{"id":36629,"date":"2025-11-13T17:16:29","date_gmt":"2025-11-13T17:16:29","guid":{"rendered":"https:\/\/todaysveterinarypractice.com\/?p=36629"},"modified":"2025-11-19T21:16:34","modified_gmt":"2025-11-19T21:16:34","slug":"perianesthetic-gastroesophageal-reflux","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/emergency-medicine-critical-care\/perianesthetic-gastroesophageal-reflux\/","title":{"rendered":"Perianesthetic Gastroesophageal Reflux"},"content":{"rendered":"

<\/div>
Abstract<\/strong><\/p>\n

Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis. The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in lower esophageal sphincter (LES) pressure. LES incompetence can occur secondary to common anesthetic medications, length of anesthesia, and type of procedure being performed. Brachycephalic anatomy, respiratory and neurologic diseases, length and type of surgery, and use of opioids are all factors that can increase a patient\u2019s risk of GER. Prevention strategies for high-risk patients include reducing repositioning as much as possible, substituting or reducing the dose of preoperative opioids, adjusting fasting time, using a GER premedication protocol for several days before the procedure, and using metoclopramide at induction. When GER is identified, treatment should be immediate and include esophageal lavage and follow-up medications for 7 days to prevent esophagitis. During this time, patients should be closely observed for a decrease in appetite or the acute onset of vomiting, regurgitation, respiratory difficulty, or coughing. The hallmark sign of an esophageal stricture is regurgitation after eating.<\/p>\n

Take-Home Points<\/strong><\/p>\n

    \n
  • Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis; it has severe potential phenotypes, including esophagitis, esophageal stricture, sinusitis, and aspiration pneumonia.<\/li>\n
  • Prevention strategies include employing premedication protocols, identifying high-risk patients, and targeting surgeries that pose the most risk of GER.<\/li>\n
  • Treatment for GER should be immediate: lavage the esophagus with saline\/bicarbonate solution with follow-up medications to prevent esophagitis.<\/li>\n
  • The hallmark sign of an esophageal stricture is regurgitation after eating.<\/li>\n
  • Prevention and treatment of GER events should be part of your hospital\u2019s anesthesia safety protocol.<\/li>\n<\/ul>\n

    <\/div><\/div><\/p>\n

    Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis, occurring in 12.5% to 55% of canine patients1-7<\/sup> and 12% to 23% of feline patients.8<\/sup> While it\u2019s challenging to manage these cases during a busy surgical day, evaluating and treating for GER events should be a routine part of anesthesia monitoring and recovery.<\/p>\n

    Gastroesophageal reflux is the passive retrograde flow of stomach contents through the lower esophageal sphincter (LES) into the esophagus. The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in LES pressure.9<\/sup> LES incompetence can occur secondary to common anesthetic medications, length of anesthesia, and type of procedure being performed. Identifying high-risk patients prior to anesthesia, following premedication protocols, and implementing other preventive strategies \u00a0are all useful ways to reduce GER events.<\/p>\n

    The potential consequences of acidic gastric contents entering the esophagus and upper respiratory tract include esophagitis, esophageal stricture, and aspiration pneumonia.4,10<\/sup> The majority of patients with perianesthetic GER will not develop complications, but when they occur, it can be devastating. It\u2019s been reported that dogs with postanesthetic esophageal dysfunction have a 23% mortality rate.4<\/sup><\/p>\n

    In an anesthetized patient, GER is a \u201csee something, do something\u201d moment and should be managed immediately. In many cases, GER is \u201csilent\u201d and gastric fluid remains in the esophagus and is unobservable, which makes prevention of the utmost importance through the use of premedications and awareness of which anesthetic cases are of greatest concern.2<\/sup><\/p>\n

    Although maropitant has been reported ineffective in reducing GER,11,12<\/sup> it is commonly used in small animal anesthetic protocols to reduce opioid-related emesis, which may reduce the risk of aspiration.11,13<\/sup><\/p>\n

    While there are conflicting reports on contributing factors and prevention strategies for perianesthetic GER, studies have identified patient risk factors and support the effectiveness of premedication to reduce GER or increase esophageal pH. The following is a summary of risk factors, recommendations, and best practices that may decrease GER events in anesthetized patients.<\/p>\n

    Identification of High-Risk Patients<\/h2>\n
      \n
    • Brachycephalic anatomy10 <\/sup><\/li>\n
    • Abdominal surgeries1,2<\/sup><\/li>\n
    • Long procedures, especially orthopedics1,14,15<\/sup><\/li>\n
    • Procedures with frequent changes in position1,9<\/sup><\/li>\n
    • Large patient size1,14,15<\/sup><\/li>\n
    • Use of high- or repeated-dose opioids6,9<\/sup><\/li>\n
    • Neurologic conditions of the respiratory or gastrointestinal tract (e.g., laryngeal paralysis, hiatal hernia)16,17<\/sup><\/li>\n
    • Patients with a history of GER, with or without anesthesia18<\/sup><\/li>\n
    • Prolonged fasting >18 hours3,19,20<\/sup><\/li>\n<\/ul>\n

