1
|
Moake MM, Presley BC, Hill JG, Wolf BJ, Kane ID, Busch CE, Jackson BF. Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients. Pediatr Emerg Care 2022; 38:e178-e186. [PMID: 32769837 PMCID: PMC7854775 DOI: 10.1097/pec.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. METHODS We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. RESULTS Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." CONCLUSIONS The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.
Collapse
Affiliation(s)
| | | | | | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Ian D Kane
- From the Department of Pediatric Emergency Medicine
| | | | | |
Collapse
|
2
|
Valero Castañer H, Vendrell Jordà M, Sala Blanch X, Valero R. Preoperative bedside ultrasound assessment of gastric volume and evaluation of predisposing factors for delayed gastric emptying: a case-control observational study. J Clin Monit Comput 2020; 35:483-489. [PMID: 32124149 DOI: 10.1007/s10877-020-00489-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/17/2020] [Indexed: 11/26/2022]
Abstract
Perioperative pulmonary aspiration of gastric content is a serious complication. Fasting guidelines try to ensure an empty stomach before intervention. Certain medications or pathologies may cause delayed gastric emptying. Bedside ultrasonography is a useful tool when gastric content status is unclear or in emergency situations where fasting is not feasible. The aim of this prospective case-control observational study was to assess differences in gastric fluid volume between fasted patients with or without predisposing factors for delayed gastric emptying. Patients were preoperatively scanned. Antral cross-sectional area was measured by two tracing methods and total gastric clear fluid volumes were calculated. Data was recorded from September 2018 to March 2019 in a university hospital setting in Barcelona, Spain. Fifty-three patients were enrolled, 23 with delayed gastric emptying predisposing factors (DGEF) and 30 without non-DGEF. Ultrasound-estimated gastric clear fluid volume was 35.21 ± 32.69 mL in the DGEF versus 53.50 ± 30.72 mL in the non-DGEF group (p = 0.08). Average volume per unit of weight was 0.61 ± 0.46 mL/kg. Only 1 patient in the DGEF group had a volume that posed a higher risk of aspiration (1.57 mL/kg). Perfect correlation (R = 0.91; p < 0.01) and concordance (0.91; 95% CI 0.83; 0.95) was found between tracing methods. Minimal gastric content was observed in scheduled surgery in spite of predisposing factors for delayed gastric emptying. Ultrasound clear gastric volume estimation was useful to assess preoperative bedside gastric content.
Collapse
Affiliation(s)
| | - Marina Vendrell Jordà
- Anesthesiology Department, Hospital Clinic Barcelona, Villaroel 170, Esc 4-3, Barcelona, Spain.
| | - Xavier Sala Blanch
- Anesthesiology Department, Hospital Clinic Barcelona, Villaroel 170, Esc 4-3, Barcelona, Spain
| | - Ricard Valero
- Anesthesiology Department, Hospital Clinic Barcelona, Villaroel 170, Esc 4-3, Barcelona, Spain
| |
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW Gastrointestinal dysmotility occurs frequently in the critically ill. Although the causes underlying dysmotility are multifactorial, both pain and its treatment with exogenous opioids are likely causative factors. The purpose of this review is to describe the effects of pain and opioids on gastrointestinal motility; outline the rationale for and evidence supporting the administration of opioid antagonists to improve dysmotility; and describe the potential influence opioids drugs have on the intestinal microbiome and infectious complications. RECENT FINDINGS Opioid drugs are frequently prescribed in the critically ill to alleviate pain. In health, opioids cause gastric dysmotility, yet the evidence for this in critical illness is inconsistent and limited to observational studies. Administration of opioid antagonists may improve gastrointestinal motility, but data are sparse, and these agents cannot be recommended outside of clinical trials. Although critical illness is associated with alterations in the microbiome, the extent to which opioid administration influences these changes, and the subsequent development of infection, remains uncertain. SUMMARY Replication of clinical studies from ambulant populations in critical care is required to ascertain the independent influence of opioid administration on gastrointestinal motility and infectious complications.
Collapse
|
4
|
Desgranges FP, Simonin M, Barnoud S, Zieleskiewicz L, Cercueil E, Erbacher J, Allaouchiche B, Chassard D, Bouvet L. Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study. Acta Anaesthesiol Scand 2019; 63:27-33. [PMID: 30084204 DOI: 10.1111/aas.13220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/06/2018] [Accepted: 07/13/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Emergent obstetrical procedures may require general anaesthesia in parturients at full cervical dilatation or immediately after vaginal birth. This study aimed to determine the prevalence and the predictive factors of higher estimated gastric content in parturients at full cervical dilatation with epidural analgesia and allowed to drink during the labour, and to assess the ability of the antral area measured in the semirecumbent position (SR-CSA) to identify higher estimated gastric content in this setting. METHODS This prospective observational study was conducted between December 2016 and July 2017. Ultrasonographic examination of the antrum was performed at full cervical dilatation, within the hour preceding the beginning of expulsive efforts. Higher estimated gastric content was defined when solid content was observed and/or if the calculated gastric fluid volume was >1.5 mL/kg. RESULTS Seventeen of 62 parturients (27%) presented higher estimated gastric content. Maximal pain intensity during the last hour of labour and time interval between the insertion of the epidural catheter and ultrasonographic examination were significantly increased in parturients with higher estimated gastric content. The threshold value of the SR-CSA to identify a higher estimated gastric content was 393 mm2 , with sensitivity = 88% and specificity = 87%. CONCLUSION Around a quarter of parturients with epidural analgesia and free access to clear fluids during labour presented higher estimated gastric content at full cervical dilatation. The SR-CSA may be of interest for the fast ultrasound assessment of the gastric content status in case of emergent obstetrical procedures at full cervical dilatation.
