I'm not sure I'd call 2L of PEG a clear and go at 2 hours. They should do a study with stomach volumes with the new protocol at 2 hours.
You don't want to aspirate it.
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Polyethylene glycol solution (PEG) is a purgative solution most commonly used for bowel preparation in both adults and children. Nasogastric infusion of PEG is considered a safe and effective means of administration when patients cannot or will not take the solution orally. Nausea, vomiting, and bloating are commonly reported adverse reactions. We present an 8-year-old girl with life-threatening respiratory failure after aspiration of PEG, which was treated successfully by bronchoalveolar lavage.
The patient was an 8-year-old girl with chronic abdominal pain. Two months before her current admission, she was diagnosed with fecal impaction and had a successful disimpaction with PEG solution. Because her abdominal pain had continued, the patient was admitted to a regional hospital for intestinal lavage and colonoscopy. A nasogastric tube was placed with difficulty and PEG solution was infused via the nasogastric tube. No radiographic verification of the position of the nasogastric tube was obtained. The patient subsequently vomited several times. Two hours after starting the infusion, the patient experienced difficulty breathing, chest pain, and tachypnea, which became worse during the following few hours. Oxygen saturation was 70% on room air. Respiratory rate was 50 to 70 breaths per minute. The patient was placed on supplemented oxygen therapy, up to 100% oxygen via a non-rebreathing mask. Arterial blood gas obtained while the patient was on 100% oxygen supplement showed pH 7.38, pCO 2 38 mm Hg, paO 2 93 mmHg, BE-2 and HCO3-22. Chest roentgenogram revealed bilateral apical and basilar diffuse pulmonary infiltrates and demonstrated that the nasogastric tube was kinked, with its tip in the mid esophagus (Fig. 1). Furosemide and ampicillin plus sulbactam were started.
Fig. 1 Image Tools
The patient was transferred to our institution, approximately 12 hours after the incident began. On arrival in our pediatric intensive care unit, the patient was tachypneic with a respiratory rate of 36 and moderate intercostal retractions. Oxygen saturation was 80% in room air. Because of the significantly increased work of breathing and impending respiratory failure, the facial mask was changed to bi-level positive airway pressure ventilation. A repeated chest roentgenogram demonstrated continued bilateral pulmonary infiltrates (Fig. 2). Methylprednisolone and clindamycin were administered intravenously.
Fig. 2 Image Tools
Because of the nonabsorbable nature of PEG, the patient's deteriorating condition and inability to oxygenate appropriately on bi-level positive airway pressure, we decided, 15 hours after the incident, to perform bronchoscopy with bronchoalveolar lavage (BAL). The patient's trachea was intubated, and a flexible fiberoptic bronchoscope BF-3C40 with a built-in suction channel of 1.2 mm was used. During bronchoscopy, diffuse inflammation and mucosal edema of the airways were seen. Bronchoalveolar lavage was performed, segment by segment, using a total amount of 750 mm normal saline. Copious amounts of bilayer pink and white thick fluid were removed. After BAL, the patient was mechanically ventilated for 16 hours, and her condition rapidly improved. The patient was extubated the following morning, 16 hours after the BAL, and oxygen supplementation was discontinued 20 hours later. A chest roentgenogram obtained 2 days after bronchoscopy showed an almost complete resolution of pulmonary infiltrates (Fig. 3).
Fig. 3 Image Tools
Four weeks later, results of repeat chest radiographs and pulmonary function tests were normal, and no sequelae from this incident were noted.
To our knowledge, this is first reported pediatric case of respiratory failure caused by PEG aspiration that was successfully treated with BAL. A compound solution of PEG, sodium chloride, sodium bicarbonate, potassium chloride, and sodium sulfate is a purgative laxative widely used for bowel cleaning and surgery preparation. It also has been recommended for preparation before colonoscopy, for treatment of constipation, and for gastrointestinal decontamination ( 1-6 ). Nasogastric infusion of PEG is considered to be a safe, effective alternative method of administration in cases where the patients cannot or will not tolerate oral ingestion ( 4,5 ). The safety and efficacy of PEG in adults as well as in children and infants is well established ( 7,8 ). The osmotic activity of this compound solution produces almost no net intestinal absorption or excretion. Therefore, large volumes may be used to induce diarrhea without significant change in fluid and electrolyte balance.
