Acute pulmonary edema after polyethylene glycol intestinal lavage in a child

Management of polyethylene glycol solution aspiration using bronchoscopic lavage in a dog

Polyethylene glycol lavage solutions are used for colonic preparation in dogs and are considered relatively safe. Aspiration is an uncommon but potentially devastating complication of polyethylene glycol administration. Full recovery is possible and often rapid in people treated with bronchoalveolar lavage. A healthy 2-year-old male Beagle used in an endoscopy teaching laboratory aspirated a small amount of polyethylene glycol lavage solution. Although initially appearing unaffected, the dog quickly became hypoxemic. Bronchoscopy was used to lavage the lungs and aspirate tracheal/pulmonary fluid 5 times over the course of 45 minutes. The dog completely recovered. This report presents the successful treatment of polyethylene glycol aspiration in a dog. Although the seriousness of aspiration might not be immediately evident, bronchoscopy and lavage should be pursued because of the rapidly progressive nature of polyethylene glycol-induced pulmonary edema.

Administering Polyethylene Glycol Electrolyte Solution Via a Nasogastric Tube: Pulmonary Complications

BACKGROUND

Patients sometimes require insertion of a nasogastric tube for the administration of a large volume of a polyethylene glycol electrolyte solution. If the tube is malpositioned, the risk for direct instillation of the solution into the lung increases. The risk for aspiration also increases if the infusion rate exceeds gastrointestinal tolerance.

PURPOSE

To review published cases of patients' experiencing adverse pulmonary events after administration of polyethylene glycol electrolyte solution via a nasogastric tube and to offer suggestions to prevent these outcomes.

METHODS

A search of the literature from 1993 through 2014 was performed by using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases.

RESULTS

In the 12 case reports located, none of the patients had radiographs to verify tube location before infusion of polyethylene glycol electrolyte solution. After symptoms developed in 3 children (ages 8-11 years), radiographs showed their tubes incorrectly positioned in the bronchus, lung, or esophagus; ports of a fourth child's tube were in the oropharynx. The remaining 8 patients (ages 5-86 years) never had radiographs to determine tube placement. Pulmonary complications from the infusions of polyethylene glycol electrolyte solution contributed to the death of 5 of the patients.

CONCLUSION

Relatively simple maneuvers to reduce the likelihood of adverse pulmonary events following the administration of large volumes of polyethylene glycol electrolyte solution via a nasogastric tube are well worth the cost and effort to protect patients from potential serious injury.

Aspiration pneumonitis caused by polyethylene glycol-electrolyte solution treated with conservative management

Polyethylene glycol (PEG) electrolyte solution, Golytely, is an osmotic laxative commonly used in preoperative bowel cleansing. In this case report, a 9-year-old boy developed aspiration pneumonitis following accidental infusion of PEG solution into his right lung following migration of his nasogastric tube (NGT). Hypoxemia and tachypnea without respiratory failure were observed after infusion. Because PEG is a nonabsorbable toxic material, previous case reports have advocated for the performance of bronchoalveolar lavage (BAL) in the treatment of PEG pneumonitis. With close monitoring, our patient was able to be successfully treated without the need for invasive interventions including BAL or intubation. Generalizations about PEG absorption in the lung based on its permeability in the gastrointestinal tract should not deter the use of more conservative treatment in the appropriate patient.

Stress Cardiomyopathy Associated with Diffuse Alveolar Hemorrhage after Colonoscopy

Stress cardiomyopathy (SCM) is usually precipitated by a physiologically or psychologically stressful event. Although it occurs only rarely, hypoxia- and hypercapnia-induced sympathetic activation may also cause SCM. We present the case of a 37-year-old woman affected with SCM after a routine colonoscopy. During the procedure, she aspirated residual polyethylene glycol from her stomach. Hypotension, resting dyspnea, and hemoptysis were subsequently observed. Laboratory findings revealed elevated cardiac enzymes, and a transthoracic echocardiogram revealed left ventricular (LV) global hypokinesia. She was ultimately diagnosed with diffuse alveolar hemorrhage-associated SCM. After successful treatment with a ventilator and corticosteroids, her LV systolic function and dimensions normalized and she was discharged without complications.

