Gastric Lavage - an overview (2022)

Generally, gastric lavage requires anesthesia (inhalation anesthetic or a short-acting barbiturate) before the procedure is initiated.

From: Small Animal Toxicology (Second Edition), 2006

Gastrointestinal Decontamination

Grant C. Fowler MD, in Pfenninger and Fowler's Procedures for Primary Care, 2020

Gastric Lavage

1.

Before lavage, obtain IV access and begin continuous cardiac monitoring and pulse oximetry.

2.

If the patient is highly anxious, consider giving a small dose of benzodiazepine (e.g., 1–2 mg midazolam IV).

3.

Consider rapid-sequence induction and intubation, with a cuffed endotracheal tube if the patient has a depressed level of consciousness, questionable airway, or if airway compromise may occur during the procedures.

4.

Premeasure and mark the length of the tube needed by estimating the distance from the nose, around the ear, and down to the midepigastrium.

5.

Position the patient the left lateral decubitus position with the head lowered approximately 20 degrees (Trendelenburg position) to reduce the risk of aspiration of gastric contents if vomiting occurs.

6.

Restrain the hands of an uncooperative patient to prevent removal of the gastric or endotracheal tube.

7.

A bite block or an oral airway may prevent the patient from biting on the orogastric tube or biting the fingers of the inserter.

8.

If using a nasogastric tube for nasal insertion, see the procedure for nasogastric tube insertion inChapter 217, Nasogastric and Nasoenteric Tube Insertion.

9.

For orogastric tube insertion, if the patient is alert, spray the posterior pharynx with topical benzocaine or Cetacaine spray. Position the patient’s head so that it is flexed as far forward as possible, and while ensuring against being bitten (bite block in place), insert your gloved finger and middle finger over the base of the patient’s tongue. Guide the lubricated gastric tube over the dorsum of your fingers as the patient swallows (Fig. 209.1). Pass it gently to avoid damage to the posterior pharynx. Never use force to pass the tube. If the patient gags, advance the tube immediately after gagging. When the pharynx has been entered, put the patient’s chin on the chest to facilitate passage of the tube into the esophagus. Cough, stridor, or cyanosis indicates tracheal intubation; withdraw the tube immediately and reattempt passage.

10.

Confirm intragastric tube placement initially by auscultating the stomach while introducing air with a 50-mL syringe. In an intubated or obtunded patient or a young child, confirm tube position radiographically before lavaging, although this is not routinely performed. Verify the final placement by aspirating and confirming gastric contents.It is critical to avoid infusion of fluids until tube placement is confirmed.

11.

Before beginning gastric irrigation, remove the gastric contents by careful aspiration with repeated repositioning of the tip of the tube.

General Approach to Poisonings

Ken Kulig MD, in Critical Care Secrets (Fourth Edition), 2007

3 What is the current role of gastric lavage in treating acute poisonings?

Gastric lavage must be performed soon after ingestion to be at all effective in removing drugs from the stomach. For this reason, many clinicians do not lavage patients who have overdosed if more than 1 hour has elapsed since ingestion. Gastric lavage may result in major morbidity (e.g., esophageal perforation). Gastric lavage can be accomplished without prior tracheal intubation in most patients, but it is advised that airway equipment including suction be immediately available at the bedside. Whenever gastric lavage is performed, a large-bore (36 or 40 French tube in adults) should be placed through the mouth, and proper location of the tube in the stomach should be verified clinically or radiographically.

Position paper: Gastric lavage. J Toxicol Clin Toxicol 42:933–943, 2004.

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Medical Toxicology

Rick D. Kellerman MD, in Conn's Current Therapy 2021, 2021

Gastric Lavage

Gastric lavage should be considered only when life-threatening amounts of substances were involved, when the benefits outweigh the risks, when it can be performed within 1 hour of the ingestion, and when no contraindications exist.

The contraindications are similar to those for ipecac-induced emesis. However, gastric lavage can be accomplished after the insertion of an endotracheal tube in cases of CNS depression or controlled convulsions. The patient should be placed with the head lower than the hips in a left-lateral decubitus position. The location of the tube should be confirmed by radiography, if necessary, and suctioning equipment should be available.