      Prevention<\/h2>\n
        \n
      • Reduce repositioning as much as possible.5<\/sup><\/li>\n
      • Substitute or reduce the dose of preoperative opioids in high-risk patients.9,12<\/sup><\/li>\n
      • Feed a small meal of canned dog food in the morning for procedures postponed to the afternoon.3,19<\/sup><\/li>\n
      • Use premedication for high-risk patients in advance of the procedure:\n
          \n
        • Omeprazole 1 mg\/kg PO the night before and 4 hours prior to induction10,11<\/sup> or<\/li>\n<\/ul>\n<\/li>\n
        • Famotidine 1 mg\/kg IV or SC and metoclopramide 0.5 mg\/kg SC as preanesthetic18<\/sup><\/li>\n
        • Administer metoclopramide 1.0 mg\/kg IV at induction followed by continuous-rate infusion of 1.0 mg\/kg\/h for high-risk patients.21<\/sup><\/li>\n<\/ul>\n

          Treatment<\/h2>\n

          During Anesthesia and Recovery<\/h3>\n

          If any fluid is noted in the oral cavity, around the endotracheal tube, or coming from the nose during anesthesia or in recovery:<\/p>\n

            \n
          • Measure pH with a test strip: pH <4 indicates gastric contents are present and lavage is recommended.22-24<\/sup><\/li>\n
          • Clear fluid from the mouth and oropharynx.<\/li>\n
          • Perform esophageal lavage before extubation. Reintubate if reflux is noted after extubation.\n
              \n
            • Position in left lateral recumbency with the head below vertical.22<\/sup><\/li>\n
            • Using a double-lumen sump catheter or red rubber catheter, gently suction and lavage the esophagus with 10 to 30 mL dilute (1% or 2%) bicarbonate solution25<\/sup> or straight 0.9% sodium chloride.23<\/sup><\/li>\n<\/ul>\n<\/li>\n
            • If a flexible gastrointestinal endoscope is available, inspect the esophagus\/LES, and lavage\/suction the esophagus and remove fluid from the stomach.1 <\/sup><\/li>\n
            • Recover the patient in sternal recumbency with the head above vertical, and extubate with the cuff partially inflated.25<\/sup><\/li>\n<\/ul>\n

              After Recovery<\/h3>\n

              Treat for potential esophagitis for at least 7 days:<\/p>\n

                \n
              • Omeprazole: 1 mg\/kg PO q12h22,26<\/sup><\/li>\n
              • Prokinetics: cisapride 0.5 mg\/kg PO q8h (preferred to metoclopramide )27<\/sup><\/li>\n<\/ul>\n

                Follow-up<\/h3>\n

                If patients have a decrease in appetite or start vomiting, regurgitating, having respiratory difficulty, or coughing during the first week postanesthesia, they should be evaluated for esophagitis and stricture formation.4<\/sup> These patients should be considered suspect for esophageal injury until proven otherwise. Esophageal strictures can occur 5 to 21 days after anesthesia.28<\/sup><\/p>\n

                The hallmark sign of an esophageal stricture is regurgitation after eating.4<\/sup> Thoracic radiographs are indicated to evaluate for aspiration pneumonia in patients with an elevated respiratory rate or cough during the postoperative period. Preanesthetic thoracic radiographs should be considered for any patient with a previous history of GER or brachycephalic anatomy because they have an increased incidence of preexisting aspiration pneumonia.16,18<\/sup><\/p>\n

                Why This Is Important<\/h2>\n

                With identification of high-risk patients, careful observation during the perianesthetic period, and immediate treatment when GER has occurred, the incidence of GER can be reduced. Subsequent complications, including esophagitis, esophageal stricture, sinusitis, and aspiration pneumonia, can also be minimized. Prevention and treatment of GER events should be part of your hospital\u2019s anesthesia safety protocol.<\/p>\n","protected":false},"excerpt":{"rendered":"

                The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in lower esophageal sphincter pressure.<\/p>\n","protected":false},"author":817,"featured_media":36637,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":2498,"footnotes":""},"categories":[342],"tags":[13],"class_list":["post-36629","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-digital-exclusive","tag-peer-reviewed","clinical_topics-emergency-medicine-critical-care"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"\nPerianesthetic Gastroesophageal Reflux | Today's Veterinary Practice<\/title>\n<meta name=\"description\" content=\"While it\u2019s challenging to manage cases of GER, evaluating and treating for it should be a routine part of anesthesia monitoring and 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