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| CASE REPORT |
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| Year : 2019 | Volume
: 3
| Issue : 3 | Page : 181-183 |
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Anesthesia management in mendelson's syndrome
Ornella Widyapuspita, Bambang Novianto Putro
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia
| Date of Submission | 20-Nov-2019 |
| Date of Acceptance | 21-Nov-2019 |
| Date of Web Publication | 23-Jan-2020 |
Correspondence Address:
Dr. Ornella Widyapuspita
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Sebelas Maret University, Surakarta
Indonesia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/BJOA.BJOA_3_19
In anesthetized patient, aspiration occurs because of insufficient airway protective reflex and subsequent aspiration of gastric contents. It is rare but potentially fatal, depending on its severity. Symptoms may vary from hypoxia to respiratory failure and acute respiratory distress syndrome, even collapsed lung and death. A 30-year-old woman who had a hysterectomy with intra-abdominal packing was scheduled for pack removal. She vomited during induction and ended up with aspiration pneumonitis (Mendelson's syndrome). She was admitted to the intensive care unit after surgery and was extubated on the 4th day. She was then moved to the ward 6 days after the surgery. Awareness and skills to minimize the risk of aspiration anesthetic practice are developing well, but it still causes more than 50% of deaths related to the airway during anesthesia. Recognizing risks and its management is essential to prevent morbidity and mortality.
Keywords: Anesthesia, aspiration, Mendelson syndrome, pneumonitis
How to cite this article:
Widyapuspita O, Putro BN. Anesthesia management in mendelson's syndrome. Bali J Anaesthesiol 2019;3:181-3 |
| Introduction | |  |
Aspiration was first considered as a cause of anesthesia-related deaths in 1948 by James Simpson, but in 1946, Mendelson explained the relationship between solid and liquid aspiration with pulmonary sequels in obstetric patients. To date, aspiration is still a rare but potentially fatal, undesirable event in total anesthesia, with incidence reaching 1 in 9000 surgery and 1 in 600 cases of emergency surgery, so it is important to consider aspiration as a risk factor in the practice of anesthesia.[1]
In the Fourth National Audit Project (NAP4) carried out by the Royal College of Anesthetists, data were collected on incidents and the main causes of airway complications in the UK. More than 50% of airway-related deaths during anesthesia were caused by aspiration, which was more than cases of difficult ventilation or intubation. Furthermore, 23% of all cases reported to NAP4 also involved primary or secondary aspiration. Cases that did not cause death usually resulted in morbidity and a longer stay in the intensive care unit (ICU).[1]
Although awareness to recognize the risk of aspiration and its management in anesthesia practice has been greatly developed, NAP4 presents evidence that aspiration often occurred as a result of noncomprehensive risk assessments during preoperative visits or failure in the modification of the anesthetic technique. This case report will discuss the assessment of risk factors in aspiration during anesthesia and its management.
| Case Report | | |
A 30-year-old female was referred from a rural hospital after hysterectomy and abdominal packing with retroperitoneal hematoma due to uterine atony after spontaneous delivery. She was scheduled for pack removal under general anesthesia. She was tachycardic, and her abdomen was distended. She was also anemic and thrombocytopenic with leukocytosis, but other vital signs and routine preoperative investigation results were all within normal limits.
We gave her 1 mg/kg ranitidine and 0.5 mg/kg metoclopramide as premedication in the preparation room. After induction with 2 mcg/kg of fentanyl and sevoflurane 2%, she vomited about 80 mL of dark brown fluid. She was immediately put in the Trendelenburg position, and we tilted her head to her side. A suction catheter was used to clean the pharyngeal area. 1 mg/kg of rocuronium was used to facilitate intubation without Sellick maneuver. Bronchial washing was performed with 10 mL 0.9% normal saline for ten times; then, the nasogastric tube (NGT) was placed.
We proceeded with surgery, and anesthesia was maintained with intermittent fentanyl and atracurium bolus, along with sevoflurane in 100% oxygen, volume control ventilation respiration rate (RR): 15 per minute, tidal volume: 350 mL, positive end-expiratory pressure (PEEP): 6 cmH2O. The uneventful surgery lasted for 2.5 h. At the end of the surgery, her oxygen saturation decreased to 88%. A PEEP of 8 cmH2O was required for her saturation to be >95%. She produced pink, frothy sputum that needed periodical suction.
