ABG 45 · Aspiration Prevention in Patients with Gastric Distension

Steward: ABG QCDR | Collection Type: QCDR Measure | First Performance Year: 2025 2026 Status: Approved by CMS for the 2026 MIPS performance period. Added in PY 2025, so it carries a 5-point scoring floor if data completeness is met.

MEASURE DESCRIPTION

Percentage of patients 18 years and older with a current diagnosis of gastrointestinal obstruction, ileus, or incarcerated hernia, or patients taking GLP-1 receptor agonists, or patients with gastroparesis, who undergo a surgical procedure under anesthesia and are treated preoperatively with a mitigation strategy that reduces the risk of aspiration during the surgical procedure.

NQS DOMAIN / MEANINGFUL MEASURES AREA

Patient Safety

MEASURE TYPE: Process HIGH PRIORITY STATUS: Yes | HIGH PRIORITY TYPE: Patient Safety INVERSE MEASURE: No | RISK ADJUSTED: No NUMBER OF PERFORMANCE RATES: 1 CARE SETTING: All settings TELEHEALTH: No DATA SOURCE: EHR, Registry, Claims, Other

2026 BENCHMARK

No historical benchmark. Measure added in PY 2025. Subject to a 5-point scoring floor if data completeness is met.

Practical implication: the second-year scoring floor depends on data completeness. Review eligible case capture and the final CMS scoring rules when selecting this measure; the floor is not a guarantee of the overall Quality score.

INSTRUCTIONS

Report each time an adult patient with one or more of the following conditions undergoes a surgical procedure under anesthesia: a) has gastrointestinal obstruction, ileus, or an incarcerated hernia b) is taking a GLP-1 receptor agonist c) has gastroparesis

Measure reporting via the QCDR: CPT codes, patient demographics, and registry codes identify patients in the denominator. The measure must capture both the surgical and the related anesthesia CPT code. G-codes and registry codes capture the numerator.

DENOMINATOR

All patients aged 18 years or older who undergo a surgical procedure under anesthesia and have one or more of the listed conditions.

Denominator Criteria (Eligible Cases): - Patients aged 18 years and older - AND Current diagnosis of gastrointestinal obstruction, ileus, or incarcerated hernia (12A49) OR Has gastroparesis (12A50) OR Is taking a GLP-1 agonist, last dose less than 4 half-lives ago (12A51) - AND Receives anesthesia (MAC, regional, general, or neuraxial) (12A57) - AND Any patient encounter during the reporting period. This measure applies to all cases regardless of CPT code, which is unusual and makes it broadly applicable across a practice.

DENOMINATOR EXCEPTIONS

- Local anesthesia only, no sedation (12A52) - Patient already intubated (12A53)

NUMERATOR

Patients in the denominator who, prior to the surgical procedure under anesthesia, have one of the following mitigation strategies applied:

1. Clinical imaging demonstrating empty stomach contents (less than 1.5 mL/kg of fluid and no solids) within one hour of the procedure, by MRI, CT, or gastric ultrasound
2. Evacuation of stomach contents by nasogastric or orogastric tube within one hour of the procedure
3. Awake intubation
4. Maintenance of airway reflexes throughout the case

Numerator Quality-Data Coding Options:

Performance Met: 12A54 One or more of the four mitigation strategies applied prior to the procedure

OR

Denominator Exception: 12A55 Patient is taking GLP-1 receptor agonists or has gastroparesis but does not display symptoms of gastric distension. Symptomatic gastric distension is defined as a patient exhibiting two of the three following symptoms: 1) nausea and/or vomiting 2) dyspepsia or abdominal pain 3) abdominal bloating or distension

OR

Performance Not Met: 12A56 None of the four mitigation strategies applied prior to the procedure

RATIONALE

A 2021 anesthesia closed claims analysis identified that patients with gastrointestinal obstruction or other acute intraabdominal process are at high risk for pulmonary aspiration. In a majority of these closed claim aspiration cases, the anesthetic management was judged to be substandard. The most common reason cited was failure to place a nasogastric tube prior to the aspiration event. Rapid sequence induction and intubation with cricoid pressure as the sole preventative measure may not be sufficient to prevent massive aspiration.

