Real-world fasting practice, airway management patterns, and pulmonary aspiration risk in pediatric anesthesia: a 10-year cohort of 3230 anesthetics

Background Pulmonary aspiration is a rare but potentially serious complication of pediatric anesthesia. Concerns regarding aspiration risk continue to influence perioperative decision-making, particularly with respect to fasting policies and airway management strategies. However, real-world clinical practice often differs from guideline recommendations [1,2]. Methods We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at a tertiary pediatric hospital over a 10-year period. Data were extracted from the institutional anesthesia database and electronic medical records. Variables included patient demographics, surgical category, fasting duration, last intake type, airway management technique, and aspiration-related events. Results A total of 3230 pediatric anesthetics were included. The median age was 4.61 years (IQR 2.1–8.0) . The median fasting duration was 5.19 hours (IQR 3.91–6.47) and 65.8% of patients fasted less than 6 hours . Supraglottic airway devices were used in 2763 cases (85.6%) , while 467 cases (14.4%) underwent primary endotracheal intubation. Conversion from supraglottic airway to tracheal intubation occurred in 93 cases (3.4%) . No intraoperative pulmonary aspiration events were observed. One intraoperative regurgitation event occurred without pulmonary complications. Two aspiration events occurred in the ward several hours after postoperative feeding. With zero intraoperative aspiration events in 3230 anesthetics, the upper bound of the 95% confidence interval estimated using the rule-of-three method was approximately 0.93 per 1000 anesthetics [13]. Conclusions In this 10-year cohort of pediatric anesthetics, no intraoperative pulmonary aspiration events were observed despite relatively short fasting durations and widespread use of supraglottic airway devices . Aspiration events occurred only after postoperative feeding, suggesting that perioperative vigilance should extend beyond the operating room to the postoperative recovery period .