La gastrolusi è ancora indicata ?

1. Roberto ZoppellariDirettore UO Anestesia e Rianimazione Ospedaliera,Azienda Ospedaliero Universitaria FerraraDirettore Dipartimento Emergenza Interaziendale Azienda Ospedaliero Universitaria e Azienda USL di FerraraSocio Società Italiana di TossicologiaSocio European Association of Poisons Centres and Clinical Toxicologists (EAPCCT)Reviewer Clinical Toxicology (abstracts Congresses EAPCCT) La gastrolusi è ancora indicata ?

2. La gastrolusi va eseguita

3. Un po’ di storia:Wien, april 12-15, 1994XVI International Congress of the European Association of Poison Centres and Clinical Toxicologist • Topic: the current role of gastrointestinal decontamination • Vale JA: Gastric Lavage • “Gastric lavage should be performed only within 1 hour after ingestion of toxic dose”

4. Position paper: gastric lavage.Vale JA, Kulig KJ Toxicol Clin Toxicol 2004; 42: 933-43

5. Position paper update:gastric lavage for gastrointestinal decontaminationClin Toxicol (Phila) 2013; 51(3): 140-6 • 9 members • American Academy of Clinical Toxicology • European Association of Poisons Centres and Clinical Toxicologists

6. Position paper update:gastric lavage for gastrointestinal decontamination • The manuscript draft was posted on the websites of American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) for 6 weeks for comment • All organization members were request for review • Final endorsement by the Boards of AACT and EAPCCT

7. Gastric lavage • Systematic review of the literature 2003-2011 • 69 new papers • Clinical studies showing beneficial outcomes have methodological flaws • Level of evidence 4 • 2c

8. EBM e decontaminazione

9. Animal studies Limitations: • Anesthetized animals: slow gastrointestinalmotility • Generally single drug in dosageformsthatmaynotmimic human exposure • Dogs: Sodiumsalicylate 500 mg/kg • Salicylaterecovered 38% at 15 min and 13% at 1 h Arnold. Pediatrics 1959

10. Experimental studies in volunteers • Gastric lavage 1 h postingestion • Reduction of absortion 32% (ampicillin)* • Reduction of absortion 8% (aspirin)** * Tenenbein. Ann Emerg Med 1987 ** Danel. Br Med J 1988

11. Experimental studies in volunteerslimitations • Use of small doses • Smaller dose is absorbed faster than real dose • So the effect of gastric lavage in reducing bioavailability is lower • Sometimes gastric lavage performed in sitting position • Experimental study utilizes lavage times that are not feasible within most clinical setting • Methods to calculate absorbed dose may be sub-optimal (e.g.: use of urinary recovery to estimate absorbed dose)

12. Experimental studies in poisoned pts Administration nontoxic markers to poisoned patients before lavage Recovery of marker (thiamine) with gastric lavage: 90% after 5 min Limitations • Administration immediately before lavage • Markers do not fully homogenize with gastric content • Delay between ingestion and lavage is not considered Auerbach. Ann Emerg Med 1986

13. Case reports Contra: • Continued drug absortion occurs after gastric lavage • Gastric lavage ineffective with drug concretion • After gastric lavage endoscopy could shows pharmacobezoar Pro: • Hypotermia in poisoned patients may reduce absortion inducing gastric atony • Anticholinergic drugs

14. Limitations of case reports • Role of activated charcoal and/or whole bowel irrigation added to gastric lavage to increase recovery ? • Gastric aspirates is lacking

15. Personal experience • Quetiapineingestion 1,4 g • Gastriclavage 4.5 h postingestion • 326 mg of quetiapineremoved • 23% of ingested dose suggests a partial benefit Zoppellari et al. ClinToxicol 2017 Quetiapine serum decay hours postingestion

16. Clinical studies:amount of drug recovered with gastric lavage • Barbiturates, tricyclic antidepressants, salycilate • The initial dose: unknown

17. Pseudo-randomized studies • Treatment : gastric lavage + activated charcoal versus activated charcoal • Frequency of clinical deterioration or clinical improvement • Gastric lavage: no influence of clinical course Kulig. Ann Emerg Med 1985 Pond. Med J Aust 1995

18. Gastric lavage on mortality associated with tetramine poisoning (China) • Tetramine: rodenticide, life-thretening seizures • 409 retrospective exposures; 1 hospital; 3 years • Mortality: gastric lavage 6%, no lavage 38% (p<0.01) • Protective effect of lavage in severe poisonings: mortality 9% vs 31% (p<0.01) Wang. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing ZaZhi, 2004

19. Controindications “In the extraordinary situations where gastric lavage seems to be a potential treatment option, the clinician must carefully consider whether potential harms outweigt theoretical benefits” ClinToxicol. Position paper update 2013

20. Controindications • Evaluate toleration : craniofacial abnormalities concomitant head trauma refusal to cooperate • Controindications: unprotected airway depressed level of consciousness risk of aspiration (hydrocarbon) risk of hemorrhage or gastric perforation (pathology, recent surgery) ClinToxicol. Position paper update 2013

21. Complications • Aspiration pneumonia • Laringospasm • Arrhythmia • Esophageal or stomach perforation • Fluid and electrolyte (Ca, Mg, Na) imbalance • Small conjunctival hemorrhages

22. Complications: aspiration pneumonia • Unprotected airway • Awake patient • Intubated patient • Ingestion of hydrocarbons

23. Indications – place in therapy • Experimental studies in animals and humans: results are variable and diminish with the elapsed time since ingestion • Weak evidence gastric lavage is of benefit • Gastric lavage should not be performed routinely • Case reports: gastric lavage occasionally produces impressive returns (level evidence 4) ClinToxicol. Position paper update 2013

