Bicitra for Esophageal Obstruction

[narcusprince]

Hyopthetical case 36 y/o female with a piece of chicken lodged in the esophageous. Otherwise healthy of note heavy drooling and patient is wretching and spitting up mucous in emesis basin. Surgeon wants to scope to remove obsturuction would you adminster bicitra? RSI is definely the answer however what adjuncts would you add?What about glycopyrollate pre-op?

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[Arch Guillotti]

No. Why would you give it?

Glyco seems ok.

 

[narcusprince]

Thought process here is I am not sure where the secretions are coming from are they gastric as result of a partial obstruction of the esophageous resulting in reflux of gastric contents or is it solely oral secretions with an inablility to clear those oral/esophageal secretions. Their is a risk that it will add to the wretching and vomiting which could ultimatley lead to a bourheve esophageal tear. The greatest risk though is aspiration of gastric/esophageal/oral secretions and without knowing the pH of the secretions I would assume its all gastric and adminster a non-particulate antacid.

 

[bigdan]

Narc -

Hey! How's married life, big timer?

I definitely wouldn't give the Bicitra. I realize it was probably less than half, but it felt like ALL the women we gave Bicitra to pre-caesarean ended up throwing up right away - seems like the chicken bone would be a huge issue (as you'd mentioned) if they strained against that while retching. Moreover, if it is an obstruction, you're simply adding more volume to a tube with no passage...seems like that'd increase her risk too.

*Thread hijack* - I'm at CCF now, Narc. It's a, um, "busy" fellowship in the Miller Building...

 

[Numbex]

I hate esophageal motility / obstruction cases. They're the pits and can burn you no matter what you do.

Glycopyrrolate seems reasonable, although if you're planning on intubating you'll need to give it well ahead of time in order for it to do you some good- if it does help, it will only be to cut down on the annoying secretions before you tube.

As far as Bicitra goes, not only no but hell no. Your patient is drooling. They are already not swallowing their own spit. Why add more volume to that? It won't go anywhere helpful and as mentioned could provoke retching which could make things a whole lot worse.

I haven't used Bicitra since residency anyway. Always thought it was kind of voodoo and an unnecessary addition to gastric volume.

 

[Doctor4Life1769]

I hate esophageal motility / obstruction cases. They're the pits and can burn you no matter what you do.

Glycopyrrolate seems reasonable, although if you're planning on intubating you'll need to give it well ahead of time in order for it to do you some good- if it does help, it will only be to cut down on the annoying secretions before you tube.

As far as Bicitra goes, not only no but hell no. Your patient is drooling. They are already not swallowing their own spit. Why add more volume to that? It won't go anywhere helpful and as mentioned could provoke retching which could make things a whole lot worse.

I haven't used Bicitra since residency anyway. Always thought it was kind of voodoo and an unnecessary addition to gastric volume.

I agree. I have not been a huge fan of bicitra because of the taste and propensity to vomit, in addition to adding gastric volume. I understand the benefits, but often times I wondered if the benefits even outweighed the potential risks. As a resident, do as told, policy, etc. blah blah blah.

 

[IlDestriero]

No way.

 

[epidural man]

Give zantac IV for the same result.

I know zantac increases sphincter tone - however, it doesn't sound like the object is passing anyway. I doubt it would make surgical fix more difficult.

 

[narcusprince]

Big D, life is good. Hope the clinic is teaching you well. I really do miss that place very special envirorment and awesome resources and GREAT staff members. If Dr Trombetta is still there tell him he still cannot bench press more then me 🙂 Hope all is well old friend!
As to the rest of this tread thanks fellas for your input. Esophageal obstruction cases are the pits can either take 20 minutes or 6 hours depending upon how macerated the food is. Essential the endoscopist removes slivers and uses multiple different basket/retrival devices to snare said object non of the objects used were designed for retrieving food out of the esophagous.

 

[Planktonmd]

Don't give anything

 

[Sleepdoctor53]

I hate esophageal motility / obstruction cases. They're the pits and can burn you no matter what you do.

Glycopyrrolate seems reasonable, although if you're planning on intubating you'll need to give it well ahead of time in order for it to do you some good- if it does help, it will only be to cut down on the annoying secretions before you tube.

As far as Bicitra goes, not only no but hell no. Your patient is drooling. They are already not swallowing their own spit. Why add more volume to that? It won't go anywhere helpful and as mentioned could provoke retching which could make things a whole lot worse.

I haven't used Bicitra since residency anyway. Always thought it was kind of voodoo and an unnecessary addition to gastric volume.

You are right on. Not only is bicitra extra volume, it's also extra acid with a pH of 4.2 (citric acid). Better than stomach acid, but probably not as good as 30 cc water.

 

[pgg]

You are right on. Not only is bicitra extra volume, it's also extra acid with a pH of 4.2 (citric acid). Better than stomach acid, but probably not as good as 30 cc water.

