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Whole Bowel Irrigation Journal of Toxicology: Clinical Toxicology ISSN: 0731-3810 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ictx19 Position Statement: Whole Bowel Irrigation To cite this article: (1997) Position Statement: Whole Bowel Irrigation, Journal of Toxicology: Clinical Toxicology, 35:7, 753-762, DOI: 10.3109/15563659709162571 To link to this article: http://dx.doi.org/10.3109/15563659709162571 Published online: 29 Jul 2009. Submit your article to this journal Article views: 55 View related articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ictx19 Download by: [UPSTATE Medical University Health Sciences Library] Date: 15 March 2017, At: 07:03 Clinical Toxicology, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA35(7), 753-762 (1997) Position Statement: Whole Bowel Irrigation American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists ABSTRACT In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Associa- tion of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Whole bowel irrigation (WBI) should not be used routinely in the management of the poisoned patient. Although some volunteer studies have shown substantial decreases in the bioavailability of ingested drugs, no controlled clinical trials have been performed and there is no conclusive evidence that WBI improves the outcome of the poisoned patient. Based on volunteer studies, WBI may be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs. There are insufficient data to support or exclude the use of WBI for potentially toxic ingestions of iron, lead, zinc, or packets of illicit drugs; WBI remains a theoretical option for these ingestions. WBI is contraindicated in patients with bowel obstruction, perforation, ileus, and in patients with hemodynamic instability or compromised unprotected airways. WBI should be used cautiously in debilitated patients, or in patients with medical conditions that may be further This Position Statement is endorsed by the American Board of Applied Toxicology and the Canadian Association of Poison Control Centers. 753 Copyright (DzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 1997 by Marcel Dekker, Inc. 754 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAACT zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAand EAPCCT zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA compromised by its use. A single dose of activated charcoal administered prior to WBI does not appear to decrease the binding capacity of charcoal or to alter the asmotic properties of WBI solution. Administration of charcoal during WBI appears to decrease the binding capacity of charcoal. The initial dqft ofzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA this Position Statement was prepared by zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAM Tenenbein.zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA SUMMARY STATEMENT ANIMAL STUDIES Two animal studies have been performed in INTRODUCTION dogs. 8*9 Overall the mortality from acute poisoning is less than one percent. The challenge for clinicians One study' demonstrated a benefit from WBI. managing poisoned patients is to identify promptly The mean total body clearance of paraquat was those who are most at risk for developing serious increased (p < 0.05) from 5.67 L/h to 13.2 L/h complications and who might potentially benefit, by WBI andzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA this procedure removed 68.9% of the therefore, from gastrointestinal decontamination. ingested dose.* RATIONALE Another study with theophylline is difficult to Whole bowel irrigation (WBI) cleanses the bowel interpret because it lacked a control (no treatment) 9 by the enteral administration of large amounts of group.-- an osmotically balanced polyethylene glycol VOLUNTEER STUDIES electrolyte solution (PEG-ES) which induces a liquid stool I Six volunteer studies have investigated the value of WBI in reducing the absorption of ingested WBI has the potential to reduce drug absorption drugs. ''-I5 by decontaminating the entire gastrointestinal tract by physically expelling intraluminal contents. Three studies involving dosing with ampicillin," delayed-release aspirin, and sustained-release The concentration of polyethylene glycol and lithium12 showed significant reduction in bioavail- electrolytes in PEG-ES causes no net absorption ability of 67%, 73%, and 67%, respectively (all or secretion of ions, so no significant changes in p < 0.05). water or electrolyte balance occur.2 In a study designed to evaluate whether WBI IN VITRO STUDIES enhanced the excretion of drugs during the post- In vitro studies demonstrate that activated charcoal absorptive phase, WBI did not reduce the does not produce a significant alteration in the bioavailability of aspirin. l3 osmolality of WBI so~ution.~ Two studie~l~*~'involving aspirin are difficult to PEG-ES may reduce the binding capacity of char- interpret because one14 lacked a control (no coal if both are administered c~ncurrently.~-~ treatment) arm and, in both, the duration and total volume of WBI were less than in other studies. However, in two other the binding of drug (mexiletine, imipramine) to charcoal was A study of WBI using coffee beans as a marker greater in WBI solution than in a slurry of failed to demonstrate enhanced expulsion from the charcoal. gastrointestinal tract. ' Position Statement: Whole Bowel Irrigation zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA755 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA CLINICAL !9l"DIES Children 9 months to 6 years: 500 mL/h Children 6-12 years: 1000 mL/h No controlled clinical studies have been per- Adolescents and adults: 1500-2000 mL/h formed. WBI should be continued at least until the rectal Eleven reports of the use of WBI in 17 patients effluent is clear although the duration of treatment have been published. 17-27 Nine patients ingested may be extended based on corroborative evidence irOn17-21 and seven ingested other agents (sus- (e.g., radiographs or ongoing elimination of tained-release verapamil ,22 delayed-release toxins) of continued presence of toxins in the fenfluramine,= latex ckets of cocaine,24 zinc gastrointestinal tract. lead oxide:End arsenic27). CONTRAINDICATIONS INDICATIONS Bowel perforation There are no established indications for the use of WBI .zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Bowel obstruction Based on experimental studies, WBI is an option Clinically significant gastrointestinal hemorrhage for potentially toxic ingestions of sustained-release or enteric-coated drugs. 11,12 Ileus WBI has theoretical value in a limited number of Unprotected compromised airway toxic ingestions. Hemodynamic instability WBI is of theoretical value in the management of patients who have ingested substantial amounts of Uncontrollable intractable vomiting iron because of the high morbidity and mortality of this poisoning and a lack of other options for COMPLICATIONS gastrointestinal decontamination. l7 Nausea, vomiting, abdominal cramps, and The use of WBI for the removal of ingested bloating have been described when WBI was used packets of illicit drugs is only of theoretical in pre aration for colonoscopy and barium benefit. 24 enema.E3 The use of WBI in patients who have ingested There are insufficient clinical data to describe substantial amounts of poisons not adsorbed by accurately the types and incidences of complica- activated charcoal is only of theoretical tions associated with the use of WBI for the benefit. 25-27 treatment of potentially toxic ingestions. DOSAGE REGIMENS Nausea and vomiting may complicate the use of WBI. l1 Vomiting is more likely to occur if the WBI fluid is best administered through a naso- patient has been treated recently with ipecac29 or gastric tube. if the patient has ingested an agent that produces vomiting. There are no dose-response studies upon which to base dosing. However, a recommended dosing Patients with compromised and unprotected schedule for WBI is: airways are at risk for pulmonary aspiration during WBI. 756 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAACT and EAPCCTzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA SUPPORTING DOCUMENTATION binding by activated charcoal decreased with increasing amounts of WBI solution from 100% INTRODUCTION binding of salicylate and charcoal alone to 68% at zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAthe clinically relevant ratio of 8: 1. Whole bowel irrigation (WBI) for the management Theophylline. Hoffman et d4evaluated the of poisoning is the enteral administration of large influence of WBI solution upon drug adsorption by volumes of PEG-ES by nasogastric
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