Introduction:
It is a gastrointestinal decontamination technique aimed at emptying the stomach to remove toxic substances by administering small volumes of fluid through a tube inserted into the stomach through the nose or mouth.
What Is the Purpose of This Procedure?
The purpose of this procedure includes the following:
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For immediate and urgent removal of unwanted ingested substances before it gets absorbed into the systemic circulation.
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To diagnose any inflammatory conditions like gastric hemorrhage.
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To empty the content of the stomach before any procedure like endoscopy.
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To help evaluate the clots if they are present.
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Obtain information about the rate of bleeding and its location
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It can also be used as a cooling technique in hyperthermic patients.
What Are the Indications to Perform Gastric Lavage?
The indications include the following:
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When the patient has swallowed anything unwanted or poisonous.
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Clearing the contents of the stomach before an upper endoscopic procedure.
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Collecting stomach acids for testing.
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To relieve pressure in the stomach which has a blockage in the stomach and nearby areas like the intestine.
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It is useful in collecting the sample of sputum from children who cannot produce it. It is a procedure of choice for children who are suspected of having pulmonary tuberculosis.
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After collecting, the gastric lavage must be sent to the lab as soon as possible or at least mix it with 10 % sodium carbonate to prevent mycobacterium loss due to gastric acid present in the lavage.
What Should Be the Size of the Tube for Performing Gastric Lavage?
In adults, a no. 42 French Ewald tube is used, or a large orogastric tube which can be inserted orally can also be used. The doctor cannot use a nasogastric tube to remove large material. The patient's age and size determine the amount of fluid to be used. 50-100 ml per lavage can be used in adults.
What Are the Types of Equipment Needed to Perform This Procedure?
The types of equipments needed for the procedure include:
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Normal saline.
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Bite block.
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Gastric tube.
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Irrigation tray.
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Adhesive tape.
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Suction equipment.
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Lubricating jelly.
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Lidocaine spray.
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60ml syringe with catheter cap.
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Lavage tube.
How Is This Procedure Performed?
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Explain and educate the patient about the pros and cons of this procedure since a person who is able to understand this procedure will tolerate better
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Before initiating the procedure, intravenous access to the veins should be given and started monitoring cardiac rate, rhythm, and pulse rate.
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Pulse oximetry can also be performed to keep in check the oxygen level in the blood.
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If the patient is feeling anxious about something, it is best to administer a sedative like Midazolam of 1-2 mg.
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Place the patient in the left lateral position lying down with head lowered at approximately 20 degrees to reduce the risk of contents aspirating back if vomiting occurs.
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An intubated or unconscious patient can lie in a supine position. Ewald tube is inserted via the nose or the mouth. Use topical anesthesia like lidocaine spray in the posterior pharynx to prevent the feeling of discomfort during insertion.
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Hold the patient's head and flex it as forward as possible at the same time, place a bite block. Then the doctor will insert his/her middle and thumb finger over the base of the tongue.
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Then, the doctor will guide the tube, which has lubrication on it, over their fingers as the patient swallows.
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After entering the pharynx, the doctor will position the patient's chin against his/her chest to facilitate the tube into the esophagus.
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Cough or cyanosis (bluish discoloration of the skin due to lack of oxygen in the blood) indicates that the tube has gone into the windpipe, and the doctor should withdraw the tube back immediately and re-enter it carefully.
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Retain the hands of the patient if he/she is uncooperative to prevent the removal of the tube. Confirm the placement of the tube by suctioning back a small amount of content from the stomach and testing its pH. This is done to ensure that the tube is not in the lungs.
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In adults, normal saline 0f 0.9 % or water is used for irrigation. In children, mostly normal saline is used since the children are at more risk. In children, confirm the position of the tube by taking radiographs.
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It is very important to avoid any ingestion of fluids until tube placement is confirmed. Then start taking the contents out from the stomach by aspiration.
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This procedure is done repeatedly till the returning fluid shows no contents of the stomach.
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Activated charcoal (single dose=1g/kg) is given at the end of the procedure since it helps in the absorption of the ingested poison.
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Alcohol, mercury, lead, and iron are not absorbed by charcoal, so if this poisoning occurs, activated charcoal need not be used.
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Administration of charcoal continuously is encouraged, starting at 1g/kg and then gradually decreasing it to 0.5-1kg every two to four hours in patients who had taken an overdose of Phenobarbital, Carbamazepine, or Theophylline.
What Could Be the Possible Complications That Can Occur When Performing This Procedure?
Complications include:
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Aspiration Pneumonia: While taking out the unwanted substances from the stomach, there is a high chance of the contents entering the lungs accidentally, which will cause shortness of breath and cough.
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Laryngospasm: Uncontrolled and involuntary contraction of muscles of the vocal cord.
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Hypoxia: Lack of oxygen in the body tissues.
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Bradycardia: Pulse becomes low and slower than normal.
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Mechanical injury: It occurs due to the insertion of a tube in the throat, esophagus, and stomach.
What Could Be the Possible Contraindications for Gastric Lavage?
The contraindications include:
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If the patient is unconscious or in a depressed state of consciousness, there might be a loss of airway protective reflexes.
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Ingestion of corrosive substances like a strong acid or alkali.
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A patient who is at risk of gastrointestinal perforation or hemorrhage or who has undergone surgery recently could be further compromised by the use of this procedure.
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It is also contraindicated if its use increases the risk and severity of aspiration, such as in patients who ingested hydrocarbons that possess high aspiration potential.
Conclusion:
Even though this procedure has its own complications, it is still a sort-out procedure of choice when it comes to poisoning. Using it with activated charcoal makes it a more effective procedure for reducing the poisoning effects.This procedure is still widely performed in developing countries like India and Sri Lanka since fatality rates are higher.The amount of toxins removed by this procedure is unreliable and often negligible especially if performed in the first hour .Thus it should be rarely used.