Bicitra isn't citric acid.

 

[BuzzPhreed]

You are right on. Not only is bicitra extra volume, it's also extra acid with a pH of 4.2 (citric acid). Better than stomach acid, but probably not as good as 30 cc water.

Is this post a joke? I hope so. Otherwise it's one of the stupidest things I've read on this forum in the past year... or longer. (Trolling?)

 

[Mman]

You are right on. Not only is bicitra extra volume, it's also extra acid with a pH of 4.2 (citric acid). Better than stomach acid, but probably not as good as 30 cc water.

So Bicitra is only what, 150 times less acidic than stomach acid? Not exactly water, but you'd be better with 30 mls of bicitra + 1 ml of stomach acid compared to just 1 ml of stomach acid.

That said I wouldn't give Bicitra for this particular case.

 

[deleted171991]

Actually 10^2.7 = 501. So it's 500 times less acidic than a stomach pH of 1.5.

The oral solution contains sodium citrate/citric acid in a dose of (500mg/334mg)/5mL or (490mg/640mg)/5mL. That's about 2mMol of sodium citrate and 1.74 vs 3.33 mMol of citric acid.

At a pH of 1.5, the stomach contains 0.031 mMol of H(Cl) per liter. That can be very nicely neutralized by the sodium citrate, generating the much less acidic citric acid.

 

[G0S2]

Narc -

Hey! How's married life, big timer?

I definitely wouldn't give the Bicitra. I realize it was probably less than half, but it felt like ALL the women we gave Bicitra to pre-caesarean ended up throwing up right away - seems like the chicken bone would be a huge issue (as you'd mentioned) if they strained against that while retching. Moreover, if it is an obstruction, you're simply adding more volume to a tube with no passage...seems like that'd increase her risk too.

*Thread hijack* - I'm at CCF now, Narc. It's a, um, "busy" fellowship in the Miller Building...

Did that today. STAT C section. Bicitra in and vomiting 2 mins after. Awesome .

 

[deleted171991]

Did that today. STAT C section. Bicitra in and vomiting 2 mins after. Awesome .

Ta-da, almost NPO. And some people have doubts about bicitra... 😀

 

[Mman]

Actually 10^2.7 = 501. So it's 500 times less acidic than a stomach pH of 1.5.

Stomach acid varies in pH between about 1 and 3. I was being conservative with my estimate.

 

[BuzzPhreed]

Bicitra = totally unnecessary in the practice of anesthesia.

One of the CRNAs I worked with at a particular job (who happened to think she was the shiznit) used to give the following for every c-section she was involved in (I'm not making this up):

• Bicitra 30mL P.O.
  
• Reglan 10mg IV
  
• Zofran 4mg IV
  
• Pepcid 20mg IV
  
• Promethazine 6.25mg IV

These were given before the baby was out. For the life of me I can't figure out how or why she thought this was a good idea. Usually keeping the SBP > 100 suffices. And fentanyl in your spinal mix. But no one could tell her that.

 

[deleted171991]

Stomach acid varies in pH between about 1 and 3. I was being conservative with my estimate.

Sorry. I was being a wiseguy.

 

[Mman]

Bicitra = totally unnecessary in the practice of anesthesia.

So you believe there is no use for it and that it harms (or doesn't add anything for) patients?

 

[BuzzPhreed]

It doesn't add anything. Except extra gastric contents.

 

[Mman]

It doesn't add anything. Except extra gastric contents.

I think that answer would be considered incorrect on oral boards and be argued against by every major textbook in the field. But that's just me.

 

[BuzzPhreed]

By the way, this is just about the stupidest rationale for using antacids. And I quote (page 846):

"The literature does not sufficiently examine the relationship between reduced gastric acidity and the frequency of emesis, pulmonary aspiration, morbidity, or mortality in obstetric patients who have aspirated gastric contents."

Interpretation: We haven't really studied this adequately.

And, then they say...

"The consultants and ASA members agree that the administration of a nonparticulate antacid before operative procedures reduces maternal complications."

Interpretation: Derp... err... duh... we're experts and it makes sense so just do it.

http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-obstetric-anesthesia.pdf#search="sodium citrate c-section practice guidelines"

But, then you go to the standard perioperative fasting guidelines (p. 499-500)...

"Both the consultants and ASA members disagree that gastrointestinal stimulants should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e., monitored anesthesia care) in patients who have no apparent increased risk for pulmonary aspiration."

http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-preoperative-fasting.pdf#search="bicitra c-section practice guidelines"

So the basic questions are is a non-sedated and spinalized women who can protect her own airway really at increased risk for pulmonary aspiration. And, if they suddenly need to be intubated is that extra gastric volume going to hurt you or help you, especially when they admit that such a relationship between antacids and improved outcome has not been sufficiently studied.

