Gastroesophageal reflux disease, colloquially known as heartburn, is a very common ailment all over the world. Almost everyone experiences acid reflux at some point in their lives, and for almost half those people, it occurs at least once a month [1]. Acid reflux occurs due to decreased lower esophageal sphincter tone, causing gastric acid from the stomach to enter and irritate the esophagus [3]. The presentation is variable, but the condition can cause significant distress and discomfort for the patient [1]. In particular, patients with acid reflux have specific care considerations when they undergo general anesthesia due to an increased risk of pulmonary aspiration [1].
Pulmonary aspiration is a risk in any patient due to the loss of protective reflexes while unconscious under anesthesia, but patients with chronic GERD, or acid reflux, have an increased risk of aspiration due to a variety of factors [1]. The first of those factors is slowed rate of gastric emptying; standard NPO guidelines (nothing by mouth) are inadequate for these patients and may lead to incomplete gastric emptying at time of operation and thus increased risk of aspiration [1]. If the surgery is non-emergent and planned ahead of time, prophylactic medication such as antihistamines and proton pump inhibitors can be given to offset this effect [1]. In addition, gastro-kinetic agents can be used in conjunction with an antihistamine to increase gastric emptying [1].
A few things can also be done perioperatively to protect patients with chronic GERD from pulmonary aspiration. Surgeons typically place a nasogastric tube in order to suction patients at risk of aspiration, but that does not always guarantee that patients will not regurgitate or aspirate [1]. Applying cricoid pressure during tracheal intubation is an effective way of preventing aspiration during that portion of the perioperative period, but it is important to make sure the pressure is just enough without closing off the airway [2]. Intubation is the most optimal way to protect the airway from aspiration, although other airway protecting devices such as laryngeal mask airway and the cuffed oropharyngeal airway also work to do the same [2].
Pulmonary aspiration is a recurring problem during anesthesia in all patients but particularly in patients with acid reflux. The final way to make sure that these patients are protected against aspiration complications is to take a comprehensive history of their past experiences undergoing anesthesia and convey this information to the anesthesia team in order to inform anesthetic choice [1]. Doing this, in addition to maximal gastric emptying, prophylactic medication, cricoid pressure and endotracheal intubation helps to ensure the least possible risk of aspiration for patients with GERD, thus improving the standard of care.
References
1. Ng A and Smith G. Gastroesophageal Reflux and Aspiration of Gastric Contents in Anesthetic Practice. Anesthesia and Analgesia, 2001; 93(2): 494-513. doi: 10.1213/00000539-200108000-00050
2. Redmond MC. Perianesthesia care of the patient with gastroesophageal reflux disease. Journal of Perianesthesia Nursing 2003; 18(5): 335-347. doi: https://doi.org/10.1016/S1089-9472(03)00182-5
3. Schoeman MS, Tippett MD, Akkermans LM et al. Mechanisms of gastroesophageal reflex in ambulant healthy human subjects. Gastroenterology 1995; 108: 289-291. doi: 10.1016/0016-5085(95)90011-x