Contraindications to gastric lavage include the following:

Ingestion of caustic substances (risk of esophageal perforation)

Uncontrolled convulsions, because of the danger of aspiration and injury during the procedure

Ingestion of low-viscosity petroleum distillate products

CNS depression or absent protective airway reflexes, without endotracheal protection

Significant cardiac dysrhythmias

Significant emesis or hematemesis prior to presentation

Delay in presentation (more than 1 hour postingestion)

Size of Tube

The best results with gastric lavage are obtained with the largest possible orogastric tube that can be reasonably passed (nasogastric tubes are not large enough to remove solid material). In adults, a large-bore orogastric Lavacuator hose or a No. 42 French Ewald tube should be used; in young children, orogastric tubes are generally too small to remove solid material and gastric lavage is not recommended.

The amount of fluid used varies with the patient’s age and size. In general, aliquots of 50 to 100mL per lavage are used in adults. Larger amounts of fluid may force the toxin past the pylorus. Lavage fluid is 0.9% saline.

Complications are rare and may include respiratory depression, aspiration pneumonitis, cardiac dysrhythmias as a result of increased vagal tone, esophageal-gastric tears and perforation, laryngospasm, and mediastinitis.

Mycobacteria

Jakko van Ingen, in Infectious Diseases (Fourth Edition), 2017

Gastric Lavage

Gastric lavage (for swallowed sputum) is useful for collecting specimens from patients who, for a variety of reasons, are unable to produce sputum by other means. Gastric lavage is the specimen of choice from infants and children (up to 12 years) suspected of having pulmonary tuberculosis. A gastric lavage must be sent to the laboratory promptly because it must be processed as soon as possible or neutralized with 10% sodium carbonate to avoid loss of mycobacteria due to gastric acidity. As with expectorated sputum specimens, gastric lavage specimens should be collected early in the morning, before eating, and on three separate occasions. Culturing NTM from these samples has little if any clinical significance.

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Poisoning

Robert M. Kliegman MD, in Nelson Textbook of Pediatrics, 2020

Gastric Lavage

Gastric lavage involves placing a large tube orally into the stomach to aspirate contents, followed by flushing with aliquots of fluid, usually water or NS. Although gastric lavage was used routinely for many years, objective data do not document or support clinically relevant efficacy. This is particularly true in children, in whom only small-bore tubes can be used. Lavage is time-consuming and painful and can induce bradycardia through a vagal response to tube placement. It can delay administration of more definitive treatment (activated charcoal) and under the best circumstances, only removes a fraction of gastric contents.Thus, in most clinical scenarios, the use of gastric lavage is no longer recommended.

Approach to Drug Overdose

Justine A. Lee DVM, DACVECC, DABT, in Small Animal Critical Care Medicine (Second Edition), 2015

When to Decontaminate

The goal of decontamination is to inhibit or minimize further toxicant absorption and to promote excretion or elimination of the toxicant from the body.2 Decontamination can only be performed within a narrow window of time for most substances (i.e., generally <1 to 2 hours); therefore it is important to obtain a thorough history and time since exposure to identify whether decontamination would be beneficial for the patient and if so would it be safe for the patient. Decontamination techniques may include ocular, dermal, inhalation, injection, gastrointestinal (GI), forced diuresis, and surgical removal to prevent absorption or enhance elimination of the toxicant.2,3

One of the most common ways of decontaminating veterinary patients is via emesis induction. Although gastric lavage is often more clinically effective at removing gastric contents, it is less often performed in veterinary medicine because it is more labor intensive. Veterinarians should be aware of which circumstances are appropriate or contraindicated for either emesis induction or gastric lavage to be performed.

Likewise, before counseling pet owners on performing “at-home” emesis induction, veterinarians should evaluate if it is medically appropriate. First, there is no safe emetic agent for pet owners to use at home in cats and immediate veterinary treatment is warranted. For dogs, the use of hydrogen peroxide can be considered at home, but only when appropriate: in asymptomatic patients with recent ingestion (i.e., generally <1 to 2 hours). Contraindications for at-home emesis induction are similar to those contraindications for emesis induction by veterinarians. For example, at-home emesis should never be performed with corrosive agents, hydrocarbons, in symptomatic patients, or those patients at risk for aspiration pneumonia. See Box 74-2 for more detailed indications and contraindications for emesis.

