SAFE anaesthesia for patients at risk of pulmonary aspiration

BACKGROUND Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive. OBJECTIVE We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals. DESIGN National interprofessional survey. SETTING All anaesthesia departments in Switzerland. PARTICIPANTS The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland. INTERVENTION None. MAIN OUTCOME MEASURES Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration. RESULTS A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound. CONCLUSION Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of ’traditional’ RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.