CASE 1

A Patient scheduled for emergency surgery, aspirated on induction. The patient was turned to the lateral position, the airway was suctioned, cricoid pressure applied and the trachea was intubated followed by fibreoptic bronchoscopy and removal of vomit from airways. The patient was transferred to critical care intubated and ventilated.

CASE 2

A frail patient with gastric outflow obstruction due to metastatic gastric cancer was scheduled for duodenal stent placement under sedation in interventional radiology. The patient had been on a liquid diet, had not vomited recently, did not have a nasogastric tube, and had fasted overnight. The risk of aspiration had been discussed during the team brief and sign-in. The left lateral position and use of endoscopic suction were used to mitigate this risk, but a decision was made not to intubate. Sedation was induced uneventfully, with spontaneous ventilation maintained throughout. The endoscopy revealed cancer and an empty stomach. After five minutes, brown liquid with particulate matter was noted in the mouth and on the pillow, without active vomiting. Endoscopic suction was ineffective. The oropharynx was suctioned, and further brown fluid was observed. The procedure was abandoned, and the breathing circuit on the anaesthetic machine was used to deliver oxygen. Although respiratory effort was maintained, oxygen saturation fell and the CO₂ trace became obtunded. An anaesthetic emergency call was put out. Respirations were assisted with face mask and PEEP, but there was no improvement in oxygen saturations or CO₂. Cardiac arrest was confirmed. Spontaneous circulation returned after 2 cycles of CPR and intubation of the trachea. Bronchoscopy confirmed material in the left lung. It is suspected that passing the endoscope beyond the cancer released unexpected distal fluid, which was then aspirated and caused a hypoxic arrest.

Commentary

Aspiration continues to be a significant cause of airway related perioperative mortality and has recently featured in PFD notices reviewed by SALG.^1,2 In the second case, small bowel obstruction should have been anticipated making the patient very high risk for aspiration. Positioning and suctioning are not effective barriers to aspiration which can occur following either vomiting or regurgitation i.e. in sedated or anaesthetised patients.

References

1. Royal College of Anaesthetists, Association of Anaesthetists and Difficult Airway Society. Response to Coroner’s Regulation 28 report to prevent future deaths in the matter of Mrs Pamela Anne Marking. 16^th April, 2025. Available from: https://www.salg.ac.uk/media/hicbrayh/reg-28-response-marking-vfinal.pdf

2. Royal College of Anaesthetists, Association of Anaesthetists. Response to Coroner’s Regulation 28 report to prevent future deaths in the matter of Mr William King. 2^nd December, 2025. Available from: https://www.salg.ac.uk/media/kskpow2p/reg-28-response-king-vfinal.pdf