ABG 45: Aspiration Prevention with Gastric Distention

MEASURE DESCRIPTION

Percentage of patients 18 years and older with a current diagnosis of gastrointestinal

obstruction, ileus, incarcerated hernia, or patients taking GLP-1 receptor agonists, or patients

with gastroparesis, who undergo a surgical procedure under anesthesia and are treated

preoperatively with a mitigation strategy that reduces the risk of aspiration during the surgical

procedure.

NQS DOMAIN / MEANINGFUL MEASURES AREA

Effective Clinical Care

MEASURE TYPE

Process

HIGH PRIORITY STATUS

High

INVERSE MEASURE

INSTRUCTIONS

This measure is to be reported each time an adult patient with one or more of the following

conditions undergoes a surgical procedure under anesthesia:

a) b) has gastrointestinal obstruction, ileus, or an incarcerated hernia

is taking a GLP-1 receptor agonists

c) has gastroparesis

DENOMINATOR

All patients aged 18 years or older who undergo a surgical procedure under anesthesia and

have one or more of the following conditions:

a) b) has gastrointestinal obstruction, ileus, or an incarcerated hernia

is taking a GLP-1 receptor agonists

c) has gastroparesis

Denominator Criteria (Eligible Cases)

Patients aged 18 years and older

AND

Current diagnosis of gastrointestinal obstruction, ileus or incarcerated hernia

Has gastroparesisOR

Is taking GLP-1 agonists (last dose < 4 half-lives)

AND

Receives anesthesia (MAC, regional, general, neuraxial)

AND

Any patient encounter during the reporting period (i.e. any CPT code)

Denominator Exceptions

Local anesthesia only (no sedation)

Patient already intubated

NUMERATOR

Patients with current diagnosis of gastrointestinal obstruction, ileus or incarcerated hernia or are

patients taking GLP-1 receptor agonists or are patients with gastroparesis, who prior to the

surgical procedure under anesthesia have one of the following mitigation strategies applied:

Clinical imaging demonstrating empty stomach contents (<1.5 ml/kg of fluid and no

solids) within one hour of procedure (MRI/CT/gastric ultrasound)

Evacuation of stomach contents by naso/orogastric tube within one hour of procedure

3. Awake intubation

Maintenance of airway reflexes throughout the case

Numerator Quality-Data Coding Options for Reporting Satisfactorily

Performance Met:

45PM One or more of the four mitigation strategies applied prior to the procedure

Denominator Exception:

45DE Patients taking GLP-1 RAs or have gastroparesis but do not display symptoms of

gastric distension. Symptomatic gastric distension may be defined as patients who exhibit two of

the three following symptoms:

1) nausea and/or vomiting

2) dyspepsia/abdominal pain

3) abdominal bloating/distension

Performance Not Met:

45PNM None of the four mitigation strategies applied prior to the procedure

RATIONALE

A 2021 anesthesia closed claims analysis identified that patients with gastrointestinal

obstruction or other acute intraabdominal process are at high risk for pulmonary aspiration. In a

majority of these closed claim aspiration cases, the anesthetic management of these cases was

judged to be substandard. The most common reason cited was the failure to place a

nasogastric tube prior to the aspiration event.1Rapid sequence induction and intubation with

cricoid pressure as the sole preventative measure may not be sufficient to prevent massive

aspiration.1

Given that gastric distension, as may be seen in patients with gastrointestinal obstruction, ileus,

incarcerated hernias, and symptomatic gastroparesis (drug induced or otherwise), puts the

patient at highest risk, four mitigation strategies have been identified which may reduce the risk

of aspiration in such patients.1,3,4,5 These include placement of an NG/OG tube with

evacuation of stomach contents, awake intubation, and maintenance of airway reflexes.2 If

recent clinical imaging demonstrates a lack of high gastric content (< 1.5 ml/kg of fluid and no

solids), then the risk of aspiration is reduced and none of the other three mitigation strategies is

required.2,6

CONCLUSION

Pulmonary aspiration remains a major perioperative patient safety issue and can be fatal.

Patients in this series had many factors previously identified as high-risk for aspiration of gastric

contents, especially existing gastrointestinal obstruction. Anesthetic management of patients

who experience perioperative pulmonary aspiration was often judged to be substandard. These

findings suggest that clinical practice modifications to preoperative assessment and anesthetic

management of patients at risk for pulmonary aspiration may lead to improvement of their

perioperative outcomes.

1. 2. 3. Mark A. Warner, Karen L. Meyerhoff, Mary E. Warner, Karen L. Posner, Linda Stephens,

Karen B. Domino; Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis.

Anesthesiology 2021; 135:284–291 doi: https://doi.org/10.1097/ALN.0000000000003831

Salem MR, Khorasani A, Saatee S, Crystal GJ, El-Orbany M. Gastric tubes and airway

management in patients at risk of aspiration: history, current concepts, and proposal of

an algorithm. Anesth Analg. 2014 Mar;118(3):569-79. doi:

10.1213/ANE.0b013e3182917f11. PMID: 23757470.

Silveira SQ, da Silva LM, de Campos Vieira Abib A, de Moura DTH, de Moura EGH,

Santos LB, Ho AM, Nersessian RSF, Lima FLM, Silva MV, Mizubuti GB. Relationship

between perioperative semaglutide use and residual gastric content: A retrospective

analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023

Aug;87:111091. doi: 10.1016/j.jclinane.2023.111091. Epub 2023 Mar 2. PMID:

36870274.4. 5. 6. 7. Girish P. Joshi, M.B.B.S., M.D., Basem B. Abdelmalak, M.D., Wade A. Weigel, M.D.,

Sulpicio G. Soriano, M.D., Monica W. Harbell, M.D., Catherine I. Kuo, M.D., Paul A.

Stricker, M.D., Karen B. Domino, M.D., M.P.H., American Society of Anesthesiologists

(ASA) Task Force on Preoperative Fasting. American Society of Anesthesiologists

Consensus-Based Guidance on Preoperative Management of Patients (Adults and

Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists. June 29, 2023

Kindel TL, Wang AY, Wadhwa A et al.: Multi-society clinical practice guidance for the

safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg

Obes Relat Dis 2024 [epub ahead of print]; doi: 10.1016/j.soard.2024.08.033

Yeo YH, Gaddam S, Ng WH, Huang P-C, Gastrointestinal Motility and Metabolic

Pharmacoepidemiology Group, Ma KS-K, Rezaie A, Increased risk of aspiration

pneumonia associated with endoscopic procedures among patients with Glucagon-like

peptide-1 receptor agonist use, Gastroenterology (2024), doi:

https://doi.org/10.1053/j.gastro.2024.03.015

Van de Putte, P. and Perlas, A. (2018), The link between gastric volume and aspiration

risk. In search of the Holy Grail?. Anaesthesia, 73: 274-279.

https://doi.org/10.1111/anae.14164