Anesthesia Considerations for Acid Reflux
Anesthesia is a vital component in surgical procedures, ensuring patients remain pain-free. However, individuals with underlying health conditions such as gastroesophageal reflux disease (GERD) or acid reflux present unique challenges during anesthesia. Acid reflux involves the backflow of stomach acid into the esophagus, causing discomfort and irritation while also increasing the risk of complications perioperatively. The primary concern during anesthesia for patients with GERD is the risk of aspiration, where stomach contents are inhaled into the lungs, causing severe respiratory issues.
The primary risk for patients with GERD is aspiration. When under general anesthesia, patients lose protective reflexes such as coughing and swallowing, which normally prevent gastric contents from entering the lungs. Aspiration can result in serious complications like chemical pneumonitis or aspiration pneumonia. Anesthesia can also further weaken the lower esophageal sphincter, which already tends to function poorly in patients with acid reflux 1. This increased vulnerability makes it essential to manage the airway carefully to prevent stomach acid from entering the trachea 2–4.
Effective preoperative planning is critical for reducing the risks of anesthesia in patients with acid reflux. First, the anesthesiologist should take a thorough history of the patient’s acid reflux symptoms, including frequency and severity. Any history of medication use, such as proton pump inhibitors (PPIs), should be noted. In addition, patients may be advised to continue their acid-suppressing medications up to the day of surgery. Some patients may also be prescribed prokinetic agents to promote gastric emptying and reduce reflux risks. Finally, following standard fasting protocols is crucial. The American Society of Anesthesiologists (ASA) recommends a fasting period of at least six hours for solid foods and two hours for clear liquids. For GERD patients, longer fasting times may be beneficial to reduce the volume of gastric contents 5–7.
Several anesthesia approaches can help reduce the risk of complications in patients with acid reflux. When possible, regional anesthesia (e.g., spinal or epidural) is preferred, as it does not affect the airway, allowing patients to retain their protective reflexes. If general anesthesia is required, rapid sequence induction can help minimize the risk of aspiration. This technique involves quickly inducing anesthesia and securing the airway via endotracheal intubation. Cricoid pressure may be applied to reduce the chance of reflux during the process 8. Finally, administering antacids before surgery can neutralize stomach acid and decrease the harmful effects in case of aspiration. Antiemetics can also help reduce the likelihood of vomiting during the procedure 9.
After anesthesia, patients with GERD still face risks related to acid reflux and aspiration. Keeping the patient in an upright position with the head of the bed elevated can help reduce reflux incidents by using gravity to keep stomach contents down. In addition, close observation is needed to detect early signs of aspiration, such as coughing or breathing difficulties. Food and liquids should only be introduced once the patient has fully recovered from anesthesia and can swallow safely 10-11.
Managing anesthesia in patients with acid reflux requires careful preparation and specialized techniques to minimize the risk of aspiration and other complications.
References
1. Anesthetic Drugs Affecting Lower Esophageal Sphincter Tone – OpenAnesthesia. Available at: https://www.openanesthesia.org/keywords/anesthetic-drugs-affecting-lower-esophageal-sphincter-tone/
2. Gastroesophageal reflux disease – NYSORA. Available at: https://www.nysora.com/anesthesia/gastroesophageal-reflux-disease/.
3. Ng, A. & Smith, G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia and Analgesia (2001). doi:10.1213/00000539-200108000-00050
4. Illing, L., Duncan, P. G. & Yip, R. Gastroesophageal reflux during anaesthesia. doi: 10.1007/BF03008711.
5. Roman, S. Pre-operative evaluation of gastro-esophageal reflux disease. Ann. Esophagus 5, (2022).
6. Redmond, M. C. Perianesthesia care of the patient with gastroesophageal reflux disease. J. Perianesthesia Nurs. 18, 335–347 (2003). doi: 10.1016/s1089-9472(03)00182-5
7. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective ProceduresAn Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 126, 376–393 (2017).
8. Rapid sequence induction and intubation (RSII) for anesthesia – UpToDate. Available at: https://www.uptodate.com/contents/rapid-sequence-induction-and-intubation-rsii-for-anesthesia.
9. Nason, K. S. Acute Intraoperative Pulmonary Aspiration. Thoracic Surgery Clinics (2015). doi:10.1016/j.thorsurg.2015.04.011
10. Gorecki, P. Gastro-esophageal reflux disease (GERD). (2001).
11. Reflux Surgery Post-Op – Division of Gastrointestinal Surgery. Available at: https://www.med.unc.edu/surgery/gisurgery/forpatients/diseases-conditions/refluxsurgery/post-op/.