24. Conclusion “…remains the same as in 2004: gastric lavage should not be performed routinely, if at all, for the treatment of poisoned patients. In the rare situation where gastric lavage might seem appropriate, clinicians should consider treatment with activated charcoal or observation and supportive care in place of gastric lavage. New evidence since 2004 suggests the need to emphasize that gastric lavage should be performed only where the expertise exists.” Clin Toxicol. Position paper update 2013

25. Conclusion: nevertheless • The evidence supporting situations where gastric lavage would provide benefit to patient (e.g. lethal ingestion, recent exposure, substance not bound to activated charcoal) is either based on theoretical grounds or is based on case reports (level of evidence 4) • However, evidence to exclude that gastric lavage could be beneficial in those situations is also lacking ClinToxicol. Position paper update 2013

26. Pub Med: papers 2012-2018 key word: gastric lavage • Deutsches Arzteblatt , 2014 • Cas Lek Cesk, 2015 (Czech) • Zhonghua Wei Zhong Bing Ji Jiu Yi Xue, 2015 (Chinese, paraquat) • Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 2015 (Chinese, paraquat) • Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 2016 (Chinese) • J Emerg Med, 2016 • Med Intensiva, 2016 (Spanish) • Rapid Commun Mass Spectrom, 2016 • Int J Biol Macromol, 2017

27. Gastric lavage in cases of poisoning. Marx C, Marx M. Deutsches Arzteblatt 2014; 111 869: 100 • Once again a claim is made that gastric lavage is not safe and should be considered only in life-threatening cases and within minutes after the ingestion • This “vagueness” demands a closer look at the relevant reference literature (Clin Toxicol 2013: position paper update) • In spite of all this, 6 out of 11 poison information centers supported gastric lavage in an international study using the example of paracetamol intoxication (Good. Clin Toxicol 2007) • In cases of life threatening intoxication, all possible options for detoxification should be considered • Gastric lavage is one such option

28. In replay. Muller D. Deutsches Arzteblatt 2014; 111 869: 100 • The consensus article under criticism was compiled by toxicologists representing 2 medical societies, which conducted a careful and systematic evidence-based evaluation including various sources • The recommendation to perform gastric lavage only within 60 minutes after ingestion of a life-threatening dose of a toxic agent is based on a consensus that has remained stable for 16 years • Poisons information centers register case reports to be added to the continuing discussion of the subject and may serve as a basis for future alignments of therapeutic recommendations

29. Gastric lavage after peroral intoxication – controversial views.Cas Lek Cesk 2015. Vecera R, et alabstract (article in Czech) • Some authors recommend gastric lavage in patients as late as 6 hours after intoxication • In some cases, when the ingested substance slows gastric emptying, they even recommend lavage until 24 hours after intoxication • Based on our experience, we recommend the extension of the time interval when to perform gastric lavage in intoxication

30. Corso itinerante AAROI-SIARED 2005: la gestione del paziente gravemente intossicatoSpotlight on seriously poisoned patient. Zoppellari, Locatelli, Lonati. Acta Anaesth Italica 2006; 57: 247 • Intervallo utile: entro 4 ore dall'ingestione (?) • efficacia minore • tossici allo stato liquido (specie a stomaco vuoto) • efficacia maggiore • tossici solidi (specie se in quantità elevata) • dopo pasto copioso • antidepressivi, Ca-antagonisti (rallentamento transito) • morfina e tallio (pilorospasmo) • atropina e spasmolitici (diminuita motilità) • shock o coma (ritardato svuotamento gastrico) • salicilici

31. Tecnica gastrolusi • posizionamento sonda (di calibro > disponibile) • aspirare contenuto gastrico + campione per laboratorio • volume massimo input • adulto 200 ml • bambino 20-50 ml • volume totale • fino a comparsa di liquido chiaro, inodore, incolore • almeno 5 litri (“effetto lavatrice”) • verifica bilancio in/out • liquidi • acqua semplice • soluzione fisiologica nel bambino (rischio di iposodiemia)

32. Sonda di Faucher 30 Fr 1 French Gauge (FC) o Charriere = 0.013 pollici SNG 18 FG = 6 mm

33. grande curvatura decubitolaterale destro contenuto gastrico piloro piccola curvatura contenuto gastrico decubitolaterale sinistro

34. Lavanda gastrica: controindicazioni a) assolute perforazione esofago-gastrica b) relative tipo di sostanza ingerita - solventi, olii essenziali, derivati del petrolio - tensioattivi schiumogeni - caustici o corrosivi patologie a carico del paziente - varici esofagee, pregressa chirurgia esofago-gastrica

35. EGDS e decontaminazione gastrica • aspirazione • verifica dell’avvenuta decontaminazione con ulteriore decontaminazione (gastroscopia) se necessaria • tossici lesionali • concrezioni di compresse • materiale adeso alla parete gastrica • progressione pilorica di corpi estranei (es. micropile)

36. Conclusion: tailored approach • Pharmacokinetics (volunteers) ws toxicokinetics (poisoning) • Timing: 1 – 6 – 12 hours (delayed absorption: shock, hypotermia, kind of drugs)? • Technique of gastric lavage ? • Asymptomatic vs symtomatic patient ? • Lethal ingestion ? • Lesional drug ? • No charchoal absortion of drug ? • Airway protection (GCS < 9) • Poison Centre or expert toxicologist judgement

37. La gastrolusi va eseguita

38. Grazie per l’attenzione roberto.zoppellari@unife.it