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Gastric Lavage for Gastrointestinal Decontamination Clinical Toxicology ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20 Position paper update: gastric lavage for gastrointestinal decontamination B. E. Benson, K. Hoppu, W. G. Troutman, R. Bedry, A. Erdman, J. Höjer, B. Mégarbane, R. Thanacoody & E. M. Caravati To cite this article: B. E. Benson, K. Hoppu, W. G. Troutman, R. Bedry, A. Erdman, J. Höjer, B. Mégarbane, R. Thanacoody & E. M. Caravati (2013) Position paper update: gastric lavage for gastrointestinal decontamination, Clinical Toxicology, 51:3, 140-146, DOI: 10.3109/15563650.2013.770154 To link to this article: http://dx.doi.org/10.3109/15563650.2013.770154 View supplementary material Published online: 18 Feb 2013. Submit your article to this journal Article views: 1315 View related articles Citing articles: 48 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ictx20 Download by: [UPSTATE Medical University Health Sciences Library] Date: 29 May 2017, At: 09:26 Clinical Toxicology (2013), 51, 140–146 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2013.770154 REVIEW ARTICLE Position paper update: gastric lavage for gastrointestinal decontamination B. E. BENSON 1 , K. HOPPU 2 , W. G. TROUTMAN 1 , R. BEDRY 2 , A. ERDMAN 1 , J. H Ö JER 2 , B. M É GARBANE 2 , R. THANACOODY 2 , and E. M. CARAVATI 1 1 American Academy of Clinical Toxicology, McLean, VA, USA 2 European Association of Poisons Centres and Clinical Toxicologists, Brussels, Belgium Context. The fi rst update of the 1997 gastric lavage position paper was published by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists in 2004. This second update summarizes the 2004 content and reviews new data. Methods. A systematic review of the literature from January 2003 to March 2011 yielded few studies directly addressing the utility of gastric lavage in the treatment of poisoned patients. Results. Sixty-nine new papers were reviewed. Recent publications continue to show that gastric lavage may be associated with serious complications. A few clinical studies have recently been published showing benefi cial outcomes, however, all have signifi cant methodological aws.fl Conclusions. At present there is no evidence showing that gastric lavage should be used routinely in the management of poisonings. Further, the evidence supporting gastric lavage as a benefi cial treatment in special situations is weak, as is the evidence to exclude benefi t in all cases. Gastric lavage should not be performed routinely, if at all, for the treatment of poisoned patients. In the rare instances in which gastric lavage is indicated, it should only be performed by individuals with proper training and expertise. Keywords Gastrointestinal decontamination; Poisoning; Gastric lavage Introduction expertise to perform gastric lavage (LOE 4). 6 The purpose Poisoning is a common form of injury throughout the of this second update of the Gastric Lavage Position Paper world. 1 A challenge for clinicians managing poisoned is to briefl y summarize the content of its forerunners and to patients is to promptly identify those who might benefi t present any relevant new data that have been published in from gastric lavage. Gastric lavage has been used as a treat- the medical literature since then. ment for poisoned patients for over 200 years. During the last decades there has been concern that complications associated with gastric lavage might outweigh the possible Method benefi ts to patients. As a consequence, a panel of experts An expert panel consisting of nine members (authors) was from the American Academy of Clinical Toxicology and the appointed by the American Academy of Clinical Toxicology European Association of Poisons Centres and Clinical Toxi- (AACT) and the European Association of Poisons Centres cologists was convened to evaluate the literature regarding and Clinical Toxicologists (EAPCCT) to update the 2004 gastric lavage. The panel ’ s fi ndings were published fi rst in Gastric Lavage Position Paper. 1997 and then were updated in 2004. 2,3 In both instances, The National Library of Medicine ’ s PubMed database the papers concluded that there was no conclusive evidence was searched using gastric lavage as textwords for 2009 – 11, to support the continued use of gastric lavage for poisoned gastric lavage/humans for 2003 – 08, and (gastric OR stom- patients. As a consequence, poison centers seldom recom- ach) AND therapeutic irrigations[mh]. International Phar- mend gastric lavage today4 and its use in emergency depart- maceutical Abstracts (via Ebsco), the Science Citation Index ments has declined steadily5 (level of evidence [LOE] 4 and (via Web of Science), the Cochrane Database of Systematic 2c). Another potential consequence of the Gastric Lavage Reviews, and the Cochrane Central Register of Clinical Trials Position Papers is reduced availability of equipment or were searched without limits using the term “ gastric lavage ” . A separate search was performed for animal studies using National Library of Medicine ’ s PubMed database using Received 10 January 2013 ; accepted 22 January 2013 . gastric lavage and (poisoning OR overdose) as textwords, Address correspondence to Blaine (Jess) Benson, Pharm.D. Director, New Mexico Poison & Drug Information Center, MSC09 5080, limiting the species to animals. The search was performed 1 University of New Mexico, Albuquerque, NM87131-0001, USA. over the time period from January 2003 to March 2011 and Tel: ϩ (505) 272-4261. E-mail: [email protected] yielded 683 articles. Sixty-nine of these offered the possibil- 140 Gastric lavage position paper 141 ity of applicable human data and were therefore incorporated were given aspirin 500 mg/kg and then lavaged and given into an evidence table showing the key characteristics of each activated charcoal (1.5 g/kg) 30 minutes after drug admin- article (see Supplementary Appendix 1 to be found online istration. The peak plasma salicylate concentrations were at http://informahealthcare.com/doi/abs/10.3109/15563650. reduced by 37% when compared to no treatment. 10 2013.770154). Each article was assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-based New studies Medicine Levels of Evidence for Therapy/Prevention/Etiol- ogy/Harm, March 2009 (Appendix 2). The rejected articles Since 2004 there have been no new animal studies published focused on specialized lavage for removal of phytobezoars addressing the utility of gastric lavage as a treatment for or diagnosis of gastric cancer, mentioned gastric lavage only poisoning. in passing, or were review articles that did not provide any new information. Ultimately, 15 articles contributed to this Experimental studies in volunteers revision of the Position Paper and their LOEs are noted. After review of the evidence, an updated Position Paper Summary of prior position paper 2004 draft and evidence table was prepared by two panel members A major limitation of human volunteer studies is that doses and submitted to the rest of the panel for comment. Panel used in mock overdoses are substantially lower than doses member comments were collated and returned to the main actually encountered during real overdoses. Smaller mock authors in an anonymous format. The lead authors responded doses used are potentially absorbed faster than the larger, to the comments and made revisions to the draft accordingly. real doses seen clinically. As a result, gastric lavage may The revised draft was distributed to the panel for approval make less of an impact in reducing the bioavailability of a or content objections. Any objections to the revised second drug during experimental studies than is seen clinically. In draft required evidence-based support and then revision addition, the studies may utilize lavage times that are not fea- by the main authors. Each revised draft was distributed to sible within most clinical settings or may utilize sub-optimal the panel for comment and vote. When all panel members methods to calculate dose absorbed. With these limitations approved the manuscript draft, it was posted on the websites in mind, there were four studies that examined the utility of AACT and EAPCCT for 6 weeks for comment by mem- of gastric lavage using simulated drug overdoses.11 – 14 The bers of the organizations. All organization members were drugs studied included ampicillin (5 g), 11 aspirin (1.5 g), 12 sent an email notifi cation regarding the posting and request and two multi-drug studies involving the same combination for review. All external comments were addressed by the of temazepam (10 mg), verapamil (80 mg), and moclobemide main authors and a fi nal draft was prepared, distributed to all (150 mg). 13,14 The reductions in absorption were 32% for panel members, and approved. This fi nal draft was sent to the ampicillin, and 8% for aspirin when lavage was performed Boards of Directors of AACT and EAPCCT for review and at 1 hour after ingestion. The aspirin study utilized urinary endorsement. Comments from the Boards were addressed in salicylate recovery to estimate absorbed aspirin doses. In the the same manner as previous comments and drafts. The fi nal multi-drug study the reductions in peak plasma concentra- product is endorsed by the Boards of both sponsoring clini- tions were not statistically signifi cant for any of the medi- cal toxicology organizations. cations when lavage was implemented within 30 minutes; however, the drug doses were small and the patients were Animal studies lavaged in the sitting position. Three studies examined the effect of lavage on recovery of markers instead of drugs in Summary of prior position paper 2004 healthy human volunteers. In these studies the markers used Animal studies suffer from several inherent fl aws that may were cyanocobalamin, 15 Tc 99m , 16 and radiolabeled water. 17 limit their generalizability to humans.
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