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 tube9 • 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. and patient cooperation during the procedure could poten- • Obtain as prescribed and assess serum toxicology screen, tially be improved. urinalysis, urine toxicology screen, and anion gap 982 Unit IV Gastrointestinal System

(overdose case) are other laboratory tests that also may be • As prescribed perform and assess a 12-lead ECG and monitored. Rationale: Baseline information for diagnosis continuous cardiac monitoring. Rationale: In an overdose is provided so that interventions can be made appropri- case, the drug or toxin ingested may be cardiotoxic. For ately and patient progress can be more accurately the patient with a GI hemorrhage, comorbid disease states monitored. may increase risk for tissue hypoxia and ischemia. • Obtain as prescribed and assess arterial blood gas (ABG) values. Rationale: Overdose victims with hypoventilation Patient Preparation and patients with GI hemorrhage with signifi cant blood • Ensure that the patient understands preprocedural infor- loss or comorbid disease are at risk for hypoxia, hyper- mation. Answer questions as they arise and reinforce capnea, and acid-base disorders. information as needed. Rationale: Understanding of pre- • Assess the adequacy of the patient ’s gag refl ex. Rationale: viously taught information is evaluated and reinforced. Lack of an adequate gag refl ex indicates the need for • Place the patient on a cardiac monitor, automatic blood endotracheal intubation before lavage begins.6,9 pressure cuff, and pulse oximeter. Rationale: Allows for • Assess the type of drugs or toxic substances ingested, close cardiovascular and respiratory system monitoring quantity ingested, and time since ingestion. Use of during the procedure. common toxidromes (classifi cations of the signs and • Set up oropharyngeal suction. Rationale: Ensures suction symptoms that develop with poisoning) can help to iden- is available for the procedure. tify unknown ingested substances (for the overdose case). • Establish and maintain intravenous (IV) access. For the Rationale: Certain substances may require neutralization patient with GI hemorrhage, place a minimum of two before tube evacuation is attempted. A poison control large-bore IVs or provide central venous access. Ratio- center should be contacted if the practitioner is unsure that nale: IV access is necessary for emergency IV medication lavage is indicated. Side effects can be anticipated if the administration and volume resuscitation in the case of GI drugs or toxins that were swallowed and the quantity are hemorrhage.8 known. • If not contraindicated, position the patient in the left • Perform careful skin assessment (overdose case). Ratio- lateral decubitus position.9 Rationale: This position facili- nale: Assessment may give evidence regarding toxin tates passage of the tube into the stomach. The left lateral ingested because various drugs can cause cutaneous position is the position of choice to prevent aspiration if changes. Changes to look for include diaphoresis, bullae, the patient should vomit. acneiform rash, fl ushed appearance, and cyanosis. • Apply oxygen via nasal prongs or mask as needed. Con- • Assess any odors present (overdose case). Rationale: tinue to evaluate the patient for possible need of airway Some toxins have a distinctive odor, which can aid in intubation. Rationale: Supplemental oxygen may opti- identifi cation of substance ingested. mize the patient’ s oxygen saturation.

Procedure for Gastric Lavage in Hemorrhage and Overdose Steps Rationale Special Considerations 1 . HH 2 . PE 3. Coat the distal end of the lavage Minimizes mucosal injury and tube with water-soluble lubricant. irritation during insertion of the tube. 4. Position the patient (if not The left lateral decubitus position Ensure adequate ventilation and contraindicated): maximizes access to the stomach oxygenation while the patient is A. Assist the patient to the left and minimizes pyloric emptying. positioned for gastric lavage. lateral decubitus position. The elevation of the head of the B. Elevate the head of the bed bed or the slight reverse 10–20 degrees or elevate Trendelenburg ’ s position also the bed using a slight decreases movement of stomach (10–20 degree) reverse contents into the duodenum and Trendelenburg ’ s position. possibly helps minimize risk of aspiration during procedure. 5. Prepare suction, lavage fl uids, Preprocedure setup facilitates smooth If the patient does not have an intact tape, and emergency equipment. technique, minimizes gag refl ex, endotracheal intubation complications, and prepares for should be done before the emergency situations. procedure.6,9 110 Gastric Lavage in Hemorrhage and Overdose 983

