After years of anesthesia practice and thousands of cases of anesthetics, I've found that the risk of aspiration is much less than what was preached in residency. Let me explain. Most of my cases involve outpatient procedures, mostly GI endoscopies. There have been many cases where after an upper endoscope was inserted, the stomach was found to be filled with hundreds of cc's of fluid and/or food, despite the patient being NPO overnight. Usually the reason is the patient is diabetic with gastroparesis, or the patient is on high dose narcotics for some chronic pain condition (being scoped for abdominal pain of unclear etiology).
Even with a full stomach, the patient rarely if ever vomits despite the scope instilling hundreds of cc's of air. The endoscopist just suctions out the fluid, sometimes requiring two cannisters to contain all the contents, then proceeds with the procedure. If there is food matter that can't be suctioned, it is left in place in the stomach, It usually adheres to the stomach wall and doesn't regurgitate up the esophagus.
I've only had one case of significant aspiration of stomach content during an endoscopy. That was in a patient who was being scoped by a GI fellow. His technique was less than slick. After much fumbling around in the mouth and esophagus, gastric contents started pouring out. We quickly placed cricoid pressure and proceeded with a rapid sequence intubation. I was able to suction much of the gastric fluids out of the bronchial tree with the aid of a fiberoptic scope and the patient did fine afterwards.
I wonder what has been the experience of other anesthesiologists in regards to the risk of aspiration in upper endoscopies. Have others made similar observations in their practices?