REGURGITATION/
ASPIRATION

Inform the surgeon
Head down, lateral posture, if feasible
Apply cricoid pressure (release cricoid pressure if active vomiting occurs)
Try to clear and suction the airway
Give 100% oxygen
Consider deepening anaesthesia (1) to visualise and clear the pharynx/airway
Try gentle mask CPAP/IPPV with cricoid pressure (2)
Ventilate the lungs with cricoid pressure
IF YOU CANNOT VENTILATE see laryngospasm
Give suxamethonium 2 mg/kg (100mg adult dosage) IV & atropine 0.6 mg IV
Intubate using cricoid pressure, expedite surgery.
 

Laryngospasm / airway obstruction
Bronchospasm / rales / crepitations
Hypoventilation / dyspnoea / apnoea
Reduced compliance (ARDS)
Desaturation / bradycardia / cardiac arrest.

Sedation, analgesia, IPPV via ETT
Suction airway, optimise FIO2 and PEEP
Bronchoscopy and lavage if necessary
Bronchodilators as necessary (4)
Chest x-ray
     if normal and saturation is adequate, extubate (5)
If stable after two hours in recovery, send to ward and arrange for follow up  (5)
If unstable or saturation is inadequate,  (5)
     maintain intubation and IPPV
     admit to a high dependency area (6)

FURTHER CARE

Consider other causes (7)
Repeat chest X-ray and blood gases
Consider PEEP, bronchodilators, inotropes (8)
Culture sputum, antibiotics when indicated
Explain what happened to the patient/family
Arrange follow up as necessary.
See After the Crisis

NOTES:
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The figures reported here are based on an analysis of 183 of the first 4000 AIMS anaesthesia incidents. Aspiration was documented in 96. It was judged that the correct use of the algorithms would have led to earlier recognition of the problem and/or better management in 19% of the 96 incidents in which aspiration was documented.
(1) An alternative is to allow the patient to recover consciousness and to start again. Deepening anaesthesia may be necessary to properly visualise and clear the pharynx/airway without precipitating laryngospasm and/or further aspiration or vomiting.
(2) An alternative, if the patient's condition allows, and the appropriate equipment and assistance is at hand, is to proceed immediately with intubation.
(3) Diagnosis of regurgitation, vomiting or aspiration was clinically obvious in 70% of cases. However 15% of cases of aspiration presented as desaturation, 6% as laryngospasm, 3% as airway obstruction, 2% as bronchospasm, 1% occurred with difficult intubation, 0.5% as pulmonary oedema and 0.5% as cardiac arrest.
(4) Salbutamol: By mask nebuliser 4 hourly
                           0.5% 1ml (5 mg)  in adults.
                           age 1 year: 0.125% (1.25 mg);
                           5-10 years 0.25% (2.5 mg)
(5) "Stable": Saturation 95% with FIO2 <0.5, heart rate <100, respiratory rate <20/minute (adults), no bronchospasm, apyrexial.
(6) Major morbidity ensued in 50% of all cases of aspiration and death ensued in 4%
(7) Bronchospasm, pulmonary oedema, ARDS, pulmonary embolism and other causes of ET tube obstruction may present a similar respiratory picture to aspiration.
(8) Steroids and antibiotics should not be used early or routinely.