Procedure for Gastric Lavage in Hemorrhage and Overdose—Continued Steps Rationale Special Considerations 6. Insert a large OG or NG tube A large-bore OG or NG tube is For overdose situations, an OG or NG (36–40 Fr) for adults. 9 preferred for the evacuation of tube should be placed that is large blood, clots, undigested pills, or pill enough to capture the pill fragments. A smaller bore tube may particulate.9 become occluded with solid A smaller bore nasogastric tube may material.9 be used if only known liquid poisons were ingested. Do not cut the end of the tube to create a larger opening because rough edges on the tube can injure the mucosal lining of the GI tract.9 A. Measure the distance from the bridge of the patient’ s nose to the ear (see Fig. 9-2A) and then from the earlobe to the tip of the xiphoid process ( Fig. 110-1 ). Mark this distance on the tube. B. Insert an oral airway (see Remove patient dentures. Procedure 9 ) or bite block if necessary. C. Position the tube toward the Prevents patient from biting on the posterior pharynx over the lavage tube or harming the tongue. practitioner during insertion of the lavage tube. D. Pass the tube slowly into the Rapid passage of the tube may lead to Asking the patient to fl ex the head stomach, encouraging the perforation or stimulate vomiting, forward may facilitate advancement patient to attempt to swallow leading to an increased risk of of the tube. as the tube is advanced. aspiration. Heart rate may decrease as a result of Continue to advance the tube vagal stimulation. Have emergency until the mark previously medication (e.g., atropine) ready for placed on the tube is reached. use as necessary. Have oropharyngeal suction available. Procedure continues on following page

3 Mark tube 1 Hold tube at tip of at earlobe nose

2 Measure to the xiphoid process

Figure 110-1 Measuring nasogastric tube. (From Luckmann J, Saunders manual of nursing care , Philadelphia, 1997, Saunders.) 984 Unit IV Gastrointestinal System

Procedure for Gastric Lavage in Hemorrhage and Overdose—Continued Steps Rationale Special Considerations 7. Utilize a variety of bedside The position of the lavage tube must If not contraindicated, ask the patient practices to assess tube location be confi rmed to be in the stomach to phonate to ensure that the tube during the insertion procedure, because of the risk for endotracheal has not been placed improperly in including: placement of the lavage tube and the trachea. A. Aspirating with a 60-mL subsequent pulmonary Be aware that auscultating an air syringe for return of stomach complications. Radiographic bolus in the stomach is an contents. 4 confi rmation of lavage tube unreliable method of placement B. Obtain radiographic placement is currently the only confi rmation.4 confi rmation of placement.4 defi nitive way to confi rm tube (Level D * ) placement.4 8. After placement is confi rmed, Manual aspiration withdraws gastric In cases of overdose, save the aspirate secure the tube with tape, and contents and toxic agents or blood in a specimen container and send to aspirate gastric contents through and clots out of the stomach. the laboratory for analysis as the lavage tube with a 60-mL prescribed. syringe. 9. Perform intermittent lavage (with In overdose cases, lavage might aid in either room-temperature normal removing toxic substances from the saline solution or tap water).9 stomach before absorption. In GI hemorrhage, lavage might aid in clearing the stomach of blood and clots to help identify the severity of bleeding and improve visualization of the gastric fundus in preparation for endoscopic evaluation or treatment. A. Slowly instill lavage fl uid into Small amounts of lavage fl uid are Lavage fl uid should be slightly the lavage tube with a 60-mL used to limit fl uid from entering the warmed or at room temperature to irrigating syringe (for adults, duodenum during lavage. prevent hypothermia in the elderly use 200–300 mL of fl uid).9 or individuals receiving large amounts of lavage fl uids. B. Aspirate gastric contents Evacuates stomach contents, blood, The amount of lavage fl uid returned through the lavage tube with clots, or ingested toxic agents. should approximate the amount an irrigating syringe. instilled. or C. Connect lavage tube to low Low levels of suction ( < 60 mm Hg) intermittent suction. should be used to prevent suction- induced mucosal damage to the GI tract. D. For patients with GI Gastric lavage may help to identify The presence of coffee ground hemorrhage, continue the severity of bleeding and clear aspirate may indicate a resolving or intermittent lavage until the the stomach of blood and clots to previous GI bleed. Note that the aspirate is clear of blood and improve visualization for absence of blood or coffee ground clots. 8 endoscopic evaluation and aspirate does not rule out the treatment.8,10 The presence of bright presence of current or past red blood can be an indicator of the bleeding. 8 need for urgent endoscopic treatment.8,10