She was then admitted to the ICU for ventilator support in assist-control mode (RR: 14;Pinspiration: 22 cmH2O, PEEP: 10 cmH2O, and FIO2: 100%). She was still tachycardic with weak distal pulsation, and her saturation was dropped to 40%, so norepinephrine infusion was started at 0.1 mcg/kg/min. Continuous sedation was given to help with ventilator support. In ICU, she was transfused with 2 units of Packed Red Cells (PRC) and 4 units of Fresh Frozen Plasma (FFP). She also had 1.5 g of ampicillin-sulbactam every 8 h, 500 mg of metronidazole every 8 h, and 1 mg/kg ranitidine every 12 h.
The chest X-ray found the appearance of extensive bilateral lower lung infiltrates. Her blood gas analysis 4 h after surgery showed compensated respiratory acidosis with pO2 of 38 mmHg and 72% oxygen saturation, and her gastric production was still dark. On the 3rd day, the blood gas analysis showed a partially compensated respiratory alkalosis (pH of 7.6, pO2 of 72.6 mmHg, lactate of 1.8, and arterial saturation of 96.8%). The latest chest X-ray showed an improved condition and her gastric production was clear. We have tried to wean her from the 3rd day and manage to extubate her on the 4th day.
She was not complaining shortness or difficulty in breathing, her hemodynamic was stable, and her gastric production was clear. After 2 days of observation, we transferred her to the high-dependency care unit. She was discharged from the hospital on the 12th day after the surgery.
| Discussion | | |
Aspiration in anesthesia usually occurs during induction because it abolishes airway protective reflex. Sign and symptoms may vary from hypoxia to respiratory failure and acute respiratory distress syndrome, even collapsed lung and death. Aspiration pneumonitis is a cause of airway-related death in anesthesia. In some cases, aspirations may end up in fatality. It is important to recognize risk factors for aspiration in every case of anesthesia. Patients with greater risk are those with a full stomach, abdominal pathology (causing a longer gastric emptying time or sphincter incompetence). Surgical factors such as upper gastrointestinal surgery, laparoscopy, or inadequate level of anesthesia could also increase the risk of aspiration.[2]
Aspiration may cause damage to the respiratory tract, mainly known as aspiration pneumonitis and aspiration pneumonia. Aspiration pneumonitis or Mendelson's syndrome is a condition that occurs as a result of aspiration of very acidic sterile gastric fluid, causing two phases of lung tissue injury. The first phase occurs due to the direct toxic injury to the lung epithelium by acid, appearing within 1–2 h. Desquamation of the bronchial epithelium increases alveolar permeability and causes interstitial edema, which decreases compliance resulting in ventilation–perfusion imbalance. The second phase appears within 3–6 h as an acute inflammatory response mediated by inflammatory cytokines with immigration and neutrophil granulocyte activation.[3],[4]
The severity of parenchymal damage is determined by acidity of gastric contents, residual volume of gastric content, and particulate matter in regurgitant. Residual volume of more than 0.4 mL/kg or ± 25 mL with pH <2.5 can cause pneumonitis, while the volume of more than 50 mL causes fatal pneumonitis. Nonsterile regurgitant or particulates can obstruct the airway and cause infectious complications. Less frequent complications in the form of acute necrotic pneumonia can also occur.[2],[3],[5]
Clinical signs and symptoms may include coughing, fever, tachycardia, tachypnea, bronchospasm, wheezing, cyanosis, and respiratory failure. Chest X-ray may reveal lobar or segmental infiltrate and consolidation, especially in the right median lobe.[3],[6] Aspiration is not always detectable, especially in critical patients with mechanical ventilation.[6]
There were several risk factors for aspiration in this patient. She was first admitted into the hospital after a damage control surgery using intra-abdominal packing. This pack may cause higher intra-abdominal pressure. High intra-abdominal pressure is a risk factor for aspiration. During induction, positive pressure ventilation may contribute to higher intra-abdominal pressure. This coupled with decreasing strength of lower esophageal sphincter caused by fentanyl and increased the possibility of regurgitation, thus causing aspiration in this patient.
