BoardsBridgeAVR Full Stomach — RSI in the Patient With Severe Aortic Stenosis and a Non-Fasted Stomach
Aspiration-prophylaxis + rapid-sequence induction + sternotomy-ready airway rescue in the preload-dependent ventricle.
AVR in a non-fasted patient mandates a modified RSI with active aspiration prophylaxis (PPI/H2 blocker, prokinetic, OG decompression), cricoid pressure, and a rehearsed rescue airway — all delivered into a preload-dependent, fixed-stroke-volume ventricle.
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**Headline: RSI with cricoid pressure; avoid mask ventilation in a full stomach - but if SpO2 falls despite preoxygenation, gentle ventilation with cricoid + small tidal volumes beats prolonged hypoxia.**
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Key numbers
- Mean gradient ≥40 mm Hg or valve area ≤1.0 cm² = severe AS (ACC/AHA 2020)
- Succinylcholine 1-1.5 mg/kg IV RSI dose
- Rocuronium 1.2 mg/kg IV RSI dose (1.0 mg/kg on RSI label)
- Cricoid pressure 30-40 N (~3-4 kg)
- Sodium citrate 30 mL PO 15-30 min pre-induction
- Preoxygenation target EtO2 ≥80% / 4 min
- NPO solids 6-8 h; clears 2 h
- Sugammadex 16 mg/kg for emergent rocuronium reversal
- LV EF ≤50% in severe AS is itself an intervention trigger per ACC/AHA 2020
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: ACC AHA Valvular Heart Disease 2020 · ACC AHA Valvular Heart Disease 2020 · ASA Difficult Airway 2022
Re-review cadence: 12 months from reviewed date.
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Card ID: avr-full-stomach · Path: aba.cardiac.valvular.avr-full-stomach