I don't routinely use the stuff personally. If some lady is telling me that she is having horrible heartburn right before we go back for a scheduled c-section, I might consider it. Might.

More voodoo.

 

[BuzzPhreed]

I think that answer would be considered incorrect on oral boards and be argued against by every major textbook in the field. But that's just me.

Well, I passed the boards 7 years ago. And if you're asked such a question, you just have to be able to justify your answer... if you're asked to. I've provided links to the relevant information. We're supposed to be practicing evidence-based medicine. And both links clearly indicate that it is expert opinion and not evidence-base that the recommendations are based on.

Voodoo.

 

[Mman]

Well, I passed the boards 7 years ago. And if you're asked such a question, you just have to be able to justify your answer... if you're asked to. I've provided links to the relevant information. We're supposed to be practicing evidence-based medicine. And both links clearly indicate that it is expert opinion and not evidence-base that the recommendations are based on.

Voodoo.

And I believe that if you attempted to argue that Bicitra was harming the patient your examiner would disagree with your reasoning.

Voodoo? I'm going to go ahead and disagree. Lots of evidence suggests that Bicitra decreases the pulmonary complications of aspiration. No evidence that it increases the risk of aspiration.

 

[Planktonmd]

Bicitra might be theoretically useful in certain circumstances but most of the time it's not necessary.

 

[Mman]

Bicitra might be theoretically useful in certain circumstances but most of the time it's not necessary.

Most patients obviously do not require it. If somebody tells me they can't lay flat at night because of their reflux despite meds, I give it to them. If they tell me they get heartburn when they eat certain foods, I just don't care.

 

[BuzzPhreed]

And I believe that if you attempted to argue that Bicitra was harming the patient your examiner would disagree with your reasoning.

Where did I ever say it harmed a patient? I just said it has never been proven to help. It tastes awful. Patients hate it. And you are putting more contents into the stomach. Not for routine use.

Voodoo? I'm going to go ahead and disagree. Lots of evidence suggests that Bicitra decreases the pulmonary complications of aspiration. No evidence that it increases the risk of aspiration.

Okay. Show me.

 

[Mman]

Okay. Show me.

You've never seen the mountains of evidence that an aspiration event with bicitra is better than without? Oh vey. I'm too lazy to look them up but it's basically animal models over and over. Can't really do it on humans since it'd be kinda unethical to make people aspirate.

 

[deleted171991]

This is beyond common sense. One can decrease the impact of aspiration by two means: decreasing acidity and decreasing volume. First means nonparticulate antacids and/or IV H2-blockers. The second means NPO, OG tube and promotility agents. Pick your poison.

 

[BuzzPhreed]

This is beyond common sense.

^^ This is the attitude that breeds dogma. There is a vast catalog of examples where what seemed to "make sense" was just flat-out wrong.

There is little evidence that aspiration of non-food/non-particulate bilious contents into the trachea during peri-intubation actually routinely causes significant harm, especially when the endotracheal tube is immediately suction following intubation. Protracted or significant aspiration pneumonitis is a rare event after such instances. And, in the cases where this occurs and voluminous gastric contents are aspirated, Bicitra is not going to meaningfully impact this anyway.

Again even the ASA practice guidelines admit this. It's the same mentality that BladeMDA railed against in the mandatory flu vaccine thread. It's the "may help, won't hurt" dogma that is, in my opinion, not challenged enough when the law of unintended consequences, evidenced by the occasional (not rare) patient vomits immediately after having to choke-down that ****, that we should strive to avoid.

There are no data to show improved outcome after the use of antacids, H2 receptor blockers, proton pump inhibitors or prokinetics. Most studies suggest improved safety from reduced gastric volume and/or increases in gastric pH. As there is no evidence to indicate the value of antacids or other means of increasing gastric pH, or of prokinetic therapy, a formal cost:benefit calculation is not possible.

Apart from a concern about aspiration of particulate matter causing hypoxia and death in the general surgical patient, and more so in the obstetric patient, are anaesthetists right in their fear of aspiration? The frequent use of pH increasing drugs or gastric volume reducers for premedication is of no proven benefit, may be harmful and is at present unwarranted.

http://bja.oxfordjournals.org/content/83/3/453.full.pdf

 

[deleted171991]

Oh, I don't support it as a guideline or standard of care. Hence the "pick your poison" conclusion. But even in the case you pointed out, in which the stomach might actually be full of bile, bicitra would add only 5 ml, less than the "sip of water" we allow patients to take their PO meds with.

I am not a big fan of "evidence-based medicine" that goes against logic. Most of the time, this is the kind of "science" that gets disproved in time. Of course, best would be quality evidence with a highly-believable scientific explanation.

Btw, I don't use any of these in my practice, except for metoclopramide occasionally (in obese or nervous patients).