The role of iNOS inhibitors on lung injury induced by gastrointestinal decontamination agents aspiration

Aspiration is a devastating complication during decontamination procedure in poisoning patients. We have investigated whether S-methylisothiourea protects different pulmonary aspiration gastrointestinal decontamination agent-induced lung injury in rats. Forty-two male Sprague-Dawley rats were assigned to one of six groups (n = 7): normal saline, activated charcoal, polyethylene glycol, normal saline + S-methylisothiourea treated activated charcoal + S-methylisothiourea treated and polyethylene glycol + S-methylisothiourea treated. Normal saline, activated aharcoal and polyethylene glycol were instilled into the lungs. The rats received S-methylisothiourea i.p twice daily for 7 days. Serum surfactant protein D, oxidative stress products and inducible nitric oxide synthase expression in the lung were investigated. The aspiration of activated charcoal significantly increased all histopathological scores (P < 0.01). Only peribronchial inflammatory cell infiltration, alveolar edema, and alveolar histiocytes were increased in the polyethylene glycol groups as compared to the normal saline group (P < 0.05). Pulmonary aspiration increased serum malondialdehyde (P < 0.001), and surfactant protein D (P < 0.05) levels and decreased serum superoxide dismutase levels (P < 0.05). S-methylisothiourea treatment decreased all histopathological scores in the activated charcoal treated S-methylisothiourea group (P < 0.01) and only decreased alveolar edema and alveolar histiocytes in the polyethylene glycol-treated S-methylisothiourea group (P < 0.05). S-methylisothiourea treatment reduced elevated oxidative factors, inducible nitric oxide synthase activity and serum surfactant protein D levels. Our findings showed that S-methylisothiourea may be a protective drug against Activated Charcoal and Polyethylene Glycol-induced lung injury.

The safety of osmotically acting cathartics in colonic cleansing

Efficient cleansing of the colon before a colonoscopy or a radiological examination is essential. The osmotically acting cathartics (those given the Anatomical Therapeutic Chemical code A06AD) currently used for this purpose comprise products based on three main substances: sodium phosphate, combinations of polyethylene glycol and electrolyte lavage solutions (PEG-ELS), and magnesium citrate. All these preparations give adequate cleansing results and have similar profiles in terms of the frequency and type of mild to moderate adverse effects. However, serious adverse events, such as severe hyperphosphatemia and irreversible kidney damage owing to acute phosphate nephropathy, have been reported after use of sodium-phosphate-based products. The aim of this Review is to provide an update on the potential safety issues related to the use of osmotically acting cathartics, especially disturbances of renal function and water and electrolyte balance. The available evidence indicates that PEG-ELS-based products are the safest option. Magnesium-citrate-based, hypertonic products should be administered with caution to elderly individuals and patients who are prone to develop disturbances in water and electrolyte balance. Sodium-phosphate-based products can occasionally cause irreversible kidney damage and should not be routinely used in bowel-cleansing procedures.

Aspiration pneumonia due to polyethylene glycol-electrolyte solution (Golytely) treated by bronchoalveolar lavage

Polyethylene glycol (PEG)-electrolyte solution (Golytely), is most commonly used for bowel preparation before colonoscopy, as well as for barium enema and colon surgery. In this case, a 70-year-old man developed ARDS following the administration of Golytely by mouth before a scheduled colonoscopy. Aspiration of PEG-electrolyte solution was suspected, and the patient was successfully treated by BAL. Therefore, early bronchoscopy and BAL should be considered as initial treatment for PEG aspiration, because removal of PEG is most important for managing the disease.

Cardiovascular and hemodynamic effect of polyethylene glycol in Rats

BACKGROUND

Polyethylene Glycol (PEG) is a solvent and used in a wide range of biomedical applications. Many fatty-acid-based molecules cannot be administered without a solvent in vivo. PEG can be used to dissolve compounds to make them water soluble. However, the effect of PEG on the cardiovascular system has not been studied. In this study, we evaluated the effect of PEG on the cardiovascular system in rat models.

METHODS

Twenty male Sprague-Dawley rats weighing 250-300 g were used in this study. The control group (10 rats) were injected intraperitoneally with 0.5 ml of 5% D/W in normal saline and the second group (10 rats) with PEG 400, 2 ml/kg ip, twice a day for 1 week. After 4 weeks, the rats underwent general anesthesia and a 1.4 French ultra miniature pressure volume catheter (Millar catheter) was placed in the left ventricle via the right carotid artery to measure comprehensive hemodynamic data. The data were analyzed with PVAN pressure-volume analysis software.

RESULTS

All the systolic and diastolic parameters were similar in both groups except for the effective arterial elastance (Ea), which was decreased in the PEG group. There were no significant differences in maximum (dp/dt(max)) and minimum (dp/dt(min)) development of pressure stroke work, cardiac output, ejection fraction, end systolic volume (Ves), and end diastolic volume.

