## Aspiration Risk Reduction in Emergency Surgery **Key Point:** When emergency surgery cannot be delayed for adequate fasting, pharmacological and airway management strategies are used to reduce aspiration risk. However, delaying emergency surgery by 6 hours to achieve fasting is **not appropriate** — emergency cases proceed with aspiration precautions regardless of fasting status. ### Appropriate Aspiration Prophylaxis Measures | Intervention | Mechanism | Timing | Evidence | |---|---|---|---| | Sodium citrate 30 mL (0.3 M) | Raises gastric pH > 2.5 (neutralizes acid) | 15–20 min before induction | Standard prophylaxis | | Metoclopramide 10 mg IV | Enhances gastric motility & emptying | 30 min before induction | Reduces gastric volume | | H₂ blockers (ranitidine) | Reduces gastric acid secretion | 60–90 min before induction | Adjunct to sodium citrate | | Rapid sequence intubation (RSI) | Minimizes time with unprotected airway | At induction | Gold standard for high-risk patients | | Cricoid pressure (Sellick maneuver) | Occludes esophageal lumen; prevents regurgitation | During RSI | Reduces aspiration incidence | **High-Yield:** In **emergency surgery**, the principle is: **do not delay for fasting**. Instead, apply aspiration precautions (RSI, cricoid pressure, antacids, prokinetics). Delaying a surgical emergency by 6 hours to achieve fasting is clinically inappropriate and may worsen the patient's condition. **Clinical Pearl:** The diabetic patient has additional aspiration risk due to gastroparesis (delayed gastric emptying from autonomic neuropathy). Metoclopramide is especially valuable in this population. **Mnemonic:** **RSI-ACE** for emergency aspiration prophylaxis: - **R**apid Sequence Intubation - **S**odium citrate - **I**V access secured - **A**ntacids (H₂ blockers) - **C**ricoid pressure - **E**mergency airway equipment ready **Warning:** Do not confuse emergency and elective surgery fasting rules. In elective cases, delay surgery if fasting is inadequate. In emergency cases, proceed with aspiration precautions — do not delay.
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