Collapse
Affiliation(s)
- François-Pierrick Desgranges
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
- Research Unit APCSe VetAgro Sup UPSP 2016.A101; Claude Bernard Lyon 1 University; Marcy-l'Etoile France
| | - Marine Simonin
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
| | - Sophie Barnoud
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
| | - Laurent Zieleskiewicz
- Department of Anesthesia and Intensive Care; University Hospital of Marseille; Marseille France
| | - Eloise Cercueil
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
| | - Julien Erbacher
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
| | - Bernard Allaouchiche
- Research Unit APCSe VetAgro Sup UPSP 2016.A101; Claude Bernard Lyon 1 University; Marcy-l'Etoile France
- Department of Anesthesia and Intensive Care; Lyon Sud Hospital; Hospices Civils de Lyon; Pierre-Bénite France
| | - Dominique Chassard
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
- Research Unit APCSe VetAgro Sup UPSP 2016.A101; Claude Bernard Lyon 1 University; Marcy-l'Etoile France
| | - Lionel Bouvet
- Department of Anesthesia and Intensive Care; Hospices Civils de Lyon; Femme Mère Enfant Hospital; Bron France
- Research Unit APCSe VetAgro Sup UPSP 2016.A101; Claude Bernard Lyon 1 University; Marcy-l'Etoile France
| |
Collapse
|
5
|
Gagey AC, de Queiroz Siqueira M, Monard C, Combet S, Cogniat B, Desgranges FP, Robinson P, Chassard D, Bouvet L. The effect of pre-operative gastric ultrasound examination on the choice of general anaesthetic induction technique for non-elective paediatric surgery. A prospective cohort study. Anaesthesia 2017; 73:304-312. [DOI: 10.1111/anae.14179] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 01/01/2023]
Affiliation(s)
- A.-C. Gagey
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | | | - C. Monard
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - S. Combet
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - B. Cogniat
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - F.-P. Desgranges
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Department of Anaesthesia; Université Claude Bernard Lyon 1; Villeurbanne France
| | - P. Robinson
- Department of Clinical Research; Hospices Civils de Lyon, Lyon France
| | - D. Chassard
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Department of Anaesthesia; Université Claude Bernard Lyon 1; Villeurbanne France
| | - L. Bouvet
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Université Claude Bernard Lyon 1; INSERM, LabTAU UMR1032; Lyon France
| |
Collapse
|
6
|
Li G, Huang C, Zhang X, Xie H, Cheng H, Tang Y, Li Z. The short-term effects of acupuncture on patients with diabetic gastroparesis: a randomised crossover study. Acupunct Med 2015; 33:204-9. [PMID: 25689986 DOI: 10.1136/acupmed-2014-010670] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acupuncture may improve gastrointestinal symptoms in patients with various disorders, but its efficacy in diabetic gastroparesis is unclear. OBJECTIVE To evaluate the short-term effects of acupuncture on gastric emptying and gastroparesis symptoms in patients with diabetic gastroparesis. METHODS In a single-blind controlled crossover trial, 25 patients with diabetic gastroparesis were randomly assigned to undergo 1 week of real acupuncture (RA) treatment followed by 1 week of sham acupuncture (SA) treatment, or vice versa, with a washout of 1 month in between. Before and after each intervention, gastric retention, the Gastroparesis Cardinal Symptom Index (GCSI), fasting blood glucose (FBG) and HbA1c levels were measured. RESULTS 21 patients completed the study. Compared with SA treatment, RA treatment was associated with significantly greater reductions in gastric retention at 2 h (-11.1±7.0%; 95% CI -13.6% to -6.2%; p<0.01) and at 4 h (-5.0±2.8%; 95% CI -6.0% to -0.2%; p=0.04) and in GCSI score (-8.0±3.4; 95% CI -8.4 to -2.8; p<0.01). There were no significant differences in FBG and HbA1c levels between RA and SA treatments. CONCLUSIONS In patients with diabetic gastroparesis, 1 week of short-term manual acupuncture reduces gastric retention and improves gastroparesis symptoms.
