Pt. drank po barium contrast - how long do you wait for NPO?

[Laurel123]

Couple attendings were arguing about this. It is a random subject... but I thought I would ask you guys what you thought?

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[dhb]

follow progression with serial x-rays 😀

 

[VentdependenT]

Its safer to aspirate barium (inert substance) than gastrografin (hypertonic stuff which can cause severe pulmonary edema).

What happens if you do aspirate it? You get a big fat shunt and your patient gets hypoxic. Who cares if it doesn't cause aspiration pneumonitis (if it truely is the only thing aspirated) your patient is still going to be hypoxic. I suppose you can try and suction that crud out with a bronchoscope in Trendelenberg.

After finding out WHY the patient had the study I'm still most likely going to wait the full 8 if the case is elective. I'm sure I'll change my mind once I'm in practice for a while. Or maybe I won't.

 

[Planktonmd]

Couple attendings were arguing about this. It is a random subject... but I thought I would ask you guys what you thought?

If emergency then no wait.
Otherwise 8 hours.
Barium in the lungs is very bad.

 

[Fastrach]

On a related note, I had a case cancelled this last week that I wanted some other opinions on. EGD under GA for otherwise healthy 14yo girl with a belly ache. Pt ate TWO cheetos that morning. Set to go at 1 pm. Staff cancelled it. Seemed to be going a little overboard to me... would you have cancelled it as well, and if so, why?

 

[Orthonut]

Thought you might be interested in this case-we recently saw and had occasion to do thoracic radiographs on a pt (cat) that had previous suspicion of barium aspiration 3 years ago-pt was suctioned w/trendelenberg positioning etc at the time of the aspiration-Today the barium still shows very obviously on the thoracic rads.


/hijack

 

[ketafol]

On a related note, I had a case cancelled this last week that I wanted some other opinions on. EGD under GA for otherwise healthy 14yo girl with a belly ache. Pt ate TWO cheetos that morning. Set to go at 1 pm. Staff cancelled it. Seemed to be going a little overboard to me... would you have cancelled it as well, and if so, why?

See a lot of that were I am at. When I question their rationale, "age" comes into big play. Most seem to be much more defensive and irrational in the pediatric population.

 

[VentdependenT]

Thought you might be interested in this case-we recently saw and had occasion to do thoracic radiographs on a pt (cat) that had previous suspicion of barium aspiration 3 years ago-pt was suctioned w/trendelenberg positioning etc at the time of the aspiration-Today the barium still shows very obviously on the thoracic rads.


/hijack

Yup. That stuff doesn't go anywhere.

 

[BISof60]

If the kid really ate only two cheetos that morning, then yes, perhaps a bit overboard.

I'd probably do the case anyway but I know alot of people that are cautious when the story doesn't make sense, esp. in peds:
I rarely wake up in the morning with a belly ache and start eating cheetos.
Also, I don't know anyone that eats only two and stops. Personally, I eat them by the handful.

Why is a healthy 14 y/o having a EGD for a belly ache?

 

[Laurel123]

Contrast, while a milky looking substance, is a liquid. It is often drank for CT's for people with possible appendicitis. As a result, we are all often presented with patients that have appendicitis and need an appy, that haven't had food in a day, but have had barium po within the last few hours. And unless the patient is toxic - these appys can technically wait a few extra hours. (We often wait for the surgeons to finish their dinner, tuck in their kids, then come in and officially book the case).

So there is a risk/benefit issue to consider. Obviously, if the patient drank contrast and then needed a breast biopsy - we wait a day. But, contrast should pass through quickly - when is it realistically gone enough to proceed with urgent surgery?

 

[Planktonmd]

Contrast, while a milky looking substance, is a liquid. It is often drank for CT's for people with possible appendicitis. As a result, we are all often presented with patients that have appendicitis and need an appy, that haven't had food in a day, but have had barium po within the last few hours. And unless the patient is toxic - these appys can technically wait a few extra hours. (We often wait for the surgeons to finish their dinner, tuck in their kids, then come in and officially book the case).

So there is a risk/benefit issue to consider. Obviously, if the patient drank contrast and then needed a breast biopsy - we wait a day. But, contrast should pass through quickly - when is it realistically gone enough to proceed with urgent surgery?

With appendicitis or any acute abdominal process you don't expect normal gastric emptying, so it really doesn't matter how long you wait.

 

[Planktonmd]

By the way these days most times the contrast medium is Gastrografin (water soluble Iodine based) and not Barium which makes it less dangerous in case of aspiration.

 

[core0]

By the way these days most times the contrast medium is Gastrografin (water soluble Iodine based) and not Barium which makes it less dangerous in case of aspiration.

I think that its worse. The absolutely worst case of chemical pneumonitis that I have ever seen was from gastrograffin. Although if you look at the literature there are several papers that essentially say "I never have a problem".

David Carpenter, PA-C

 

[s204367]

Overboard?? Absolutely foolish....I challange anyone to look at the evidence based medicine behind NPO status.......How many of you have seen a person aspirate without an ongoing acute abdomen, and even in that situation, how many have seen someone aspirate???


