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COMMENTS ON PUBLISHED ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 160-161  

Gastric ultrasound as an aspiration risk assessment tool


1 Department of Anaesthesia, AZ Monica, Deurne, Belgium; Department of Anaesthesia, UMC Radboud, Nijmegen, The Netherlands
2 Department of Anaesthesia, University Hospital Antwerp, Edegem, Belgium
3 Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. P Van de Putte
Department of Anaesthesia, AZ Monica, F. Pauwelslei 1, 2100 Deurne

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_756_18

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How to cite this article:
Van de Putte P, Vernieuwe L, Bouvet L. Gastric ultrasound as an aspiration risk assessment tool. Indian J Anaesth 2019;63:160-1

How to cite this URL:
Van de Putte P, Vernieuwe L, Bouvet L. Gastric ultrasound as an aspiration risk assessment tool. Indian J Anaesth [serial online] 2019 [cited 2019 Aug 22];63:160-1. Available from: http://www.ijaweb.org/text.asp?2019/63/2/160/251984



We read with interest two publications in the Indian Journal of Anaesthesia that used gastric ultrasound (GUS) to preoperatively assess gastric contents and residual gastric volumes (RGVs) in fasted adult surgical patients.[1],[2] GUS is used increasingly as an aspiration risk assessment tool and we congratulate the authors for their respective contributions. However, we are concerned about the internal and external validity of both studies for the following reasons given below.

Previous literature suggests a high aspiration risk when GUS demonstrates the presence of (a) solid gastric contents, (b) an estimated total gastric fluid volume >1.5 mL/kg which is calculated using a mathematical model with patients being in the right lateral decubitus position and (c) the ultrasonographic presence of clear fluids in both the supine and lateral decubitus positions (Perlas grade 2 antrum).[3] Two previous studies in a large group of patients have reported that 5%–6.2% of fasted surgical adult patients present with solid gastric contents, RGV >1.5 mL or a Perlas grade 2 (n = 538 and 440, respectively).[4],[5]

Both the current articles, however, reported the presence of RGV >1.5 mL/kg or solid contents in 22% and 28% of patients, respectively.[1],[2] These very high numbers are in contrast to the much lower above-mentioned percentages.[4],[5] However, the authors of the current studies failed to mention previous literature,[4],[5] and also did not address this difference in their discussion. Additionally, G Sharma et al.[2] performed the calculation of fluid volumes in the supine position though the mathematical model they used has not been validated and therefore cannot be used for this position.[3] They also described the initial help of a radiologist to confirm their findings for the first 20 cases which they deemed sufficient to continue on their own, while a performance of 33 examinations under supervision has been reported to achieve a 95% success rate in bedside qualitative assessment.[3]

Furthermore, G Sharma et al. described the presence of antral fluid in the supine position in 82% of patients.[2] This presence of fluid in the supine position automatically implicates the presence of fluid in the right lateral decubitus and is consistent with a Perlas grade 2 although they did not use the Perlas grading system. This is an exceptionally large number of elective patients compared with the existing literature that reports a 3%–5% average of a Perlas grade 2 in elective patients.[3],[4],[5] On the other hand, the authors described that 8%–18% of their patients had an RGV >80 mL, whereas it has been consistently proved that 75% of grade 2 patients have RGV >100 mL.[3],[6] These conflicting results need further clarification.

Finally, both the articles reported a statistically significant relationship between RGV and comorbidities such as chronic kidney disease and gastroesophageal reflux disease (GERD),[1],[2] without defining chronic kidney disease (mild stage, end-stage) or GERD (which could be considered when reflux has been investigated, treated or both, with or without hiatal hernia). There was no record of the exact number of patients with chronic kidney disease nor of the number of patients with GERD with GRV > or <1.5 mL/kg. Yet, existing literature again failed to show any association between GERD or chronic kidney disease and increased RGV, but this is not mentioned nor addressed by the authors.[4],[5]

Hence, we think that the results of these studies should be interpreted in light of these concerns. Nevertheless, these articles emphasise that gastric content volume may not always be predictable, even in elective patients, and that the ultrasound examination of the gastric antrum may provide valuable information, provided that a standardised, reproducible and rigorous method is applied.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sharma S, Deo A, Raman P. Effectiveness of standard fasting guidelines as assessed by gastric ultrasound examination: A clinical audit. Indian J Anaesth 2018;62:747-52.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Sharma G, Jacob R, Mahankali S, Ravindra MN. Preoperative assessment of gastric contents and volume using bedside ultrasound in adult patients: A prospective, observational, correlation study. Indian J Anaesth 2018;62:753-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Perlas A, Arzola C, Van de Putte P. Point-of-care gastric ultrasound and aspiration risk assessment. A narrative review. Can J Anesth 2018;65:437-48.  Back to cited text no. 3
    
4.
Van de Putte P, Vernieuwe L, Jerjir A, Verschueren L, Tacken M, Perlas A. When fasted is not empty. A retrospective study in fasted surgical patients. Br J Anaesth 2017;118:363-71.  Back to cited text no. 4
    
5.
Bouvet L, Desgranges FP, Aubergy C, Boselli E, Dupont G, Allaouchiche B, et al. Prevalence and factors predictive of full stomach in elective and emergency surgical patients: A prospective cohort study. Br J Anaesth 2017;118:372-9.  Back to cited text no. 5
    
6.
Roukhomovsky M, Zieleskiewicz L, Diaz A, Guibaud L, Chaumoitre K, Desgranges FP, et al. Ultrasound examination of the antrum to predict gastric content volume in the third trimester of pregnancy as assessed by MRI: A prospective cohort study. Eur J Anaesthesiol 2018;35:379-89.  Back to cited text no. 6
    




 

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