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110 Gastric Lavage in Hemorrhage and Overdose 981 PROCEDURE Gastric Lavage in Hemorrhage 110 and Overdose Ann Will Poteet PURPOSE: When gastric hemorrhage is suspected, gastric lavage can be used for the initial assessment of upper gastrointestinal bleeding to potentially identify the severity of bleeding and clear the stomach of blood and clots. Gastric lavage may improve visualization of the gastric fundus in preparation for endoscopy or endoscopic treatments. In overdose, gastric lavage may be used to evacuate drugs or toxins within 1 hour of ingestion, potentially minimizing the consequences of systemic absorption of drugs or toxins. PREREQUISITE NURSING and Clinical Toxicologists do not recommend the use KNOWLEDGE of gastric lavage in the routine management of poi- soned patients because of the limited evidence of • Gastric lavage is not recommended as a routine procedure improved patient outcomes and potential risks of the in the management of hemorrhage and overdose. Current procedure. 6 Supportive care should be considered as evidence shows limited improvement in patient outcomes the primary treatment before initiating the use of gastric after lavage, and the procedure may contribute to lavage. 2,6 If gastric lavage is utilized for decontamina- additional complications, including gastric or esophageal tion, it should be performed by individuals specifi cally perforation, aspiration, laryngospasm, dysrhythmias, trained and skilled in gastric lavage. 6 Lavage may be hypothermia, fl uid and electrolyte abnormalities, pain, initiated in symptomatic patients within 1 hour (60 and hypoxia. 3,6,8,10–13 The risk-benefi t ratio of gastric lavage minutes) of ingestion of a potentially life-threatening should be considered before the procedure is performed. amount of a highly toxic substance if the substance • The use of gastric lavage has been found to be of potential slows GI motility, if the substance is a sustained-release benefi t in some cases of hemorrhage and overdose. Spe- medication, or in cases where an individual is hypo- cifi c indications for the use of gastric lavage include: thermic with slowed GI motility. 1,2,9 Gastric lavage is ❖ Gastrointestinal (GI) hemorrhage: The patient who has contraindicated in the use of overdose if the patient has had GI hemorrhage may present with signs and symp- consumed strong corrosives or hydrocarbons (e.g., toms of volume loss and a decrease in oxygen-carrying gasoline, strong acids, or alkali) and if the pills or pill capacity. These symptoms include tachypnea, tachy- fragments are known to be larger than the opening of cardia, hypotension, orthostatic changes, decreased the orogastric (OG) tube. 9 The administration of acti- hemodynamic fi lling pressures, decreased urine output, vated charcoal (AC) has been used in combination with pallor, cold and clammy skin, confusion, anxiety, gastric lavage for specifi c toxins; however, its use must and somnolence. The patient may also show signs of be approached cautiously because the combination of hematemesis, maroon or tarry stools, or hematochezia. therapies may result in an increased risk for aspiration. Gastric lavage in GI hemorrhage may be helpful in It should be noted that the endpoint of gastric lavage clearing the stomach of blood and clots to facilitate is not clearly defi ned if particulate cannot be clearly evaluation of the source of bleeding and to improve observed; however, the amount of lavage fl uid instilled visualization of the gastric fundus in preparation for should approximate the amount of fl uid returned. endoscopic treatment. 8 The presence of bright red Gastric lavage after overdose or toxin ingestion has blood in the aspirate could be an indicator for the need variable effi cacy. The amount of toxin or drug recov- for urgent endoscopy. 8,10 Bloody aspirate might also ered depends on variables such as time from ingestion, be predictive of higher risk gastric lesions when whether liquid or pills were ingested, specifi c agent the patient is hemodynamically stable and has no ingested, and size of lavage tube used. Even if lavage hematemesis, while clear aspirate might indicate a is performed close to the time of ingestion, not all the lower risk lesion. 3,10 In cases of nonvariceal upper gas- ingested toxin will be recovered and treatment related trointestinal bleeding, placement of a nasogastric tube to effects of the overdose will still be necessary. 9 can be considered for prognostic purposes. 5 • Nonintubated patients who need gastric lavage must be ❖ Overdose: The American Academy of Clinical Toxi- alert and have adequate pharyngeal and laryngeal refl exes. cology and European Association of Poisons Centers If the patient has a limited gag refl ex or is unable to protect 980 110 Gastric Lavage in Hemorrhage and Overdose 981 the airway, the patient should be intubated before gastric • Evaluate patient and family need for information on pre- lavage is performed. 