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 110 Gastric Lavage in Hemorrhage and Overdose 985

Procedure for Gastric Lavage in Hemorrhage and Overdose—Continued Steps Rationale Special Considerations E. In the overdose case, continue Gastric lavage may help to remove Note that the endpoint of gastric intermittent lavage until the life-threatening levels of ingested lavage is not clearly defi ned if aspirate is clear of the toxic toxic substances from symptomatic particulate cannot be clearly substance or particulate matter. patients if performed within 1 hour observed and that the lack of poor Once lavage is complete, of ingestion.2,9 Activated charcoal is lavage return does not rule out activated charcoal can be used for absorption of the residual signifi cant ingestion of the toxic instilled through the tube if substance ingested (unable to be substance. indicated. removed with lavage). If the patient is alert and has an intact gag refl ex, activated charcoal can be swallowed. 10. Remove the OG or NG tube. The OG or NG tube should be for single use only. Remove the tape holding the OG Prepares for removal. If the lavage tube does not remove or NG tube in place. easily, discontinue removal and Pull the OG or NG tube out Minimizes risk for vomiting or evaluate for causes of obstruction. slowly and steadily. complications. 11. Remove PE and dispose of Reduces transmission of equipment in appropriate microorganisms; Standard receptacle. Precautions. 12. HH

Expected Outcomes Unexpected Outcomes • Evacuation of blood and clots from the stomach • Endotracheal intubation rather than gastric intubation • Prevention of blood aspiration with lavage tube • Improved visualization of the gastric fundus for • Esophageal or gastric perforation endoscopy • Trauma to the nose, throat, or esophagus • Identifi cation of the severity of GI hemorrhage • Epistaxis if NG route is used for lavage • Prevention or minimization of systemic complications • Hypothermia in the elderly patient from the absorption of drugs or toxic agents • Bradydysrhythmias or ECG changes • Minimization of mucosal damage by toxic agents • Vomiting • Pulmonary aspiration of gastric contents, with risk for aspiration pneumonia • Movement of gastric contents into the duodenum, potentially increasing the amount of toxin absorbed • Fluid and electrolyte imbalance • Laryngospasm • Hypoxia or hypercapnia • Intubation as a result of hypoxia, aspiration, or other respiratory compromise • Prolonged absence of the gag refl ex Procedure continues on following page 986 Unit IV Gastrointestinal System

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Monitor vital signs every 15 Continued blood loss or side effects • Increase in heart rate 10–20 beats minutes throughout the procedure of drugs or toxins ingested may or more above baseline and every hour after lavage for at cause changes in vital signs. Cold • Decrease in systolic blood pressure least 4 hours or longer, depending lavage fl uid may cause hypothermia 20–30 mm Hg or more below on patient condition. in the elderly patient. baseline Complications from the procedure • Respiratory rate < 8 or > 24 breaths may not present during or per minute or rate changes > 20% immediately after the procedure. of baseline normal • Temperature < 97.5°F (36.5°C) or > 101°F (38°C) 2. Monitor the neurological status Side effects from toxic agents • Decreasing level of consciousness continuously throughout the ingested or signifi cant blood loss • Loss of gag refl ex procedure and after lavage. may lead to a decrease in level of consciousness. 3. Monitor respiratory status Determines pulmonary complications. • Decrease in oximetry below continuously throughout the baseline or 92% procedure and after lavage. • Increase in respiratory rate above baseline • Symptoms of shortness of breath • Increasing oxygen requirements 4. Monitor cardiac status Bradydysrhythmias may be caused by • Heart rate < 60 beats per minute or continuously throughout the passage of the lavage tube or an > 100 beats per minute with or procedure and after the lavage. increase in heart rate may indicate without a decrease in blood continued blood loss. Toxic effect pressure below baseline of drugs ingested may also cause • Chest pain, diaphoresis, change in ECG changes, including level of consciousness, and prolongation of the PR, QRS, and shortness of breath QT intervals. • Change in ECG rhythm or length of PR, QRS, and QT intervals from baseline 5. Assess for normal pharyngeal The left lateral position is the position • Prolonged absence of gag refl ex function and laryngospasm. After of choice to prevent aspiration lavage, keep the patient in the left should the patient not be able to lateral position with slight head control secretions or emesis. elevation until normal gag refl ex returns. 6. For the patient with GI • Bright red emesis or bleeding from hemorrhage: the OG or NG tube • Decrease in hemoglobin or hematocrit below baseline • Decrease in systolic blood pressure 20–30 mm Hg or more below baseline • Increase in pulse 10–20 beats per minute or more above baseline • Urine output < 0.5–1 mL/kg/hr • Increasing confusion or decreasing level of consciousness • Continued bleeding • Changes in pulmonary status A. Measure blood volume loss. Aids in assessment of fl uid balance and volume resuscitation requirements. 110 Gastric Lavage in Hemorrhage and Overdose 987

