

*Airway Management in Full Stomach Conditions DOI: http://dx.doi.org/10.5772/intechopen.93591*

aspiration [44, 45].

aspiration [47].

intubations) [49].

be avoided [50].

**7.3 Obstetric population**

**7.2 Pediatric population**

induction and intubation (RSII), awake fiberoptic intubation or inhalational induction may be considered. The advantages of awake tracheal intubation are maintenance of protective airway reflexes, uncompromised airway oxygenation and ventilation and maintenance of normal muscle tone, which helps in the identification of anatomic landmarks. It is accomplished by adequate preoperative preparation, use of an intravenous anti-sialagogue to reduce oral secretions, cautious use of intravenous sedation and an experienced skill anesthetist. Topicalization of the airway is controversial, as airway reflexes might be abolished after topical anesthesia of lower airways putting the patient at risk of aspiration as the larynx will no longer be "AWAKE". It is recommended to use topical anesthesia on base of tongue, vallecula and epiglottis while spraying the local anesthesia directly to vocal cord, transtracheal anesthesia and anesthesia to recurrent laryngeal nerve should be avoided in high risk of aspiration [43]. Presently, Supraglottic Airway Device (SAD) is recognized in the ASA difficult airway algorithm. It could be used as ventilation device or serves as conduit for intubation, or both. The **Proseal**™ Laryngeal mask airway is potentially useful device especially in patient with high risk for gastric regurgitation and pulmonary aspiration as it has been shown to protect adult and pediatric patients from large-volume aspiration in some studies, however no studies have confirmed its effectiveness comparing to cuffed endotracheal tubes at reducing the risk of

The accurate incidence rate of aspiration pneumonitis in pediatric anesthesia is unknown. However, it has been acknowledged as a rare event, it was reported as three times more common than in adults [46]. A prospective survey between 1978 and 1982 found only four aspirations among 40,240 in pediatric general anesthesia reported with no morbidity or mortality was reported. Other studies based on esophageal pH monitoring and barium contrast have stated that silent pulmonary aspiration may be more frequent in pediatric population with no neurological or anatomical abnormalities than in adults, with no respiratory consequences. Diagnosis of aspiration pneumonia in children should be made only if there are swallowing difficulties, known gastro-esophageal reflux or a witnessed

Mendelson was the first to describe 66 cases of aspiration between 1932 and 1945, with an incidence of 1 in 667 parturient and two deaths, both caused by acute upper airway obstruction. The mortality incidence was estimated about 1 in 22,008 [48]. In ASA closed claims, obstetric related aspiration constituted a 21% of all claims. A dramatic decreasing trend over time, in the 1970–1979; 43% of the respiratory claims compared to 20% in the 1980s and only 7% (two claims) of the aspiration claims in the 1990s. This suggests that benefit of the aspiration prevention strategies in the obstetric populations that introduced into clinical practice in the 1980s. A recent literature review found an incidence of failed tracheal intubation of 2.6 per 1000 obstetric general anesthesia (1 in 390) and associated maternal mortality of 2.3 per 100,000 general anesthesia (one death for every 90 failed

The main recommendation is to adopt the neuraxial blocks as a main anesthetic technique, optimum pharmacological prophylaxis, avoiding of general anesthesia, minimizing airway manipulation and relying on RSII if general anesthesia cannot

#### *Airway Management in Full Stomach Conditions DOI: http://dx.doi.org/10.5772/intechopen.93591*

*Special Considerations in Human Airway Management*

**Immediate steps in clinically significant aspiration**

2.**Suction** for the fluid/particulate in the oropharynx and trachea.

7. **Lung recruitment** to patients to maintain adequate saturation. 8.Portable **chest radiograph** as a baseline documentation.

9.**Stabilization** before surgical incision If the surgery cannot be postponed

ventilation or cardiovascular effects such as hypotension and shock.