Collapse
Affiliation(s)
- Guomin Li
- Department of Rehabilitation Medicine, The First People's Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Chengfei Huang
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xuezhu Zhang
- Acupuncture and Moxibustion Research Institute, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hui Xie
- Department of Rehabilitation Medicine, The First People's Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Haiyan Cheng
- Department of Traditional Chinese Medicine, Hubei Jianghan Oilfield General Hospital, Jianghan, Hubei, China
| | - Yinshan Tang
- Department of Acupuncture and Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Zhigang Li
- Department of Acupuncture and Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
7
|
Bhatia N, Palta S, Arora K. Comparison of the effect of a single dose of erythromycin with pantoprazole on gastric content volume and acidity in elective general surgery patients. J Anaesthesiol Clin Pharmacol 2013; 27:195-8. [PMID: 21772679 PMCID: PMC3127298 DOI: 10.4103/0970-9185.81832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Pulmonary aspiration of gastric contents remains one of the most feared complications of anesthesia. A gastric pH of 2.5 or less and a volume of 25 ml (0.4 ml/kg body weight) or more in average adult patients are considered critical factors for the development of pulmonary damage in adults. MATERIALS AND METHODS This study compared the efficacy of a single oral dose of erythromycin (a macrolide antibiotic) with oral pantoprazole (a proton pump inhibitor) on pre-operative gastric fluid volume and pH in a prospective, randomized, double-blind controlled fashion in 80 adult patients (of ASA physical status I and II) planned for elective surgery under general anesthesia. Patients were divided into two groups of 40 patients each. The pantoprazole group (Group I) received oral pantoprazole 40 mg and the erythromycin group (Group II) received oral erythromycin 250 mg at least 1 h prior to the induction of anesthesia. After tracheal intubation, gastric fluid was aspirated via a Salem Sump tube and its volume and pH were measured. RESULTS Although both erythromycin and pantoprazole decreased the gastric fluid volume to a similar extent, the decrease in gastric fluid acidity by pantoprazole was significantly greater than that by erythromycin. The proportion of patients at risk of pulmonary aspiration according to traditional criteria, i.e. pH ≤2.5 and volume ≥25ml, was lower in the pantoprazole group. CONCLUSION Administration of pantoprazole was found to be more useful than a sub-therapeutic dose of erythromycin in decreasing both volume and acidity of gastric content.
Collapse
Affiliation(s)
- Nidhi Bhatia
- Department of Anaesthesiology, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | | | | |
Collapse
|
8
|
Could a single standardized ultrasonographic measurement of antral area be of interest for assessing gastric contents? A preliminary report. Eur J Anaesthesiol 2009; 26:1015-9. [DOI: 10.1097/eja.0b013e32833161fd] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Zingg U, Miskovic D, Pasternak I, Meyer P, Hamel CT, Metzger U. Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial. Int J Colorectal Dis 2008; 23:1175-83. [PMID: 18665373 DOI: 10.1007/s00384-008-0536-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections. MATERIALS AND METHODS Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea. RESULTS One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups. CONCLUSION Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.
Collapse
Affiliation(s)
- U Zingg
- Department of Surgery, Triemli Hospital, Birmensdorferstr. 497, 8063, Zurich, Switzerland.
| | | | | | | | | | | |
Collapse
|
10
|
Friedenberg FK, Palit A, Parkman HP, Hanlon A, Nelson DB. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol 2008; 103:416-23. [PMID: 18070232 DOI: 10.1111/j.1572-0241.2007.01676.x] [Citation(s) in RCA: 220] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Observational data suggest that intrapyloric injection of botulinum toxin A (BoTN/A) reduces symptoms and accelerates gastric emptying in idiopathic and diabetic gastroparesis. Our purpose was to determine whether botulinum toxin improves symptoms to a significantly greater extent than placebo. An additional objective was to determine whether there is an acceleration of gastric emptying after injection. METHODS A single-institution, randomized, double-blind, placebo-controlled trial* was done. Eligible patients had a Gastroparesis Cardinal Symptom Index score > or = 27 with randomization to intrapyloric botulinum toxin, 200 U (units), or saline placebo. Reassessment of symptoms and repeat gastric emptying scan at 1-month follow-up were done. RESULTS Thirty-two patients were randomized to botulinum toxin (N = 16) and placebo (N = 16). At 1-month follow-up, 37.5% randomized to botulinum toxin and 56.3% randomized to placebo achieved improvement as defined by this study. There were no identifiable clinical predictors of response. The botulinum toxin group demonstrated improvement in gastric emptying; however, this was not superior to placebo. No serious adverse events were attributable to botulinum toxin. CONCLUSIONS Intrapyloric injection of botulinum toxin improves gastric emptying in patients with gastroparesis, although this benefit was not superior to placebo at 1 month. Also, in comparison to placebo, symptoms do not improve significantly by 1 month after injection. Overall, we are unable to recommend botulinum toxin therapy for widespread use in the treatment of delayed gastric emptying until more data are available.
Collapse
Affiliation(s)
- Frank K Friedenberg
- Section of Gastroenterology, Temple University School of Medicine, Philadelphia, PA 19140, USA
| | | | | | | | | |
Collapse
|