Position Paper Update: Gastric Lavage for Gastrointestinal Decontamination
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to placebo among 274 individuals with leg cellulitis recruited from 28 hospitals in the United Kingdom and Ireland from July 2006 to January 2010. The primary outcome was risk of repeat cellulitis, and secondary outcomes included number of episodes of repeat cellulitis, adverse drug reactions, and length-of-stay for hospital admissions. Cox proportional-hazard models were used to estimate the risk of recurrence during the 12 months of prophylaxis and during the 24 months after prophylaxis. Of the 136 individuals assigned to the penicillin group, 36 (22%) experienced a recurrence, and of the 138 participants in the placebo group, 51 (37%) experienced a recurrence. During the prophylaxis period, those assigned to penicillin were 45% less likely to develop a recurrent cellulitis (hazard ratio 0.55, 95% confidence interval 0.35–0.86). After the prophylaxis was discontinued, there was no difference between groups in rate of recurrence. Adverse events were not significantly differ- ent between groups with 37 events in the penicillin group and 48 events in the placebo group (p = 0.50). In conclusion, low-dose penicillin may be effective for the reduction in risk of subsequent leg cellulitis in the 12 months after initial infection, but protection seems to wane after cessa- tion of therapy. [Lauren M. Abbate, MD, PHD Denver Health Medical Center, Denver, CO] Comment: This study suggests that low-dose penicillin may reduce the time to recurrence of leg cellulitis; however, therapy likely needs to be maintained to obtain benefits. Furthermore, penicillin seems to be safe, with no difference between groups in adverse events. This study assumes that most infections are due to penicillin-susceptible streptococci. It is possible that re- current infections, especially among those with multiple recur- rences, may include resistant strains or non-streptococcal organisms, and future studies should include culture for organ- isms as well as different classes of antibiotics for those who are penicillin allergic. , POSITION PAPER UPDATE: GASTRIC LAVAGE FOR GASTROINTESTINAL DECONTAMINATION. Benson BE, Hoppu K, Troutman WG, et al. Clin Toxicol (Phila) 2013; 51:140–6. The objective of this study was to summarize previous rec- ommendations for the use of gastric lavage in poisoned patients and to review new data since the previous position paper was published in 2004. The expert panel was appointed by the American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT). The panel performed a comprehensive literature search for gastric lavage in both human and animal studies from January 2003 to March 2011, yielding 683 articles. Of these, 69 were evalu- ated in greater depth, and, ultimately, 15 articles were included. Since 2004, there have been no new studies in animals or marker studies in volunteers or poisoned individuals. However, there have been a few new case reports where gastric lavage may be useful in cases of delayed absorption (i.e., sustained re- leased drugs, hypothermia). In addition, a systematic review of several clinical studies conducted in China was performed, though the results were inconclusive secondary to poor methodology. Ad- ditional studies from China suggest that gastric lavage may be helpful in tetramine poisoning; those were also methodologically flawed. Finally, since 2004, several studies have shown that gas- tric lavage is associated with complications including pneumonia, electrolyte abnormalities, and esophageal perforation. In conclusion, gastric lavage should not be used routinely for the treatment of poisoned patients; rather, activated charcoal or observation and supportive care may be more appropriate. [Lauren M. Abbate, MD, PHD Denver Health Medical Center, Denver, CO] Comment: This position statement by the AACT and the EAPCCT provides updated information for clinicians for the use of gastric lavage based on international data. Given the dearth of new evidence favoring gastric lavage and the increase in data suggesting complications with the procedure, routine use of gastric lavage seems to be waning. , POSITION PAPER UPDATE: IPECAC SYRUP FOR GASTROINTESTINAL DECONTAMINATION. Hojer J, Troutman WG, Hoppu K, et al. Clin Toxicol (Phila) 2013;51: 134–9. The goal of this systematic review article was to summarize recommendations for the use of ipecac for treatment of acute toxic ingestions. The authors referenced a position paper pub- lished in 2004 and aimed to compare this article with the current literature. The 2004 position paper concluded that ipecac had little ben- efit and may result in further complications. This position paper did recommend the use of ipecac in very rare situations. For ex- ample, in cases where there is a risk of serious toxicity and no available alternative therapy. The authors conducted a search of the literature using five different search engines with dates ranging from 2003 to March 31, 2011. Of 157 articles, 42 were included. Review articles were excluded. The authors found that since the 2004 study, no new animal, volunteer, or marker studies have been published. One case re- port was cited showing a benefit of ipecac reducing iron pills af- ter ingestion from 50 to 9 tablets. A retrospective cohort from 1995–2005 was reviewed in which children younger than 6 years ingested mushrooms. In this study, ipecac was compared to activated charcoal vs. no gastrointestinal decontamination. The study showed no major differences in the three treatments, although the study was difficult to interpret as 99.3% of children had positive outcomes. Complications of ipecac include delay in the administration of activated charcoal by 1–2 h, diarrhea, lethargy, prolonged vomiting, aspiration, pneumomediastinum, and Mallory-Weiss tears. A 1989 study showed a higher complication rate in pa- tients receiving ipecac and activated charcoal vs. activated char- coal alone. More recent publications show an association between the abuse of ipecac by patients with eating disorders and myopathy or cardiomyopathy. The authors conclude that there is not sufficient evidence to warrant any change to the 2004 position paper recommendations. 310 Abstracts
Transcript of Position Paper Update: Gastric Lavage for Gastrointestinal Decontamination
310 Abstracts
to placebo among 274 individuals with leg cellulitis recruitedfrom 28 hospitals in the United Kingdom and Ireland fromJuly 2006 to January 2010. The primary outcome was risk ofrepeat cellulitis, and secondary outcomes included number ofepisodes of repeat cellulitis, adverse drug reactions, andlength-of-stay for hospital admissions. Cox proportional-hazardmodels were used to estimate the risk of recurrence during the12 months of prophylaxis and during the 24 months afterprophylaxis.