3.**Definitive** airway management with a cuffed endotracheal tube with mechanical ventilation. 4.**Continuous monitoring** of vital signs, baseline chest radiograph and arterial blood gas

volume with relatively high respiratory rate along with positive end expiratory pressure.

5.**Hemodynamic support** (two wide bore intravenous cannula, vasopressors with conservative fluid

6.**Respiratory support** using lung protective ventilation strategy if required which combined low tidal

10.**Postponing** the surgery is recommended in significant airway obstruction, impaired oxygenation or

11.**Multidisciplinary team** of intensivist, Infection disease and pulmonologist for post-operative

1.Call for **help** for **senior** anesthesiologist.

administration to avoid pulmonary edema)

**6.1 Chemical pneumonitis**

intensive care.

**Table 4.**

**6.2 Bacterial pneumonia**

tinued if there are no signs of infection [41].

*Summary for immediate steps in aspiration prophylaxis.*

**7. Full stomach in special populations**

The main stay of treatment in chemical pneumonitis includes immediate tracheal suctioning to remove the aspirated material followed by pulmonary support. Use of antibiotics must be revaluated by the team after 48–72 h and its use discon-

The antibiotic regimen should include aerobic and anaerobic coverage, especially against gram-negative bacilli and *Staphylococcus aureus*. **Carbapenem** (Imipenem, Meropenem) or Piperacillin Tazobactam in resistant Gram-negative bacilli or in patients who have received intravenous antibiotic coverage in the past 90 days. If anaerobic bacteria are suspected, parenteral antibiotic of Ampicillin-Sulbactam 1.5–3 g intravenous every 6 h or **Amoxicillin Clavulanate** (immediate release 875 mg orally twice daily or extended release 2 g orally twice daily) is an appropriate alternative.

Other alternative regimens include **Metronidazole** 500 mg orally or intravenous three times daily plus either amoxicillin 500 mg orally three times daily or Penicillin G intravenous 1–2 million units intravenous every 4 to 6 hours. In penicillin allergy Clindamycin 600 mg intravenous every 8 h or **Ceftriaxone** 1–2 g intravenous daily or **Cefotaxime** 1–2 g intravenous every 8 h in combination with Metronidazole. Oral antibiotics switch from parenteral antibiotics is based on clinical improve-

If a difficult airway is predicted, the risk of aspiration may be weighed against the risk of difficult or failed airway management. In such a case, modified rapid sequence

ment, hemodynamic stability, tolerance for oral medications [41, 42].

**7.1 Difficult airway management in full-stomach patient**

**116**

induction and intubation (RSII), awake fiberoptic intubation or inhalational induction may be considered. The advantages of awake tracheal intubation are maintenance of protective airway reflexes, uncompromised airway oxygenation and ventilation and maintenance of normal muscle tone, which helps in the identification of anatomic landmarks. It is accomplished by adequate preoperative preparation, use of an intravenous anti-sialagogue to reduce oral secretions, cautious use of intravenous sedation and an experienced skill anesthetist. Topicalization of the airway is controversial, as airway reflexes might be abolished after topical anesthesia of lower airways putting the patient at risk of aspiration as the larynx will no longer be "AWAKE". It is recommended to use topical anesthesia on base of tongue, vallecula and epiglottis while spraying the local anesthesia directly to vocal cord, transtracheal anesthesia and anesthesia to recurrent laryngeal nerve should be avoided in high risk of aspiration [43].

Presently, Supraglottic Airway Device (SAD) is recognized in the ASA difficult airway algorithm. It could be used as ventilation device or serves as conduit for intubation, or both. The **Proseal**™ Laryngeal mask airway is potentially useful device especially in patient with high risk for gastric regurgitation and pulmonary aspiration as it has been shown to protect adult and pediatric patients from large-volume aspiration in some studies, however no studies have confirmed its effectiveness comparing to cuffed endotracheal tubes at reducing the risk of aspiration [44, 45].
