International Variability in Gastrointestinal Decontamination With Acute Poisonings.

BACKGROUND AND OBJECTIVES: Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings to emergency departments. METHODS: This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists' recommendations. Multivariate logistic regression was performed to identify independent risk factors for performing GID procedures. RESULTS: We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1%-22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5%-51.2%), the GID procedure was considered appropriate, with significant differences between regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region where the intoxication occurred (P < .001). CONCLUSIONS: Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented.

[Six-year review of cigarette ingestion in children--gastric lavage versus medical observation].

During 2006, the Japan Poison Information Center received 2583 inquiries about ingestion of cigarette, which is the most frequent household products ingested by children in Japan. During 2001-2006, two hundred and seventy-six children under seven years of age ingesting cigarettes and its related substances presented to the emergency department in Japan Red Cross Hospital Wakayama Center. The peak age was one year and younger, so-called "ingestion age". Patients were frequently detected chewing cigarettes and the situation of cases varied individually. It was impossible to estimate the amount of ingested cigarette based on the medical interview. Eighty-three percent of the patients were asymptomatic. Treatment strategy has been changed into a noninvasive one. Gastric lavage has not been performed by emergency physicians since 2001, and by pediatricians since 2006. After the medical observation for two hours following ingestion, all the children except one (who was hospitalized because of his family's request) were discharged from the emergency department. Independent of doing gastric lavage, all the 276 children had good prognosis. We conluded that ingestion of cigarette in children is generally benign. No gastric lavage, but medical observation for two hours following ingestion in emergency department is our recommendation of management.

Is syrup of ipecac still for sale? Comparison of pharmacies in a large urban area--2003 versus 2005.

There has been considerable publicity about the lack of benefit and potential dangers of syrup of ipecac. In November 2003, the American Academy of Pediatrics recommended against its use. Pharmacies in Houston, Texas were surveyed by telephone before (survey 1) and after (survey 2) the American Academy of Pediatrics' recommendation to determine whether ipecac availability changed. There were 126 pharmacies interviewed at survey 1, and 128 interviewed at survey 2. Pharmacies in survey 1 were more likely than those in survey 2 to sell ipecac (79% versus 64%, P < .01) and to have it in stock (75% versus 48%, P < .001). Pharmacies mostly stored ipecac on the shelves (67%, survey 1; 59%, survey 2, P = .27). Although syrup of ipecac availability has declined significantly, it is still available in more than 50% of pharmacies. Health care providers should advise against its use and advocate that pharmacies remove it.

Differences in treatment advice for common poisons by poisons centres--an international comparison.

OBJECTIVE: To investigate how poisons centres advise on management of common drug poisonings and compare advice on gut decontamination with the EAPCCT/AACT Position Statements. METHODS: An interactive questionnaire was sent to 14 poisons centres asking about working practices, "top 20" enquiries in 2002, and management of 4 specific drug poisonings. RESULTS: Replies were received from centres in 11 countries. Annual telephone enquiry numbers varied from 620 (Sri Lanka) to over 50,000 (Germany for 2000). Recommendations for gut decontamination for acetaminophen poisoning were: activated charcoal (AC) alone (5 centres); gastric lavage (GL) alone (1); AC and/or GL (3); AC, GL and/or ipecac (2). Only 40% (4/10) recommended AC and 50% (3/6) GL within 1 hour. Intervention doses for gut decontamination ranged from 100-200 mg/kg (nine centres) and for "high-risk" groups 75-100 mg/kg (3). Plasma concentration for N-acetylcysteine (NAC) treatment ranged from 150 mg/L (four centres) to 200 mg/L (6) at 4 hours. Results were similarly varied for three other common drug poisons (benzodiazepines, amitriptyline, and paroxetine). CONCLUSIONS: Most poisons centres have protocols that differ in terms of gut decontamination, timing, and intervention doses. Many centres recommend charcoal or gastric lavage after the 1-hour limit proposed in the Position Statements. There is scope for rationalization of approaches to the management of common poisons.

The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives.

