The CT-scan of a 75-yrs old male, with recently discovered biliary pancreatitis for which he underwent multiple endoscopic retrograde cholangiopancreaticography (ERCP) showed an increased development of necrosis. Due to this acute setting, indication for video assisted retroperitoneal drainage was determined. Before the procedure, the patient was seen by an anesthesiologist. Because of the emergency setting no pre-operative optimization was feasible. Patient underwent procedural sedation analgesia (PSA), but almost instantly after initiation of sedation regurgitation and aspiration was observed, what made immediate intubation ventilatory support (↓ SpO2) and the placement of a gastric tube necessary. The procedure was continued, during which the patient became hemodynamically instable. The patient was admitted to the ICU afterwards, but four days postoperatively little had changed in ventilation requirements.
The main predisposing factors for aspiration are emergency settings and inadequate anaesthesia.1 This makes one wonder what could have been done differently to avoid aspiration; Postponing the procedure (due to emergency not a real option), placement of a gastric tube pre-procedurally, use of a different patient positioning, or anesthesia with rapid sequence intubation (RSI) instead of PSA? There is no clear evidence for the use of, for instance, anti-Trendelenburg position during intubation, but it should be avoided in morbidly obese patients2,3. Though, aspiration is reduced in a semi-sitting position4, airway management might be more difficult. The nauseousness caused by the patient’s condition, made him regurgitate. Suctioning via a beforehand placed gastric tube might have reduced gastric volume. However, this would have only worked for clear fluids, more solid contents cannot be suctioned via a gastric tube, thus success of this intervention is debatable. Moreover, the gastric tube had to be removed since otherwise the lower esophageal sphincter remains open increasing the likelihood of regurgitation. Furthermore, there is no evidence that RSI is able to reduce aspiration and it has several complication of its own.5 Nevertheless, it might have been done, since RSI is recommended for patients at risk of aspiration by all guidelines.
In the future, use of anesthesia with RSI instead of PSA for patients with increased likelihood of regurgitation will most likely be the better choice.
M. Nazir & M.W. Hollmann
- Kluger, Anaesthesia; 1999(54)19
- Dixon, Anesthesiology; 2005(102)1110
- Altermatt, British Journal of Anaesthesia; 2005(95)706
- Orzoci-Levi, American Journal of Respiratory and Critical Care Medicine; 1995(152)1387
- Neilipovitz, Canadian Journal of Anesthesia; 2007(54)748