Who out there uses cricoid??? What is the evidence behind that???

Look into the ER literature, which is skewed somewhat, and see howmany patients underdo GA...what they call conscious sedation..on a full stomach and aspirate?? Near zero...

 

[dhb]

Overboard?? Absolutely foolish....I challange anyone to look at the evidence based medicine behind NPO status.......How many of you have seen a person aspirate without an ongoing acute abdomen, and even in that situation, how many have seen someone aspirate???

I've seen vomiting on induction without aspiration

Who out there uses cricoid??? What is the evidence behind that???

I don't think the evidence is strongly in favor of cricoid pressure

Look into the ER literature, which is skewed somewhat, and see howmany patients underdo GA...what they call conscious sedation..on a full stomach and aspirate?? Near zero...

Near 0 is not 0 and eating 2 cheetos is like drinking 2 beers 😉
Have a x-ray done 2h after the contrast has been given and you'll see where it is...

 

[Planktonmd]

Overboard?? Absolutely foolish....I challange anyone to look at the evidence based medicine behind NPO status.......How many of you have seen a person aspirate without an ongoing acute abdomen, and even in that situation, how many have seen someone aspirate???


Who out there uses cricoid??? What is the evidence behind that???

Look into the ER literature, which is skewed somewhat, and see howmany patients underdo GA...what they call conscious sedation..on a full stomach and aspirate?? Near zero...

Here is the deal:
We are held to a higher standard than ER physicians when it comes to aspiration, and we practice in a society where the right thing to do is what the majority of people (in a certain specialty) do, even if the scientific evidence is lacking.
So, you might think that there is no evidence supporting a certain practice but most of your peers are doing it and willing to testify against you if you don't and something goes wrong. This makes this practice a "standard of care" and you would be "foolish" if you don't do it.

 

[militarymd]

Overboard?? Absolutely foolish....I challange anyone to look at the evidence based medicine behind NPO status.......How many of you have seen a person aspirate without an ongoing acute abdomen, and even in that situation, how many have seen someone aspirate???


Who out there uses cricoid??? What is the evidence behind that???

Look into the ER literature, which is skewed somewhat, and see howmany patients underdo GA...what they call conscious sedation..on a full stomach and aspirate?? Near zero...

couldn't agree with s more.

 

[militarymd]

barium used to be used for "bronchograms"....it is utterly safe in the airway...unless you aspirate so much of it that you prevent air exchange.

 

[coprolalia]

Evidence base?

As with massive aspiration of gastric acid, the overall mortality rate associated with massive barium aspiration is approximately 30% and exceeds 50% in patients with initial shock or apnea, secondary pneumonia, or adult respiratory distress syndrome.

http://radiographics.rsnajnls.org/cgi/content/full/20/3/673

Although the aspiration of barium sulfate into the bronchial tree was once thought to be harmless, this assumption was based on the fact that low-density barium suspensions were used for bronchography. Moreover, serious consequences and even several deaths have been reported after the aspiration of either low-density or high-density barium by patients in all age groups, ranging from a two-month-old boy to elderly patients. There have been a number of experimental studies in animals in which barium has been shown to provoke a severe local reaction in the lung parenchyma. For example, in rats, barium caused a severe pulmonary inflammatory reaction. Furthermore, postmortem studies in two elderly women who died soon after the aspiration of barium demonstrated an intense acute inflammatory reaction characterized by neutrophil infiltrates in the alveolar spaces. Although one cannot rule out aspiration of gastric contents as a contributing cause of death in our patient, our aim was to stress that the aspiration of barium is potentially life-threatening because of its direct harmful effects on lung tissue.

http://content.nejm.org/cgi/content/full/348/25/2582?ck=nck

-copro

 

[militarymd]

copro,

you failed to cite the other "opinion" that was cited on that letters to the editor page.

Essentially you have 2 government doctors...one from the VA saying it is safe....and one from the NIH expressing his opinion that it is not safe based on a couple of case reports.

Whereas, there has been a long history of barium and its use involving the airway....I would have to say that the "evidence" goes with it's safety.

 

[coprolalia]

Well, the point is that there is opinion that it is safe, and there is evidence and data that suggest that it isn't.

-copro

 

[militarymd]

Well, the point is that there is opinion that it is safe, and there is evidence and data that suggest that it isn't.

-copro

case reports....

If you aspirate enough water you'll have a chemical pneumonitis...while at the same time saline/water is routinely used in BALs.

 

[coprolalia]

case reports....

If you aspirate enough water you'll have a chemical pneumonitis...while at the same time saline/water is routinely used in BALs.

But, what do you think about the data that shows that barium induces histopathologic changes within the intrapulmonary space? Bogus? Not clinically relevant? Does saline do this?

Unfortunately, based on these case reports I don't think that this is a phenomenon that will ever get studied prospectively. And, of course, there's always the possibility that prior use of barium in lungs for bronchography resulted in un/undereported of serious adverse events. Either way, the consensus was this practice should be stopped and that was likely for good reason.

-copro