Gastric distension, as seen in patients with gastrointestinal obstruction, ileus, incarcerated hernias, and symptomatic gastroparesis (drug-induced or otherwise), places the patient at highest risk. Four mitigation strategies have been identified that may reduce aspiration risk in such patients: placement of an NG or OG tube with evacuation of stomach contents, awake intubation, and maintenance of airway reflexes. If recent clinical imaging demonstrates a lack of high gastric content (less than 1.5 mL/kg of fluid and no solids), aspiration risk is reduced and none of the other three strategies is required.

CONCLUSION

Pulmonary aspiration remains a major perioperative patient safety issue and can be fatal. Patients in the closed claims series had many factors previously identified as high-risk for aspiration of gastric contents, especially existing gastrointestinal obstruction. Anesthetic management of patients who experienced perioperative pulmonary aspiration was often judged to be substandard. These findings suggest that clinical practice modifications to preoperative assessment and anesthetic management of at-risk patients may improve perioperative outcomes.

REFERENCES

1. Warner MA, Meyerhoff KL, Warner ME, Posner KL, Stephens L, Domino KB. Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis. Anesthesiology 2021;135:284-291. doi:10.1097/ALN.0000000000003831 2. Salem MR, Khorasani A, Saatee S, Crystal GJ, El-Orbany M. Gastric tubes and airway management in patients at risk of aspiration: history, current concepts, and proposal of an algorithm. Anesth Analg 2014;118(3):569-79. PMID: 23757470 3. Silveira SQ, et al. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth 2023;87:111091. PMID: 36870274 4. Joshi GP, Abdelmalak BB, Weigel WA, et al., ASA Task Force on Preoperative Fasting. American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists. June 29, 2023 5. Kindel TL, Wang AY, Wadhwa A, et al. Multi-society clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Obes Relat Dis 2024. doi:10.1016/j.soard.2024.08.033 6. Yeo YH, Gaddam S, Ng WH, et al. Increased risk of aspiration pneumonia associated with endoscopic procedures among patients with Glucagon-like peptide-1 receptor agonist use. Gastroenterology 2024. doi:10.1053/j.gastro.2024.03.015 7. Van de Putte P, Perlas A. The link between gastric volume and aspiration risk. In search of the Holy Grail? Anaesthesia 2018;73:274-279. doi:10.1111/anae.14164

RELEVANT FIELDS (Graphium capture)

- Date of birth / patient age - Diagnosis of GI obstruction, ileus, or incarcerated hernia - Gastroparesis diagnosis - GLP-1 receptor agonist use and timing of last dose - Symptoms of gastric distension (nausea/vomiting, dyspepsia/abdominal pain, bloating/distension) - Anesthesia type - Mitigation strategy applied and which one - Already intubated on arrival

REPORTING CODES

Code	Definition
12A49	Current diagnosis of gastrointestinal obstruction, ileus, or incarcerated hernia
12A50	Has gastroparesis
12A51	Is taking GLP-1 agonists (last dose less than 4 half-lives)
12A57	Receives anesthesia (MAC, regional, general, neuraxial)
12A52	Local anesthesia only, no sedation
12A53	Patient already intubated
12A54	One or more of the four mitigation strategies applied prior to the procedure
12A55	Patient taking GLP-1 RAs or with gastroparesis but not displaying symptoms of gastric distension
12A56	None of the four mitigation strategies applied prior to the procedure

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DENOMINATOR CPT CODES

No CPT gate. The denominator is any patient receiving anesthesia (MAC, regional, general, or neuraxial) who has one of the listed conditions, so every anesthetized case is in scope regardless of procedure code.

Source: 2026 AQI NACOR QCDR Measure Book.