Of the 136 individuals assigned to the penicillin group, 36(22%) experienced a recurrence, and of the 138 participants inthe placebo group, 51 (37%) experienced a recurrence. Duringthe prophylaxis period, those assigned to penicillin were 45%less likely to develop a recurrent cellulitis (hazard ratio 0.55,95% confidence interval 0.35–0.86). After the prophylaxiswas discontinued, there was no difference between groups inrate of recurrence. Adverse events were not significantly differ-ent between groups with 37 events in the penicillin group and48 events in the placebo group (p = 0.50).
In conclusion, low-dose penicillin may be effective for thereduction in risk of subsequent leg cellulitis in the 12 monthsafter initial infection, but protection seems to wane after cessa-tion of therapy.
[Lauren M. Abbate, MD, PHDDenver Health Medical Center, Denver, CO]
Comment: This study suggests that low-dose penicillin mayreduce the time to recurrence of leg cellulitis; however, therapylikely needs to be maintained to obtain benefits. Furthermore,penicillin seems to be safe, with no difference between groupsin adverse events. This study assumes that most infections aredue to penicillin-susceptible streptococci. It is possible that re-current infections, especially among those with multiple recur-rences, may include resistant strains or non-streptococcalorganisms, and future studies should include culture for organ-isms as well as different classes of antibiotics for those who arepenicillin allergic.
, POSITIONPAPERUPDATE:GASTRICLAVAGEFORGASTROINTESTINAL DECONTAMINATION. BensonBE, Hoppu K, Troutman WG, et al. Clin Toxicol (Phila) 2013;51:140–6.
The objective of this study was to summarize previous rec-ommendations for the use of gastric lavage in poisoned patientsand to review new data since the previous position paper waspublished in 2004.
The expert panel was appointed by the American Academyof Clinical Toxicology (AACT) and the European Associationof Poisons Centres and Clinical Toxicologists (EAPCCT). Thepanel performed a comprehensive literature search for gastriclavage in both human and animal studies from January 2003to March 2011, yielding 683 articles. Of these, 69 were evalu-ated in greater depth, and, ultimately, 15 articles were included.
Since 2004, there have been no new studies in animals ormarker studies in volunteers or poisoned individuals. However,there have been a few new case reports where gastric lavagemay be useful in cases of delayed absorption (i.e., sustained re-leased drugs, hypothermia). In addition, a systematic review of
several clinical studies conducted inChinawas performed, thoughthe resultswere inconclusive secondary to poormethodology.Ad-ditional studies from China suggest that gastric lavage may behelpful in tetramine poisoning; those were also methodologicallyflawed. Finally, since 2004, several studies have shown that gas-tric lavage is associatedwith complications including pneumonia,electrolyte abnormalities, and esophageal perforation.
In conclusion, gastric lavage should not be used routinely forthe treatment of poisoned patients; rather, activated charcoal orobservation and supportive care may be more appropriate.
[Lauren M. Abbate, MD, PHDDenver Health Medical Center, Denver, CO]
Comment: This position statement by the AACT and theEAPCCT provides updated information for clinicians for theuse of gastric lavage based on international data. Given thedearth of new evidence favoring gastric lavage and the increasein data suggesting complications with the procedure, routine useof gastric lavage seems to be waning.
, POSITION PAPER UPDATE: IPECAC SYRUP FORGASTROINTESTINAL DECONTAMINATION. Hojer J,Troutman WG, Hoppu K, et al. Clin Toxicol (Phila) 2013;51:134–9.
The goal of this systematic review article was to summarizerecommendations for the use of ipecac for treatment of acutetoxic ingestions. The authors referenced a position paper pub-lished in 2004 and aimed to compare this article with the currentliterature.
The 2004 position paper concluded that ipecac had little ben-efit and may result in further complications. This position paperdid recommend the use of ipecac in very rare situations. For ex-ample, in cases where there is a risk of serious toxicity and noavailable alternative therapy.
The authors conducted a search of the literature using fivedifferent search engines with dates ranging from 2003 to March31, 2011. Of 157 articles, 42 were included. Review articleswere excluded.
The authors found that since the 2004 study, no new animal,volunteer, or marker studies have been published. One case re-port was cited showing a benefit of ipecac reducing iron pills af-ter ingestion from 50 to 9 tablets. A retrospective cohort from1995–2005 was reviewed in which children younger than 6years ingested mushrooms. In this study, ipecac was comparedto activated charcoal vs. no gastrointestinal decontamination.The study showed no major differences in the three treatments,although the study was difficult to interpret as 99.3% of childrenhad positive outcomes.
Complications of ipecac include delay in the administrationof activated charcoal by 1–2 h, diarrhea, lethargy, prolongedvomiting, aspiration, pneumomediastinum, and Mallory-Weisstears. A 1989 study showed a higher complication rate in pa-tients receiving ipecac and activated charcoal vs. activated char-coal alone. More recent publications show an associationbetween the abuse of ipecac by patients with eating disordersand myopathy or cardiomyopathy.
The authors conclude that there is not sufficient evidence towarrant any change to the 2004 position paper recommendations.