Gastric lavage, which is more labor intensive compared with emesis induction, requires intravenous (IV) catheter placement, sedation, intubation with a cuffed endotracheal tube (ETT), orogastric tube placement, multiple gavage cycles (followed by administration of activated charcoal, if appropriate), postanesthesia management, and supportive care.3 As a result, many veterinarians often feel hesitant to perform it because of the time commitment and labor-intensiveness. Typically, gastric lavage is indicated for toxicants that remain in the stomach for a long time or that form large bezoars (e.g., bone meal, blood meal, large wads of aspirin, prenatal iron tablets).3 Gastric lavage is also indicated in certain situations where emesis is contraindicated. In symptomatic patients at risk for aspiration (e.g., comatosed, seizuring, tremoring, hyperthermic), the use of gastric lavage may be beneficial to protect the airway while simultaneously removing any further toxicant within the stomach. Gastric lavage is also warranted with certain toxicants that have a very narrow margin of safety, result in severe clinical signs, or that approach 50% of the lethal dose (LD50).3 Some examples of toxicants that warrant gastric lavage include the following:

Metaldehyde

Strychnine

Calcium channel blockers

Baclofen

β-Blockers

Macrocyclic lactones (e.g., ivermectin, moxidectin)

Organophosphates/carbamates

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Toxicology

Stan K. Bardal BSc (Pharm), MBA, PhD, ... Douglas S. Martin PhD, in Applied Pharmacology, 2011

Gastric Lavage

Gastric lavage involves placing a tube through the mouth (orogastric) or through the nose (nasogastric) into the stomach. Toxicants are removed by flushing saline solutions into the stomach, followed by suction of gastric contents.

Mechanism of action

Physical removal of toxicant

Adverse effects

Aspiration of lavage into lungs

Mechanical injury caused by placement of the gastric tube

Endotracheal placement (into the trachea and thus into the lungs) of gastric tube

Electrolyte imbalance

Contraindications

Gastric lavage should not be used with toxicants such as the following:

Petroleum distillates (e.g., gasoline, furniture polish)

Corrosives (strong acids, strong bases) (e.g., drain cleaner)

CNS stimulants, because the act of vomiting may trigger convulsions

Unless a secure (intubated) airway has been established, gastric lavage should not be used in the following patients:

Those who are unconscious

Those with impaired airway reflexes

Although in theory gastric lavage would seem to be the most direct way of removing a toxicant, the available evidence does not support the routine use of gastric lavage. Gastric lavage may be useful in cases in which there has been very recent ingestion (30 minutes to 1 hour) of a life-threatening toxicant.

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Poisoning

Jian-Da Lu, Jun Xue, in Critical Care Nephrology (Third Edition), 2019

Gastric Lavage

GL also commonly is called stomach pumping or gastric irrigation. After insertion of a large-bore tube (32- to 40-French [Fr] in adults, and 16- to 28-Fr in children), GL is accomplished with 100- to 200-mL aliquots of normal saline or water with the intent of removing toxic substances present in the stomach.

The clinical benefit of gastric lavage has not been demonstrated unequivocally. A system review of 56 controlled studies from China showed that the lavage may be useful as a treatment of organophosphorus pesticide poisoning even more than 60 minutes after the ingestion. However, the study potentially suffer from significant methodologic flaws that threaten their reality.16 There are some severe complications that have been observed in the controlled studies, including hypoxia, aspiration, pneumonia, perforation, and laryngospasm.15 Therefore the indications for limiting the absorption of poisonous substances have been restricted.17 In a relevant position paper dated February 2013, it is recommended that GL should be administered only by an experienced physician.18

The position statement recommends that GL should not be used routinely in the management of poisoned patients. It may be considered only in a patient who has ingested a potentially life-threatening amount of toxin within 60 minutes, or if the ingestant was an agent that delays gastric emptying (e.g., tricyclic antidepressants) or a drug not adsorbed by activated charcoal (e.g., ferrous sulfate, lithium).18 Contraindications include ingestion of corrosive substances such as acid or base, low viscosity hydrocarbons such as gasoline, and loss of the protective airway reflexes.