OBJECTIVE: To describe the frequency of alternative medication use in bulimia nervosa (BN), and to review available nonprescription emetic (ipecac) and laxative products and their potential toxicities. METHOD: Survey data were collected from 39 consecutive treatment-seeking patients with BN or subthreshold BN. Survey data of the available nonprescription and herbal products from local retail stores were also collected. Toxicology information was reviewed on these agents from MEDLINE and herbal textbooks. RESULTS: Ipecac use occurred in 18% of the 39 patients. Laxatives had been used at some point to control weight or "get rid of food" by 67% of the patients. Of these, 31% had abused laxatives during the month prior to evaluation. In the product survey, 248 laxative-containing products were identified. CONCLUSION: There are numerous laxative products readily available to patients, and many of them have significant associated toxicities. Patients with BN tend to endorse high rates of laxative use. While ipecac is used infrequently, it can have deleterious consequences. Patients with BN should be screened for use of both ipecac and laxatives and should be educated about the potential consequences associated with the misuse of these agents.

Gastrointestinal decontamination.

Overall, no conclusive data support the use of gastric decontamination in the routine management of the poisoned patient. Studies of asymptomatic patients suggest that no treatment is required, and, given the complications that have been reported, this may be a reasonable approach to' most patients. Even in symptomatic patients, the only demonstrable benefit was found in a post-hoc subgroup analysis and involved an outcome of questionable clinical importance. Given these data, it would be easy to conclude that GI decontamination has no role in the management of the poisoned patient. This conclusion is valid when considering poisoned patients as a group, but all poisoned patients are not the same. Patients with trivial ingestion do well without treatment, and their greatest risk is an iatrogenic complication. Even patients with more serious ingestions usually have good outcomes with supportive care alone. It is no longer sufficient to justify GL or forced administration of AC with the supposition that "the patient could have taken something bad." However,there are some overdoses where limiting the systemic absorption of the poison may limit the toxic effects and prevent serious toxicity. After careful consideration of the risks, GI decontamination should be targeted at patients who, in the opinion of the treating physician, have a potentially life-threatening exposure.

Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons.

The use of gastric emptying techniques, including ipecac-induced emesis, in the management of poisoned patients has declined significantly in recent years. Historically, poison centers used ipecac syrup in two ways. Ipecac syrup was administered to patients prior to referral to the emergency department in attempts to start the gastric emptying process as early as possible. Additionally, poison centers used ipecac syrup in attempts to keep patients from requiring referral to medical facilities. In these situations, ipecac syrup was administered in the home and poison center staff performed follow-up telephone calls to gauge progress and outcome. Studies to determine the effectiveness of ipecac syrup demonstrate that it induces vomiting in a high percentage of people to whom it is administered and that it decreases the gastrointestinal absorption of ingested substances in a time-dependent fashion. However, the effectiveness of ipecac syrup in affecting patient outcome has not been studied in adequate clinical trials. Its effectiveness in preventing drug absorption has only been documented for a limited number of substances and is substantially reduced if it is given more than 30-90 minutes following ingestion of the toxic material. There are potentially significant contraindications, adverse effects and related problems associated with the use of ipecac syrup. It is the consensus of the panel that the circumstances in which ipecac-induced emesis is the appropriate or desired method of gastric decontamination are rare. The panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations in which: there is no contraindication to the use of ipecac syrup; and there is substantial risk of serious toxicity to the victim; and there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal); and there will be a delay of greater than 1 hour before the patient will arrive at an emergency medical facility and ipecac syrup can be administered within 30-90 minutes of the ingestion; and ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. In such circumstances, the administration of ipecac syrup should occur only in response to a specific recommendation from a poison center, emergency department physician, or other qualified medical personnel. The panel decided not to address the issue of whether ipecac should remain a nonprescription, over-the-counter product. The panel does not support the routine stocking of ipecac in all households with young children but was unable to reach consensus on which households with young children might benefit from stocking ipecac. Instead, the panel concluded that individual practitioners and poison control centers are best able to determine the particular patient population, geographic and other variables that might influence the decision to recommend having ipecac on hand.

