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Preoperative Evaluation/Patient Issues/Should patients with acid reflux or hiatal hernia have anesthesia in an ASC?

QUESTION:

Acid reflux is increasingly common in our patient population. Many patients have mild symptoms or in fact no symptoms at all while taking acid suppressive therapy. Is there evidence to suggest a higher risk of aspiration in these patients? What about the patient with an asymptomatic hiatal hernia? And is acid reflux a contraindication to the use of the laryngeal mask airway?"

-- Anonymous

REPLY:

The writer states that acid reflux is more prevalent than in the past. I am not sure that this is true. Is it really more prevalent, or are more patients being treated for it, in part due to the massive effort in direct-to-consumer marketing?

-- From Alan P. Marco, M.D., M.M.M., Toledo, OH

REPLY:

I haven't seen any evidence contraindicating an LMA when acid reflux is asymptomatic or controlled by medication. We will tell the patient to take their acid suppressive therapy the morning of surgery or we will pretreat with Pepcid and then we will place an LMA if it is indicated for the operation.

I think the central point is whether the acid reflux is symptomatic. If there are no symptoms, I don't believe there are is a contraindication.

The other point to consider is the diagnosis of acid reflux or hiatal hernia. I think this a very over diagnosed condition perhaps due to the frequency of television commercials. It has become an "in-vogue" disease for anyone with occasional or food-related heartburn. As these medicines become over the counter (and the volume of commercials increase), the problem will become even more prevalent.

-- From David S. Rapkin, M.D., Richmond Hts, OH

REPLY:

I agree that the increased "prevalence" is due to awareness, partly caused by marketing by drug companies.

It occurs to me that the use of other supraglottic airways that have greater "occlusivity" as evidenced by effective airway pressures before "leak" is noted and ex vivo gastric pressure testing might be more wise. The classic LMA is convenient, but more limited in that regard.

-- From Charles B. Watson, MD, FCCM, Bridgeport, CT

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