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Treatment

Robert Poppenga, in Clinical Veterinary Toxicology, 2004

Gastric lavage.

GL can be used when gastric evacuation is indicated but administration of an emetic is contraindicated (presence of seizures, severe depression or coma, loss of normal gag reflex, hypoxia, species unable to vomit, and known prior ingestion of corrosives or volatile petroleum products). In a conscious animal, GL requires anesthesia. Airway protection is necessary whenever GL is performed. As large a gastric tube as possible with terminal fenestrations is introduced into the stomach. Tube placement is confirmed by aspiration of gastric contents or air insufflation with a stethoscope placed over the stomach. After the tube is placed, the mouth should be kept lower than the chest. Tepid tap water or normal saline (5 to 10 ml/kg) is introduced into the stomach with minimal pressure application and is withdrawn by aspiration or allowed to return via gravity flow. The procedure is repeated until the last several washings are clear; numerous cycles may be required. AC (with or without cathartic) can be administered via the tube just before its removal. The initial lavage sample should be retained for toxicologic analysis.

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Approach to Poisoning and Drug Overdose

Julie C. Schildt DVM, L. Ari Jutkowitz VMD, DACVECC, in Small Animal Critical Care Medicine, 2009

Gastric Lavage

Gastric lavage is the administration and evacuation of small volumes of liquid through an orogastric tube to remove toxic substances within the stomach. This procedure may be indicated when emesis has failed, when emesis is contraindicated (depressed mental state, loss of gag reflex), or when administration of charcoal is critical and emesis would delay its administration. Contraindications to gastric lavage include ingestion of hydrocarbons because of high aspiration potential, ingestion of corrosive substances, and risk of hemorrhage or GI perforation resulting from pathology or recent surgery. As with induction of emesis, the effectiveness of this procedure is dependent on the time of ingestion and is likely to be most effective within the first 1 to 2 hours postintoxication.6-8

In the conscious animal, gastric lavage is performed after induction of general anesthesia with the patient intubated to prevent aspiration. The cuff of the endotracheal tube should be assessed before initiation of gastric lavage to ensure a snug fit. The patient is positioned in lateral recumbency with the head lower than the thorax. A large-bore gastric tube with a fenestrated end is placed alongside the patient and the distance measured from the tip of the nose to the last rib. The fenestrated end of the tube may then be lubricated and gently passed down the esophagus into the stomach to the marked distance on the tube. Tube placement may be confirmed by aspiration of gastric contents, air insufflation with a stethoscope placed over the stomach, or by radiographic confirmation. Warm water or saline is infused into the tube, with approximately 5 to 10 ml/kg per cycle to moderately distend the stomach. The fluid is then allowed to drain from the tube via gravity flow. The procedure is repeated until clear fluid is returned. Activated charcoal may then be administered through the tube. The end of the tube should be occluded before removal to prevent spillage of tube contents into the pharynx.

In human patients, gastric lavage is not recommended in the routine treatment of poisoned patients because of the lack of evidence that it improves clinical outcome and because of the potential for increased morbidity.16 Three studies performed in animals have similarly failed to demonstrate substantial drug recovery. If gastric lavage was performed within 15 to 20 minutes of ingestion, the mean recovery of the marker was 29%8 and 38%.6 When this procedure was performed after 60 minutes, mean recoveries were only 8.6%7 and 13%.6

Several risks are associated with gastric lavage. Aspiration pneumonia is the most commonly reported complication and emphasizes the need for endotracheal intubation during the procedure. In humans, electrolyte imbalances such as hyponatremia have been reported, so it is recommended that pediatric patients receive normal or half-strength saline instead of tap water. Mechanical injury to the throat and esophagus may also occur, because the gastric tubes are often rigid. Hypoxia and hypercapnia have also been reported in human patients that have undergone this procedure.16

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