Position paper: Ipecac syrup.

Syrup of ipecac should not be administered routinely in the management of poisoned patients. In experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned. There are insufficient data to support or exclude ipecac administration soon after poison ingestion. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. Ipecac should not be administered to a patient who has a decreased level or impending loss of consciousness or who has ingested a corrosive substance or hydrocarbon with high aspiration potential. A review of the literature since the preparation of the 1997 Ipecac Syrup Position Statement revealed no new evidence that would require a revision of the conclusions of that Statement.

Evaluation of the time frame for home ipecac syrup use when not kept in the home.

INTRODUCTION: The home administration of ipecac syrup remains a recommendation in some guidelines for the management of specific pediatric poisonings. A common challenge for poison specialists is how to approach the situation when ipecac syrup is indicated but not kept in the home. This study examines whether or not ipecac syrup can be administered and produce timely emesis in this situation. METHODS: Over a 6-month period, a prospective observational study was undertaken to determine if ipecac syrup can be administered in a timely manner when it is indicated but not available in the home. Cases where ipecac syrup was indicated but not kept in the home were included if parents stated that they could obtain ipecac within 15 minutes. Timely administration and the onset of emesis were defined as < 30 min and < 60 min, respectively. RESULTS: During our study 14,603 human exposures were evaluated; ipecac syrup was recommended by a poison specialist in 75 cases, and 25 of these were included in our study. Ages ranged from 1 to 6 years. The mean time to administration of ipecac from exposure time was 40 min (SD +/- 14 min). Administration of ipecac syrup occurred in < 30 min in 20% of the cases. The mean time to first emesis from exposure was 58 min (SD +/- 13). Initial emesis occurred in < 60 min in 36% of the cases. CONCLUSIONS: Ipecac syrup was rarely recommended by our center and was frequently unavailable when it was recommended. Ipecac syrup often could not be administered in a timely manner because it was not kept in the home. Parents of pediatric patients who have a significant ingestion should not be referred to purchase ipecac syrup.

Single dose pharmacokinetics of syrup of ipecac.

Syrup of ipecac (SI) has been used medicinally since the 1500s; however, little is known about the pharmacokinetics in humans of SI's active ingredients, emetine and cephaeline. The objective of this study was to evaluate the rate of absorption and the rate of elimination of emetine and cephaeline. Ten healthy, adult, human volunteers between 18 and 45 years of age who were of ideal body weight (body mass index 20-25) completed this study. After an overnight fast, 30 mL SI were ingested. Blood samples were collected 30, 45, 60, 90, 120, 150, and 180 minutes post-ingestion and urine was collected throughout the study period. Plasma and urine concentrations of emetine and cephaeline were measured by reverse-phase HPLC with fluorescence detection. In virtually all subjects, emetine and cephaeline were detected within 5-10 minutes of dosing with the time to maximum concentration being approximately 20 minutes. The mean areas under the concentration-time curve (AUC) for both emetine and cephaeline were similar; however, the ratio of mean cephaeline maximum concentration (Cmax) to emetine Cmax was approximately 1.5. Four of the ten subjects exhibited a type of concentration-time profile in which the levels of cephaeline were substantially higher than those of emetine and the levels of cephaeline were substantially higher than noted for the other six subjects. In these remaining six subjects, the levels of emetine and cephaeline were lower than 10 ng/mL at all time-points. An initial elimination phase was noted in some subjects but not in others. Individuals in whom an initial elimination phase was not observed also exhibited low levels of both alkaloids as compared with the other subjects suggestive of a slower distribution phase. Less than 0. 15% of the administered emetine and cephaeline was recovered in the urine at 3 hours. No relationship between vomiting episodes and peak concentrations of emetine or cephaeline was found. Administration of SI results in rapid appearance and disappearance of emetine and cephaeline in plasma becoming almost undetectable at 3 hours. Very little of either alkaloid is eliminated in the urine within this time period, suggesting extensive distribution. The length of time that an administered dose of SI can result in the detection of emetine and/or cephaeline in the urine has not been determined; future studies in humans are required.