Patients with high intra-abdominal pressure should have careful induction, and preparation for crisis management should occur aspiration. We gave her 1 mg/kg ranitidine as premedication in the preparation room. Histamine antagonists (H2) given 30 min–2 h or proton-pump inhibitors given 12 h before anesthesia can be used to increase the pH of gastric content.[3] Head-down position and cricoid pressure during intubation are necessary to prevent the aspiration. Rapid sequence induction (RSI) is the method of choice before intubation.[3]
A NGT was not placed before induction because it was thought to be unnecessary, seeing that the patient was scheduled for an elective rather than emergency surgery. Elective surgery means sufficient fasting time and empty gaster. She also fasted for more than >12 h. In this case, a longer duration of fasting did not decrease the volume of regurgitant. About 50% of patients who have fasted still have much more than 25 ml of residual gastric volume with a mean pH of 2.0. In theory, NGT is placed before the induction to prevent aspiration, but currently, there is no evidence supporting its routine placement for aspiration prevention.[3]
Suspicion of aspiration was confirmed by persistent hypoxia, high airway pressure, bronchospasm, and abnormal breath sounds after intubation, which all presented in this patient.[2] Initial management includes visualizing the contents of the stomach in the oropharynx area, immediately positioning the patient to Trendelenburg with the head in lateral rotation and cleaning the pharyngeal and tracheal area wherever possible. 100% oxygen supplementation followed by RSI should be done before protecting the airway with a cuffed endotracheal tube.[3]
Tracheal suctioning is preferable before positive pressure ventilation to prevent gastric content from going deeper into the tracheobronchial tree. Positive pressure ventilation of 5 cmH2O is considered useful to prevent distal atelectasis if particulate aspiration is suspected. Symptomatic treatment with a bronchodilator may be needed, tailored to the needs of the patient.[3] In this case, our anesthesia team gave a great response with immediate Trendelenburg positioning, lateral head tilting, suctioning, intubation, and bronchial washing to reduce irritation due to the gastric acid. Sellick maneuverwas not performed in this patient to avoid esophageal rupture due to reverse peristalsis. Fluid balance is important in her treatment because there can be a shift in volume and hemodynamic changes as the pulmonary edema occurs.[6]
Bronchoscopy, pulmonary wash, and broad-spectrum antibiotics are not indicated unless particulate aspiration occurs. Corticosteroid is generally not recommended. The decision to continue surgery should be discussed with the operator, taking into account several factors such as emergency conditions, patient oxygen saturation, lung compliance, and response to interventions such as bronchodilators and the use of PEEP. The initial setting and maintenance of mechanical ventilation should be adjusted to the patient's current condition and its development over time.[2] As the patient was still responding to the given intervention, we decided to continue the surgery while adjusting the ventilator settings; we also maintain a tight fluid balance.
At the end of the surgery, if the patient satisfies extubation criteria, monitoring in the recovery room for 2 h is recommended. If the patient is stable (O2 saturation >95% with FIO2 <0.5, heart rate <100/min, <20 per minute, no bronchospasm, fever, or pathological changes on the chest x-ray compared to preoperative), she may return to the general ward.[3],[6] Her saturation was 89% with FiO2 100%. Therefore, positive pressure mechanical ventilation was necessary for the ICU because pulmonary edema might have occurred.
Antibiotics were started because regurgitant might not be sterile. It might be contaminated with bacteria from the oral or gastric cavity, which were generally nonvirulent and anaerobic but had the potential to induce pulmonary infections due to a large number of colonies.[4] Ampicillin-sulbactam was considered as effective as a combination of clindamycin and cephalosporin in the management of aspiration pneumonia and lung abscess.
| Conclusion | | |
The management of critical events is one of the challenges that anesthetists can experience in everyday practice; the success of intraoperative management of pulmonary aspirations requires rapid alertness and responsiveness, by implementing the management principles of critical events, which include observation, decision-making, action, and reevaluation. Aspiration is one of those critical events where inappropriate management may turn fatal. Therefore, comprehensive assessment and its management are very important in everyday practice to prevent mortality and morbidity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Robinson M, Davidson A. Aspiration under anaesthesia: Risk assessment and decision-making. Contin Educ Anaesth Crit Care Pain 2014;14:171-5.  |
| 2. | Nason KS. Acute intraoperative pulmonary aspiration. Thorac Surg Clin 2015;25:301-7. |
| 3. | Chandra S. Anesthesia management of a parturient with meningioma underwent elective Cesarean section. Bali J Anesthesiol 2019;3:78-81. |
| 4. | Son YG, Shin J, Ryu HG. Pneumonitis and pneumonia after aspiration. J Dent Anesth Pain Med 2017;17:1-2. |
| 5. | Suranadi IW, Sukrama DM, Budayanti NN, Pradhana AP, Amin YS. Surgeons behavior toward prophylaxis antibiotics in Sanglah hospital. Bali J Anesthesiol 2018;2:98-101. |
| 6. | Janda M, Scheeren TW, Nöldge-Schomburg GF. Management of pulmonary aspiration. Best Pract Res Clin Anaesthesiol 2006;20:409-27. |
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