Engum et al. ( 9 ) found home administration of PEG for preparation of elective colonic procedures to be a safe, effective, and cost-efficient method, leading to a high degree of family satisfaction. Common adverse symptoms from PEG include nausea, abdominal fullness, and bloating. Although less common, allergic reactions ( 10 ), angioedema ( 11 ), colonic perforation ( 12 ), esophageal perforation ( 13 ), Mallory-Weiss tear ( 12 ), ventricular arrhythmia ( 14 ), and pancreatitis ( 15 ) have also been reported. Three cases of life-threatening aspiration after PEG lavage have been reported in children ( 16-18 ). All of these three cases involved young children in whom respiratory failure developed and who required intubation and prolonged mechanically assisted ventilation. Two of the cases involved an isotonic lavage solution ( 16,17 ). In the first case, respiratory failure was further complicated by significant hemodynamic instability, requiring volume expansion and continuous infusion of dopamine. The patient required mechanical ventilation for 3 days. In the second case, the authors could not rule out systemic fluid overload as a possible cause of the respiratory symptoms ( 17 ). Wong and Briars ( 18 ) recently reported a third case of PEG aspiration in a child. In this case, nasogastric tube placement was confirmed by auscultation and litmus testing. It was speculated that vomiting resulted in migration of the nasogastric tube into the esophagus. The patient experienced respiratory failure, requiring intubation and mechanical ventilation for 36 hours. The long-term pulmonary sequelae after prolonged ventilatory support and exposure to nonabsorbable toxic materials left in the lungs are yet unknown.
In adults, toxic pulmonary edema ( 19 ), adult respiratory distress syndrome, and even death have been reported after PEG aspiration. Bronchoscopy with bronchoalveolar lavage, concomitant with administration of systemic corticosteroid and positive pressure ventilation were performed successfully in one adult patient who recovered within 3 days after experiencing pulmonary edema induced by aspiration of PEG. Our patient improved dramatically after BAL and steroid administration. The patient was successfully extubated the following morning (16 hours after BAL), and oxygen supplementation was successfully discontinued 20 hours thereafter. Four weeks after discharge, results of repeated chest radiographs and pulmonary function tests were normal, and no sequelae from this incident were noted. We recommend that early bronchoscopy and BAL should be considered in pediatric patients who aspirate a significant amount of polyethylene glycol and in whom respiratory failure or rapid clinical deterioration develop. Using this approach may prevent pulmonary edema and parenchymal lung damage and lead to shortening of both the need for ventilatory support and overall hospitalization time. We also suggest that preventive measures such as careful verification position of nasogastric tube by obtaining a chest roentgenogram or by checking the pH of gastric aspirates be obtained before infusing potentially toxic materials. In the event of recurrent vomiting, tube position should be rechecked. Given the routine use of PEG solution, its presumed safety, and the paucity of case reports of severe complications, our case likely represents a rare, yet important, complication, in which the use of bronchoscopy and early BAL may prove to be beneficial.
Netherlands Journal of Medicine Fatal aspiration of polyethylene glycol solution de Graaf, P; Slagt, C; de Graaf, JLCA; Loffeld, RJLF Netherlands Journal of Medicine, 64(6): 196-198.
Respirology Aspiration pneumonia due to polyethylene glycol-electrolyte solution (Golytely) treated by bronchoalveolar lavage Hur, GY; Lee, SY; Shim, JJ; In, KH; Kang, KH; Yoo, SH Respirology, 13(1): 152-154. 10.1111/j.1440-1843.2007.01209.x CrossRef
Home > August 2003 - Volume 37- Issue 2 > Therapy for Pulmonary Aspiration of a Polyethylene Glycol So...
Journal of Pediatric Gastroenterology & Nutrition: August 2003 - Volume 37 - Issue 2 - pp 192-194 Case Reports
Therapy for Pulmonary Aspiration of a Polyethylene Glycol Solution
Liangthanasarn, Passara; Nemet, Dan; Sufi, Raminder; Nussbaum, Eliezer
Article Outline
Department of Pediatrics, Division of Pulmonary Medicine, University of California, Irvine, CA Received April 17, 2003; accepted April 30, 2003. Address correspondence and reprint requests to: Dr. Passara Liangthanasarn, Pediatric Pulmonary Division, 3rd Floor, Miller Children's Hospital, 2801 Atlantic Avenue, Long Beach, CA 90801 (e-mail:
[email protected]).
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CASE REPORT
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