Assessing gastric contents in children before general anesthesia for acute extremity fracture: An ultrasound observational cohort study
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Updated: Oct 12, 2025
Author Spotlight: Point-of-Care Ultrasound for Gastric Content Assessment and Risk Stratification in Perioperative Care
Published on: September 22, 2023
Jean-Noël Evain1, Zoé Durand1, Kelly Dilworth1
1Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France.
Insights
Over a third of children with extremity fractures have high-risk gastric contents, increasing aspiration risk during anesthesia. Gastric ultrasound effectively identified these risks, preventing aspiration events in the study.
Area of Science:
- Pediatric Anesthesiology
- Emergency Medicine
- Radiology
Background:
- Children with acute extremity fractures are considered at risk for pulmonary aspiration of gastric contents during anesthesia induction.
- Preoperative assessment of gastric volume is crucial for anesthetic management in pediatric patients.
Purpose of the Study:
- To evaluate the proportion of children with acute extremity fractures who have high-risk gastric contents using preoperative gastric ultrasound.
- To identify factors associated with high-risk gastric contents in this pediatric population.
Main Methods:
- A prospective observational cohort study was conducted involving children undergoing surgery within 24 hours of an acute extremity fracture.
- Preoperative qualitative and quantitative ultrasound analysis of gastric contents was performed in supine and right lateral decubitus positions.
- Multivariable analysis was used to identify factors associated with high-risk gastric contents.
Main Results:
- 37% of 110 children studied had high-risk gastric contents, with 24% having solids or thick liquids.
- Proximal limb fractures, preoperative opioid administration, and absence of bowel sounds were associated with high-risk gastric contents.
- Surgery the day after trauma was a protective factor; no pulmonary aspirations occurred.
Conclusions:
- At least one-third of children with acute extremity fractures present with high-risk gastric contents, posing a significant risk for pulmonary aspiration.
- Preoperative gastric ultrasound is a valuable tool for stratifying aspiration risk in these children.
- While history can guide anesthetic decisions, ultrasound provides clearer risk stratification.
Study Objective:
Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound.
Design:
Prospective observational cohort study.
Setting:
Specialist pediatric center over a 30-month period.
Patients:
Children undergoing surgery within 24 h of an acute extremity fracture.
Interventions:
None.
Measurements:
According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg-1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis.
Main Results:
Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred.
Conclusions:
At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.
