Pulmonary Aspiration During Electroconvulsive Therapy in a Patient on Multiple Psychotropic Medications: A Case Report and Risk-Stratified Approach to Preprocedural Gastric Ultrasound.

Abstract

Electroconvulsive therapy (ECT) is usually performed under general anesthesia using a sedative-hypnotic and a short-acting neuromuscular blocker, typically without instrumentation of the airway. We report a case of pulmonary aspiration during ECT in a 27-year-old man on multiple psychotropic medications who was fully compliant with standard American Society of Anesthesiologists (ASA) preoperative fasting (Nil per Os, NPO) guidelines. A postprocedure point-of-care (POC) gastric ultrasound revealed a full stomach with solid contents. The cumulative anticholinergic burden of his medication regimen, including clozapine, benztropine, quetiapine, paliperidone, and prazosin, combined with the recognized association between psychiatric illness and disordered gastric motility, likely contributed to retained gastric contents at the time of induction. We review the limitations of fasting-based risk assessment, the prevalence of residual gastric content in appropriately fasted patients, the evidence supporting POC gastric ultrasound as a decision-support tool, and the practical constraints of equipment availability and operator training. We propose a risk-stratified approach in which preprocedural POC gastric ultrasound is recommended for ECT patients with one or more risk factors for delayed gastric emptying-rather than as a universal, mandatory examination.