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions B. Monitor for recurrence of Bleeding may recur despite bleeding, color, and interventions. consistency of gastric drainage, serial hemoglobin and hematocrit, postural vital signs, urine output, and change in level of consciousness. C. Administer crystalloid IV Replaces volume, prevents fl uids as prescribed for hemorrhagic shock, and improves volume resuscitation. Switch oxygen-carrying capacity. Goal to the administration of hemoglobin level should be packed red blood cells and 8 g/dL.7 fresh frozen plasma (FFP) or platelets when available for volume replacement and reversal of coagulopathies. D. Administer proton pump PPIs inhibit the proton pump in the inhibitors (PPIs) as prescribed. parietal cells of the stomach, Initiation of a PPI should not suppressing gastric acid secretion. occur before endoscopic evaluation. 5 E. Prepare for possible Administration of erythromycin may administration of intravenous help to accelerate gastric emptying erythromycin (250 mg) before and might decrease the need for endoscopy as prescribed when repeat endoscopy.11,12 a diagnosis of GI hemorrhage is suspected.11 F. Prepare the patient for Endoscopic evaluation is the gold possible endoscopy. standard in the diagnosis and treatment of GI hemorrhage and should occur within 24 hours of initial presentation.5,11 7. For the patient with drug overdose: • Patient reporting intent to harm self • Patient reporting that ingestion was a suicide attempt • Deviation of test results outside normal limits A. Evaluate the patient ’ s need for The drug or toxin ingestion may be a follow-up psychiatric support result of suicidal ideations. for suicide ideation. B. Institute suicide precautions until the patient has been cleared by psychiatric services. Precautions include removal of objects from the patient ’ s room that could be used by the patient to infl ict self-harm. C. In the hours and days after Laboratory tests ordered depend on ingestion, repeat laboratory the drug or toxins ingested. Lavage tests, including electrolytes, may cause electrolyte abnormalities. glucose, blood urea nitrogen Liver function tests may be and creatinine, liver function, necessary if the drug is toxic to the and drug or toxin levels. liver. Drug or toxin level tests validate the clearance of the drug or toxin from the patient’ s system. Procedure continues on following page 988 Unit IV Gastrointestinal System

Documentation Documentation should include the following: • Patient and family education • Amount and characteristics of aspirate • History of ingestion of drug or toxin or upper GI • Assessment of gastric drainage after lavage bleeding • Name and dosage of medications given after the • Date, time, and reason for lavage lavage • Type and size of lavage tube inserted • Aspirated specimen sent to laboratory for analysis • Patient tolerance of tube placement and lavage • Referral to psychiatry if potential for suicide is procedure suspected • Verifi cation of lavage tube placement (method used) • Occurrence of rebleed in the patient with GI • Type and amount of lavage fl uid used hemorrhage • Unexpected outcomes • Blood products given during volume resuscitation • Nursing interventions

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .