Safety of gastric lavage using nasogastric ryle’s tube in pesticide poisoning

doi:10.4236/health.2011.37067

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Vol.3, No.7, 401-405 (2011)

doi:10.4236/health.2011.37067

Health

Safety of gastric lavage using nasogastric ryle’s tube in

pesticide poisoning

Uday Bhan Bhardwaj, Anand Subramaniyan, Ashish Bhalla, Navneet Sharma, Surjit Singh*

Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India; *Corresponding

Author: [email protected], [email protected]

Received 13 April 2011; revised 1 June 2011; accepted 10 June 2011.

ABSTRACT

Objective: Gastric lavage is mandatory irre-

spective of nature in all patients w ith acute poi-

soning in India. Present study was undertaken

with aim whether lavage done using naso-ga-

stric Ryle’s tube and small aliquots of water or

normal saline is safe. Patients and Methods: All

the patients above 12 years of age admitted

consecutively with pesticide ingestion or ex-

posure between July 2004 to June 2005 were

studied with respect to complications associ-

ated with lavage using Ryle’s tube. Forty five

patients were admitted directly to our hospital

and lavage was undertaken using Ryle’s tube

(16F ) with 100 - 200 mL of aliquots till 1 - 1.5

liters of fluid was lavaged, with prophylactic

endotracheal intubation in patients with Glas-

gow coma scale ( GCS) < 10 (group I). The inci-

dence of complications related to lavage in

group I was compared to that in 53 patients

admitted during same period with pesticide

poisoning but lavaged outside using naso-

gastric Ryle’s tube and referred to our institute

(group II). Results: The significant complica-

tions observed in group I were significant drop

in SaO2 (6 patients) laryngospasm, tachycardia,

electrolyte imbalance and tube getting struck in

throat (one each). In one patient in group I (had

no prophylactic intubation though GCS 3) In

group II, 7 had aspiration pneumonia (no pro-

phylactic intubation). Other significant compli-

cation was drop in SaO2 during lavage. None of

them had any serious life threatening complica-

tion. Conclusion: Gastric lavage carried out us-

ing naso-gastric Ryle’s tube and small aliquots

of water or normal saline is relatively safe in

patients with pesticide poisoning when com-

bined with prophylactic endotracheal intubation

in patients with GCS < 10. In absence of pro-

phylactic intubation, risk of aspiration is there.

However aspiration pneumonia is generally mild

and not life threatening.

Keywords: Pesticide Poisoning; Gastric Lav age;

Nasogastric Ryle’s Tube; Complicat ions

1. INTRODUCTION

Gastric lavage has to be carried out by treating physi-

cian in all patients with acute poisoning in India irre-

spective of nature, severity of poisoning and time inter-

val between ingestion and arrival to hospital as lavage

sample has to be provided to legal authorities in addition

to blood, urine and other samples. As per Indian penal

code (I.P.C,1973), the attending physician should collect,

preserve and seal the evidence related to the case of poi-

soning such as the gastric lavage fluid, vomiting, faeces,

urine etc. for onward transmission to forensic science

laboratory for chemical analysis. If doctor deliberately

fails to do so he is liable to be punished under section of

201 of I.P.C i.e. causing disappearance of evidence of

offence or giving false information to screen offender [1].

This is punishable with imprisonment up to 7 years or

fine or both. As per Indian law, attempt to commit sui-

cide is an offence under section 309 of I.P.C which states

that whoever attempts to commit suicide and does any

act towards the commission of such offence, shall be

punished with simple imprisonment for a term which

may extend to one year or with fine or wi t h both [2].

This is in contrast to developed countries where sui-

cide is not a criminal offence and lavage is rarely carried

out as there is no evidence that it is effective at all [3-7]

and can lead to significant morbidity and mortality [3,8 ].

Moreover in developed countries unlike developing

countries, drug overdoses are commonest form of poi-

soning [4]. These carry a low case fatality ratio due to

availability of effective antidotes and patients being ma-

naged in well equipped hospitals [4-7]. This is unlike

developing countries including India, where pesticide

U. B. Bhardwaj et al. / Health 3 (2011) 401-405

402

poisoning is the commonest [9-11]. These cases carry

high case fatality ratio as specific antidotes eith er do n ot

exist or unavailable or unaffordable or only partially

effective [11,12]. As gastric lavage in case of poisoning

is necessary due to legal reasons in India [1,2] and as

studies regarding its safety in pesticide poisoned patients

do not ex ist [13], th e pr esent stu d y was undertak en using

naso-gastric Ryle’s tube with lavage being carried out,

using 100 - 200 mL aliquots of water or normal saline

till 1 - 1.5 liters are lavaged, to find its safety. The study

was not designed to determine whether gastric lavage

removes poison adequately or not.

2. PATIENTS AND METHODS

All the patients age 12 or more consecutively admitted

to emergency medical services of Nehru Hospital at-

tached to Postgraduate Institute of Medical Education

and Research, Chandigarh (India) who had ingested or

were accidentally exposed to pesticides and reached our

hospital with in 24 hrs were included in the study be-

tween July 2004 to June 2005. The patien ts were div ided

into 2 groups. Group I included patients with pesticide

poisoning who reached our hospital directly and were

lavaged by a nurse under supervision of a medical resi-

dent or by medical resident. Group II comprised patients

who had consumed or exposed to pesticides and had

undergone lavage outside our hospital using naso-gastric

Ryle’s tube and were then referred to us for further

management. Only those patients who had symptoms

and signs consistent with pesticide poisoning were in-

cluded in study and all other poisoned patients were ex-

cluded.

In group I, gastric lavage was carried out with na-

sogastric Ryle’s tube (16F) and using 100 - 200 mL ali-

quots of water or normal saline at a time till 1 - 1.5 liters

of lavage was completed. Prophylactic endotracheal in-

tubation was carried out in patients with GCS < 10. In

addition to measuring SaO2 by pulse oximeter, arterial

blood gases (ABG) were measured before, during and

after lavage. In those, where ABG could not be done,

SaO2 was continuously determined by pulse oximeter

alone. In addition continuous cardiac monitoring was

done. A chest x-ray was undertaken before and 4 hours

after lavage. Serum electrolytes (Na+, K+, Mg+ were

measured before and 4 hours after lavage. In group II

patients, no lavage was undertaken in our hospital and

they were assessed for any complications related to it. It

was not possible to know the exact amount of water or

normal saline they were lavaged with. However fro m the

hospitals they were referred to us, we checked the lavage

practices and it was found that lavage is undertaken

generally using smaller aliquots after passing naso-gas-

tric Ryle’s tube and fluid volume used generally does not

exceed 2 liters.

We could not undertake any tests to find how much

compound was removed by lavage from stomach or

from blood. The complication rate was determined by

determining percentages with confidence interval. The

groups were compared using Student t-test. Where ever

possible we tried to take patient’s consent though it is

not necessary as procedure being required by law. The

study plan was approved by the ethics committee of the

Institute.

3. RESULTS

A total of 131 patients with acute poisoning were ad-

mitted during this period to our medical emergency. Of

these, 98 had history of ingestion or exposure to pesti-

cides and had toxidrome consistent with it. In group I,

there were 45 patien ts. In group II, of 54 one had under-

gone lavage outside with orogastric tube and was ex-

cluded. Thus 98 patients fulfilled the criteria for inclu-

sion in two groups and were taken up for final analysis.

Of 45 patients in group I, 40 had ingested with suicidal

intent and in 5 poisoning was alleged accidental expo-

sure during spraying (they were found unconscious, in-

gestion could no t be ruled out). Of 53 in group II, 46 had

ingested with suicidal intent where as 6 patients were

exposed accidentally during spray (as they were found

unconscious, ingestion could not be ruled out). In one,

circumstances could not be known. In group I, of 11

patients who had GCS < 10, prophylactic endotracheal

intubation was undertaken in 10. In 1 patient with GCS

of 3, medical resident failed to intubate the patient and

lavage was under taken. None in group II had prophylac-

tic endotracheal intu bation.

The mean ±S.D time interval between ingestion or

exposure and lavage was 1.95 ± 2.05 hours (range 0.5 -

10) in group I and in group II it was 2.5 ± 3.42 hours

(range 0.5 - 24). The mean ± S.D age in grou p I was 28.4

± 13.2 (range13 - 65) where is in group II was 27.6 ±

10.8 (range 12 - 68). The compounds ingested or acci-

dentally exposed to in two groups are shown in Table 1.

Table 1. Pesticides ingested or acc identally exposed to in 98

patients.

Pesticide consumed Group I Group II Total

Organophosphates 12 26 38

Aluminum phosphide14 19 33

Carbamates 4 0 4

Pyrethroids 2 2 4

Unknown 13 6 19

Total 45 53 98

U. B. Bhardwaj et al. / Health 3 (2011) 401-405

403

In group I, mean volume of water or normal saline la-

vaged was 1108 mL (range 800 - 1500 mL). This could

not be known in group II. Hypoxemia i.e. SaO2 < 90%

was present before lavage in 11 (24.4%) patients where

as in group II, 23 (42.6%) had it at presentation (Table

2). In group I, significant drop in SaO2 (drop in SaO2 to

90% or lower) during lavage and post lavage was ob-

served in 6 and 2 patients respectively. (Tab le 3 ). In 5

patients post lavage SaO2 could not be known as they

died before lavage could be completed. All these patients

had severe aluminum phosphide poisoning.

The complications which occurred during or follow-

ing lavage are shown in Table 4. In group I, 44 patients

did not develop aspiration pneumonia (prophylactic en-

dotracheal intubation carried out in patients with GCS <

10). However, in one patient who had GCS of 3 and

prophylactic endotracheal intubation was not undertaken,

developed aspiration pneumonia (being defined as ap-

pearance of fresh patches of consolidation or increase in

patches as seen in post lavage chest x-ray. The other

complications observed in this group were sinus tachy-

cardia during lavage in 5 patients (11.1%), electrolyte

imbalance i.e. hyponatremia in one (2.2%), laryn-

gospasm in one (2.2%) and in one Ryle's tube got stuck

in throat (2.2%). In group II, 7 (13.2%) had aspiration

pneumonia. None of them had prophylactic endotracheal

intubation.

Thirteen patients in group I and 18 in group II died. In

Table 2. Baseline BP, HR and SaO2 at admission in group I (45 patients) and group II (53 patients).

Systolic < 90* Systolic > 90* HR < 60** HR > 61 - 100**HR > 100**SaO2 < 90***SaO290-94*** SaO2 > 94***

Group No.# No. No. No. No. No. No. No.

I 7 38 1 2 9 15 11 12 22

II 18 35 1 29 23 23 8 22

*Blood Pres sure ( mm HG), **Heart rate/min, ***%O2 satur ation, # Number of patients.

Table 3. SaO2 pre, during lavage and post lavage in group I.

SaO2 SaO2 (admission) SaO2 (dur in g lavag e) SaO2 (post lavage)

< 90% 11 6 2

90% - 94% 12 3 4

> 94% 22 36 34

Total 45 45 40

Table 4. Complications related to gastric lavage in two groups.

Complication Group I (45) Group II (53) Fisher’s Exact test p

Aspiration pneumonia 1(2.2%) 7 (13.2%) 0.039*

Drop in SaO2 during lavage 6 (13.3%) -**

Laryngospasm 1 (2.2%) -**

Pneumothorax 0 0

Empyema 0 0

Tachycardia 1 (2.2%) -**

Ectopics/ST elevation 0 -**

Esophageal perforation 0 0

Gastric hemorrhage 0 -**

Electrolyte imbalance 1 (2.2%) -**

Conjunctival hemorrhage 0 0

Ryle’s tube stuck in throat 1 (2.2%) -**

U. B. Bhardwaj et al. / Health 3 (2011) 401-405

404

none, death could be related to lavage associated com-

plications. The important cause of death in both groups

was severe aluminum phosphide poisoning.

4. DISCUSSION

Gastric lavage has to be carried out in all patients with

acute poisoning in India by treating physician irrespec-

tive of whether suicidal or accidental as lavage sample

has to be provided to legal authorities [1,2]. This is un-

like West where suicide is not considered a criminal of-

fence and it is not necessary to collect gastric lavage

sample. In West it has fallen out of favor having been

found ineffective [2-6]. and can lead to significant mor-

bidity and mortality [1,7] and in recent years, it is much

less carried out and if done at all is in either in a con-

senting or an unconscious intubated patient and is done

if poisoning is severe and patient comes very early.

However these studies on effectiveness of gastric lavage

have been carried out in well eq u ipped Western ho sp itals

in patients with drug overdoses wh ere effective antidotes

are available e.g. paracetamol and have low case fatality

ratio [4-6]. This is un like developing countries including

India where pesticide poisoning is the commonest [8-10].

These cases carry high mortality e.g. 70% with alumi-

num phosphide. The antidotes against pesticides either

do not exist or unavailable and unaffordable or partially

ineffective. Further, hospitals especially in rural areas

are poorly equipped. As the mortality is high and as

theoretically gastric lavage may offer some benefit, the

practice is common in developing countries [14,15].

Further in India, it is necessary to carry it out for medico

legal reasons [1,2].

In the present study, we tried to establish the safety of

gastric lavage using naso-gastric Ryle’s tube with small

aliquots of 100 - 200 mL of water or normal saline being

given till 1 - 1.5 liters were lavaged. A significant com-

plication observed was aspiration pneumonia (1/45 in

group I and 7/53 in group II) all these patients had not

undergone prophylactic endotracheal intubation when

patient was obtunded (GCS < 10). The higher incidence

of aspiration pneumonia in group II could also have been

due to lavage independent factors i.e. deep enin g of co ma

with time due to poison itself and transportation of pa-

tient with unprotected airway. However in none of

these patients it was severe and most of them, unless

they had ingested ALP survived (5/8 including one in

group I). The other complications in group I were sig-

nificant drop in oxygen during lavage (6/45) and post

lavage (2/40), tachycardia, electrolyte imbalance, laryn-

gospasm during lavage or post lavage was in very small

number of patients in group I (one each). We cannot say

about these in group II as we could not get any informa-

tion about these. None of the patients in both groups had

serious complications like gastric hemorrhage, gastric

perforation, empyema, ST elevation and conjunctival

hemorrhage.

These results are unlike those of Eddleston et al. from

SriLanka [8] where mainly orogastric tube was pre-

dominantly used with large volumes resulting in major

complications like severe aspiration, gastric perforation

and death. In north-west India where this tertiary centre

is located, in majority of peripheral hospitals usually

nasogastric Ryles tube is used for gastric lavage using

small aliquots and total small volume are being though

prophylactic intubation is uncommon due to both lack of

equipment and trained manpower. Though doctors and

nurses do carry lavage commonly at times it is also car-

ried out by non medical staff (unpublished data). This

observation however, cannot be extrapolated to hospitals

in other parts of India especially in rural areas where

Ryle’s tube is not always used and lavage is often being

carried out by untrained staff with no intubation being

carried out.

The study was not designed to know effectiveness of

gastric lavage in removing the pesticide and we cannot

comment on this. There is need to undertake studies to

find whether gastric lavage effectively removes pesti-

cides or not and if it is not effective why it should be

necessary to carry out lavage in all patients with acute

poisoning in India irrespective of nature, severity and

time interval and this will require Governmental action

in bringing about an amendment in IPC.

To conclude gastric lavage carried out with nasogas-

tric tube, using small aliquots of water or normal saline

with total lavage fluid less thn 2 L coupled with careful

prophylactic intubation in patients with pesticide poi-

soning is very safe. However, significant risk of aspira-

tion pneumonia remains if prophylactic intubation is not

carried out in patients with < GCS 10. Though aspiration

does occur if not intubated prphylactically, generally

aspiration pneumonia is not severe and doesn’t add to

mortality. A significant drop in SaO2 during lavage can

also occur.

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