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Toxicology - Whole bowel irrigation

Indications

Life-threatening toxic ingestion of sustained release or enteric coated preparations

Contraindications (absolute in bold)

Immediate resuscitation required

Good outcome expected with supportive care and antidote therapy alone

Vomiting

Ileus or intestinal obstruction

Uncooperative patient

Decreasing level of consciousness or risk of seizure (unless intubated)

Alternatives

Supportive care and antidote therapy

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Vomiting and diarrhoea (interfering with other interventions)

Pulmonary aspiration

Bowel obstruction with perforation

Metabolic acidosis

Distraction from resuscitation and supportive care priorities

Hypothermia (if solution not warmed)

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, aprons, protective eyewear

Area

Acute bed or resuscitation bay (depending on conscious level, expected course and risk assessment)

Staff

Procedural clinician

1:1 nursing required for at least six hours

Equipment

12g nasogastric tube with position confirmed by X-ray

Commode (severe diarrhoea expected)

Positioning

Sitting up or supine with head of bed elevated to at least 45 degrees

Commode nearby

Medication

Polyethylene glycol electrolyte powder (macrogol 3350 powder with electrolytes prewarmed to 37 degrees)

Water for mixing solution (up to 12 litres over six hours)

Metoclopramide 10mg IV

Ondansetron 4mg IV

Activated charcoal (depending on toxicology discussion)

Sequence

Toxicology discussion prior to starting therapy (call poisons information on 13 11 26)

Allocate an extra nurse to carry out the procedure (for up to six hours)

Place nasogastric tube for all patients, confirming position on chest X-ray

Consider activated charcoal 50g (children 1g/kg) via the nasogastric tube (if indicated)

Administer polyethylene glycol (PEG) solution via the nasogastric at 2l/hour (25ml/kg/hour in children)

Administer IV metoclopramide and ondansetron to minimise vomiting and to enhance gastric emptying

Continue irrigation until effluent is clear (this may take up to six hours)

Cease whole bowel irrigation if abdominal distension or loss of bowel sounds are noted

If vomiting occurs, reduce infusion rate by 50% for 30 minutes, then return to the original rate

Continue infusion until rectal effluent is clear or there is resolution of the toxic effect

Post-procedure care

Toxicology discussion (call poisons information on 13 11 26)

Maintain head up positioning and observe for vomiting

Supportive care and monitoring

Check electrolytes after treatment (electrolyte disturbance may occur)

Tips

Toxicology discussion is always recommended prior to whole bowel irrigation

Always confirm nasogastric position with an X-ray prior to administration of activated charcoal

Abdominal X-ray is useful to assess decontamination of radio-opaque substances (e.g. iron and potassium salts)

Discussion

The aim of whole bowel irrigation is to physically flush ingested toxins out of the gastrointestinal tract before absorption.

Whole bowel irrigation is potentially useful for:

Iron overdose >60mg/kg

Slow-release potassium chloride ingestion >2.5mmol/kg

Slow-release diltiazem and verapamil

Life-threatening slow-release verapamil or diltiazem ingestions

Symptomatic arsenic trioxide ingestion

Lead ingestion

Body packers

Patients with intact airway-protective reflexes may drink the solution, however nasogastric tube placement is recommended for all patients as the large volume and taste often limit intact. Unconscious intubated patients with may receive whole bowel irrigation via a nasogastric tube. Waste products may be passed on a commode or via a rectal tube (if intubated).

Toxicology discussion is recommended prior to this therapy, with additional discussion of whether 100g of activated charcoal should be added to each litre of irrigation solution. It is essential to carefully balance the possible benefits against the significant risk of aspiration and practical difficulties of administering whole bowel irrigation. Vomiting and profuse diarrhoea can interfere with timely retrieval and life-saving interventions.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Murray L, Little M, Pascu O, Hoggett KA. Toxicology handbook. 3rd ed. Sydney: Elsevier Australia; 2015.

eTG complete. Melbourne: Therapeutic Guidelines; 2012 Jul (updated 2018 Jul). Toxicology: general approach. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=toxicology-general-approach

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Hendrickson RG, Kusin S. Gastrointestinal decontamination of the poisoned patient. In: UpToDate. Waltham (MA): UpToDate. 2019 Mar 15. Retrieved Apr 2019. Available from: https://www.uptodate.com/contents/gastrointestinal-decontamination-of-the-poisoned-patient

Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015;53(1):5-12. doi:10.3109/15563650.2014.989326

Tenenbein M. Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):753-762. doi:10.3109/15563659709162571

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