6,9 All patients undergoing gastric vention of accidental ingestion of drugs or toxic agents. lavage should be positioned in the left lateral decubitus Rationale: The patient and family may be unaware or position to assist with passage of the gastric tube. 9 uninformed that the agent or drug is potentially toxic. • Passage of the lavage tube may cause vagal stimulation • Evaluate patient and family need for information on emer- and precipitate bradydysrhythmias. gency treatment for accidental ingestion of drug or toxic • Patients with esophageal varices, coagulopathy, a recent agents. Rationale: Emergency fi rst aid measures may be history of upper GI tract surgery, craniofacial abnormali- helpful with some ingestions to decrease potential toxicity ties, head trauma, or an underlying pathology should be or systemic absorption. carefully evaluated for the risk-benefi t ratio before gastric • Evaluate patient and family need for information regard- lavage is performed. 6,9 ing monitoring and restrictions postprocedure, including dietary restrictions, and assessment for aspiration and EQUIPMENT other complications. Rationale: The patient and family may be unaware or uninformed about what to expect • Nonsterile gloves postprocedure. • Eye and face protection • Barrier gowns and underpads PATIENT ASSESSMENT AND • Large bore (36–40 Fr for adults) nasogastric or orogastric PREPARATION tube 9 • 60-mL irrigating syringe Patient Assessment • Water-soluble lubricant • Perform baseline cardiovascular and neurological assess- • Lavage fl uid (warm normal saline solution or tap water) ments and assess hemodynamic status, cardiac rhythm, • Measurable container for lavage fl uid and vital signs. Rationale: Passage of the lavage tube may • Disposable basin or suction canister for aspirate cause heart rate or blood pressure changes or vagal stimu- • Suction source and connecting tubing lation, which can precipitate bradydysrhythmias or other • Rigid pharyngeal suction-tip (Yankauer) catheter electrocardiographic (ECG) changes, including ST eleva- • Endotracheal suction equipment tion. In the overdose case, toxic levels of certain classes • Tape for securing nasogastric (NG) or OG tube of drugs can also cause ECG changes. • Stethoscope • Perform baseline respiratory assessment and pulse oxim- • Cardiac monitor etry. Rationale: Gastric lavage has been shown to cause • Pulse oximeter changes in oxygen saturation, leading to hypoxia. Patients • Automatic blood pressure cuff who are unable to protect the airway should be intubated Additional equipment, to have available as needed, includes before gastric lavage. the following: • Signs and symptoms of major blood loss are as follows. • Specimen container for aspirate (for overdose) Rationale: Esophageal or gastric varices can cause sig- • Absorptive agent for instillation (for overdose, if nifi cant blood loss. The clinical presentation is dependent prescribed) on amount of blood lost. • Emergency intubation and cardiac equipment ❖ Tachycardia • Bite block or oral airway (if patient needs intubation for ❖ Tachypnea procedure) ❖ Decreased urine output • Emergency medications (e.g., atropine) ❖ Hypotension ❖ Decreased hemodynamic fi lling pressures PATIENT AND FAMILY EDUCATION ❖ Pallor, cold and clammy skin ❖ Changes in mental status or somnolence • Explain the indications and procedure for gastric lavage. ❖ Hematemesis Rationale: Patient and family anxiety may be decreased. ❖ Maroon or tarry stools • Evaluate the patient and family understanding of the risks ❖ Hematochezia and benefi ts of gastric lavage. Rationale: The patient and • Evaluate the patient for a history of esophageal varices, family may be unaware of the risks and benefi ts of the recent GI surgery, coagulopathy, or underlying pathology. procedure. Rationale: Varices, recent surgery, coagulopathies, or • Explain the patient ’ s role in assisting with passage of the other contraindications may predispose the patient to tube and lavage of the stomach. Rationale: The patient ’ s complications during lavage tube insertion. cooperation during the procedure is elicited. • Obtain baseline coagulation studies as prescribed and • Explain the purpose of the cardiac monitor, automatic assess hematocrit and hemoglobin values, basic metabolic blood pressure cuff, and pulse oximeter. Rationale: panel, renal and liver function tests, and blood type. Patient and family anxiety may be decreased. Rationale: Baseline information is provided so that treat- • Assess the need for family presence during the procedure. ment can be determined and progress can be more accu- Rationale: Patient and family anxiety may be decreased rately monitored.
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