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Pulmonary aspiration of gastric contents during the perioperative period may be associated with postoperative mortality or pulmonary morbidity. Recent determination of the incidence of perioperative pulmonary aspiration and evaluation of factors related to clinical outcomes is lacking.We retrospectively reviewed the perioperative courses of 172,334 consecutive patients 18 yr of age or older who underwent 215,488 general anesthetics for procedures performed in all surgical specialties from July 1985 to June 1991. Pulmonary aspiration was defined as either the presence of bilious secretions or particulate matter in the tracheobronchial tree or, in patients who did not have their tracheobronchial airways directly examined after regurgitation, the presence of an infiltrate on postoperative chest roentgenogram that was not identified by preoperative roentgenogram or physical examination.Pulmonary aspiration occurred in 67 patients (1: 3,216 anesthetics). Fifteen aspirations occurred in 13,427 (1: 895) anesthetics of patients undergoing emergency surgery, and 52 occurred in 202,061 (1:3,886) anesthetics of patients undergoing elective surgery (P <.001). Of the 66 patients who survived their surgery, 42 (64%) did not develop a cough or wheeze, a decrease in arterial hemoglobin oxygen saturation while breathing room air >10% less than the preoperative value, or radiographic abnormalities within 2 h of aspiration. These 42 patients had no respiratory sequelae. Of the 24 patients who had one or more of these findings, 13 required mechanical ventilatory support for more than 6 h. Three of the six patients whose lungs required mechanical ventilation for more than 24 h died from pulmonary insufficiency (overall mortality = 1:71,829 anesthetics).This study suggests that patients with clinically apparent aspiration who do not develop symptoms within 2 h are unlikely to have respiratory sequelae.