2024 FSA Podium and Poster Abstracts

P059: MANAGEMENT OF MASSIVE INTRAOPERATIVE ASPIRATION IN A TRAUMA PATIENT
Albert J Varon, MD, MHPE, FCCM, FASA; Shawn E Banks, MD; Victoria Fernandez, MD; University of Miami Miller School of Medicine

Introduction: The ASA Practice Guidelines recommend a patient to fast for a minimum of 8 hours following the consumption of fried or fatty foods prior to a scheduled procedure to reduce the risk of perioperative aspiration. Aspiration can lead to severe morbidity and mortality. Trauma patients are particularly at risk for aspiration and subsequent morbidity. Approximately one-third of trauma patients who aspirate oral or gastric contents will develop acute lung injury or acute respiratory distress syndrome according to the American Association for the Surgery of Trauma. 

Methods: A 73-year-old obese female with a history of hypertension and atrial fibrillation sustained a left intertrochanteric fracture on a cruise four days prior to presenting to the trauma center. The patient was scheduled for definitive fixation of her fracture the following day. She had been experiencing nausea since her injury that was refractory to ondansetron. She denied having consumed solid food for at least 48 hours prior to her procedure and had not consumed any liquids for over 12 hours. She attributed her nausea to not having eaten solid foods. No abdominal imaging was available at this time. 

Results: The patient aspirated approximately one liter of gastric contents seconds after a rapid sequence induction. Direct laryngoscopy was performed and the airway was secured with an endotracheal tube. An orogastric tube was subsequently inserted with removal of an additional liter of gastric contents. Flexible bronchoscopy was performed with suctioning of gastric contents that were spread diffusely throughout both lungs. The surgical procedure was canceled, the patient’s trachea remained intubated and the patient was transferred to the intensive care unit. A radial arterial line and a left internal jugular triple lumen central line were placed. Four hours later the patient suffered hypoxic respiratory failure refractory to 100% oxygen, high positive end expiratory pressure, paralysis, and nitric oxide. She subsequently sustained cardiovascular collapse. The patient underwent emergent ECMO cannulation with TEE assistance and the right femoral and right internal jugular veins were cannulated. Her oxygen saturation increased from 50% to 100% immediately following initiation of venovenous ECMO. 

Discussion: Aspiration of oral and gastric contents in trauma patients can lead to severe morbidity and mortality. This patient had acute and catastrophic decompensation within four hours of her aspiration. She had been appropriately fasted and denied any episodes of emesis. Abdominal imaging obtained after the patient arrived at the Intensive Care Unit was notable for multiple dilated loops of small and large bowel, which were consistent with ileus. A chest CT revealed diffuse infiltrates with associated inflammation in both lungs. Although the patient’s fasting time was consistent with ASA guidelines, she still suffered perioperative aspiration. Point of care gastric ultrasound may prove to be useful when assessing gastric contents in patients who may be predisposed to delayed gastric emptying, such as in trauma patients. Further research is warranted on this topic.