10-21-20 Full Stomach - Dr. Landgraf

10-21-20 Full Stomach - Dr. Landgraf

Transcript

1. Management of the Full Stomach Ben Landgraf, MD October 2020
2. Why is this a big deal? • Prevention of pulmonary aspiration! • Anesthetic induction depresses intrinsic ability to “protect the airway” • Urgent procedures soon after food ingestion • Aspiration pneumonitis • Can we control gastric contents? • Urgent procedures • Elective procedures
3. Aspiration Pneumonitis Chemical irritation of the tracheobronchial tree and parenchyma Bronchospasm Atelectasis Hypoxemia Morbidity increases directly with volume (as little as 20 cc) and inversely with pH Epithelial degeneration, alveolar edema, hemorrhage into airspaces ARDS Treatment (Supportive)
4. Who is at risk? Full stomach (see next slide) Diabetes mellitus GERD / Hiatal Hernia Pregnancy Acute Pain / Opioid therapy Bowel obstruction Intra-abdominal process
5. Controlling gastric contents • NPO guidelines • Clear Liquids –2 hours • Human Breast Milk – 4 hours • Infant Formula – 6 hours • Small Meal (Tea and Toast) – 6 hours • Non-Human Milk – 6 hours
6. So my patient needs an urgent procedure and just ate… • Other methods to minimize risk • Decrease gastric acidity and volume • Prokinetic agents (example: metoclopramide) • NG tube • Non-particulate antiacid (example: sodium citrate) • H2 receptor blockers (famotidine) • PPIs (lansoprazole, omeprazole) • Airway management techniques • Rapid sequence intubation • Cricoid pressure
7. How do these medicines work? • Reduces volume and increases gastric pH better than ranitidine given several hours prior to surgery Famotidine • Most effective given in two doses, the evening prior and the morning of surgery PPIs • Neutralizes stomach acid, 15-30 mL given 1 hours prior Sodium citrate • 10 mg IV = prokinetic effects Metoclopramide
8. Should I place an NGT? • Does not guarantee an empty stomach • May impair • LES function • UES function • High risk situations • Bowel obstruction • Cancers • Prior surgeries • Pyloric stenosis
9. Case 65 year old male with history of pancreatic adenocarcinoma presents with worsening abdominal distension. CT scan shows large mass obstructing the duodenum. The stomach is distended. The GI service is consulted to place a duodenal stent endoscopically. What questions do you ask and what do you say?
10. Rapid Sequence Intubation • Gain control of the airway in as short an amount of time after ablation of the protective airway reflexes • 1) IV anesthetic (propofol) • 2) Rapidly acting NMB agent (succinylcholine or high dose rocuronium) • 3) Cricoid pressure (Sellick Maneuver) • 4) NO ventilation • 5) Securing airway • 6) Cricoid pressure maintained until EtCO2 confirmed
11. Awake Intubation • If any difficulty is suspected in securing the airway and risk of aspiration is high, awake intubation may be required. • https://www.youtube.com/watch?v=bDRTz muwMnQ