CONCLUSIONS

We have demonstrated that PEG, as a solvent, decreases Ea in rats in comparison to a placebo. Therefore, PEG as a solvent should be used cautiously in the cardiovascular research.

The treatment of chronic constipation in elderly people: an update

Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition. Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives. Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified. Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.

Safety Issues Regarding Colonic Cleansing for Diagnostic and Surgical Procedures

There are various methods available to cleanse the colon in preparation for diagnostic and surgical procedures. The popular options are diet and cathartic regimens, gut lavage and phosphate preparations. Each method has its own unique characteristics and safety profile. Diet and cathartic regimens are based on traditional methods of colonoscopy preparation and remain an acceptable and safe alternative for patients unwilling or unable to tolerate other bowel preparations. Gut lavage methods involve ingestion of 2-4L of osmotically balanced solutions containing polyethylene glycol, which have been shown to be safe and effective for colon cleansing, including for special patient populations with cardiac, renal or hepatic dysfunction. Phosphate preparations have also been shown to be safe and effective for colon cleansing and are generally better tolerated than counterpart gut lavage solutions. However, this method has safety concerns for some patients with cardiac, renal and hepatic dysfunctions.

Mechanisms of airway protection during retching, vomiting, and swallowing

We investigated the mechanisms of airway protection and bolus transport during retching and vomiting by recording responses of the pharyngeal, laryngeal, and hyoid muscles and comparing them with responses during swallowing and responses of the gastrointestinal tract. Five dogs were chronically instrumented with electrodes on the striated muscles and strain gauges on smooth muscles. Retching and vomiting were stimulated by apomorphine (5-10 ug/kg iv). During retching, the hyoid and thyroid descending and laryngeal abductor muscles were activated; between retches, the hyoid, thyroid, and pharyngeal elevating, and laryngeal adductor muscles were activated. Vomiting always occurred during the ascending phase of retching and consisted of three sequential phases of hyoid and pharyngeal muscle activation culminating in simultaneous activation of all recorded elevating and descending laryngeal, hyoid, and pharyngeal muscles. Retrograde activation of esophagus and pharyngeal muscles occurred during the later phases, and laryngeal adductor was maximally activated in all phases of the vomit. During swallowing, the laryngeal adductor activation was followed immediately by brief activation of the laryngeal abductor. We concluded that retching functions to mix gastric contents with refluxed intestinal secretions and to impart an orad momentum to the bolus before vomiting. During retches, the airway is protected by glottal closure, and between retches, it is protected by ascent of the larynx and closure of the upper esophageal sphincter. The airway is protected by maximum glottal closure during vomiting. During swallowing, the airway is protected by laryngeal elevation and glottal closure followed by brief opening of the glottis, which may release subglottal pressure expelling material from the laryngeal vestibule.

Home bowel preparation for elective colonic procedures in children: cost savings with quality assurance and improvement

BACKGROUND/PURPOSE

The current health care environment pressures providers to lower cost and demands quality care that is measured by outcomes and patient satisfaction. Most insurers will not approve bed days for in-hospital preoperative bowel preparations for elective colorectal procedures. This policy does not take into account that infants and children are unable to tolerate large volumes of enteral preparation, which adversely affects outcome because of an inadequate preparation. This report describes a prospective evaluation of a standard home bowel preparation regimen utilizing local and regional home health care agency support.

METHODS

For an elective colorectal procedure, pediatric patients underwent a home bowel preparation using GoLYTELY (100 mL/kg) via a nasogastric tube infused over 4 hours by a pediatric home health nurse trained in this technique. During the bowel preparation, the nurse educated the family members about the service and performed physiological monitoring to insure safety. At the completion of the preparation, any unusual events were transmitted to the staff surgeon for further instructions. Our initial 30 patients were treated by our hospital home health agency personnel to insure safety. Since then, 41 additional bowel preparations have been performed by statewide agencies.

RESULTS

Seventy-one patients underwent complete home bowel preparation (45 boys; 26 girls). The age range was 3 months to 9 years (average, 5 months). There was one complication caused by incorrect mixing of GoLYTELY causing gastrointestinal cramping. All 71 home bowel preparations were recorded as good at the time of the colorectal procedure by the staff pediatric surgeon. The average cost for home bowel preparation was $300 in network, and $350 out of network. This compares with an inpatient hospital day cost of greater than $800 ($36,000 savings).

CONCLUSIONS

This technique offers the pediatric surgeon an opportunity to maintain a high standard of quality care while using home health agency personnel to minimize cost. This program is safe, effective, and associated with a good outcome and a high degree of family satisfaction.