What are the consequences of a failed gastric lavage?

Consequences of Failed Gastric Lavage

Failed gastric lavage can lead to serious complications including aspiration, perforation, hypoxia, hypotension, and even cardiac arrest, requiring immediate intervention to prevent further deterioration of the patient's condition. 1

Causes of Failed Gastric Lavage

• Buried bumper syndrome (BBS) where the internal fixation device of a gastrostomy tube migrates into the gastric wall, preventing proper flow 1
• Formation of gastric mucosa 'pockets' around the bumper of gastrostomy tubes, obstructing flow 1
• Excessive pressure between internal and external bolsters of gastrostomy tubes, leading to tube dysfunction 1
• Improper tube positioning or insufficient advancement into the stomach (ideally 5-10 cm) 1
• Technical complications related to guide wire placement in closed lavage procedures (42% of complications) 2
• Inadequate fluid return, which can occur in both open and closed lavage techniques 2

Potential Complications

Respiratory Complications

• Aspiration occurs in 0.3-1.0% of cases during gastric procedures, leading to hypoxia and hypotension 1
• Risk of aspiration is significantly higher when airway protective reflexes are compromised 3
• Aspiration of lavage fluid can lead to pneumonia, acute respiratory distress syndrome, and respiratory failure 4

Gastrointestinal Complications

• Perforation (complete laceration of the stomach) occurs in 0.5-1.3% of cases 1
• Esophageal impaction of the lavage tube has been reported, requiring endoscopic intervention 5
• Damage to gastric mucosa, especially when large volumes of fluid are used per cycle (200-1000+ ml) 4

Cardiovascular Complications

• Cardiac arrest has been observed as a direct complication of gastric lavage procedures 4
• Hemodynamic instability can occur, particularly in patients with pre-existing cardiovascular disease 4

Other Complications

• Failed source control in cases of peritonitis when lavage is used as the primary treatment 6
• Higher failure rates (57-60%) when using lavage alone for management of intraperitoneal gas or peritonitis 6
• Increased risk of intra-abdominal abscesses when laparoscopic lavage is used as the sole treatment for peritonitis 6

Management of Failed Gastric Lavage

Immediate Interventions

• Assess airway, breathing, and circulation immediately if complications occur 6
• For respiratory distress, provide supplemental oxygen and consider intubation if aspiration is suspected 4
• If perforation is suspected, obtain immediate surgical consultation 1

Technical Troubleshooting

• Gently rotate or reposition the tube while avoiding excessive manipulation 1
• Check for proper tension between bolsters - should be neither too loose nor too restrictive 1
• Consider switching from closed to open lavage technique if difficulties persist, as open technique has fewer technical complications (3% vs 25%) 2

Alternative Approaches

• For peritonitis cases where lavage has failed, consider surgical resection with or without anastomosis based on patient stability 6
• In hemodynamically unstable patients with peritonitis, damage control surgery with temporary closure (laparostomy) may be required 6
• For bariatric surgery complications, internal drainage approaches may be superior to lavage when perigastric collections are present 6

Prevention of Complications

• Gastric lavage should not be performed routinely in poisoned patients 3, 7
• Lavage should only be considered within 60 minutes of ingestion of a potentially life-threatening poison 3
• Airway protection through intubation is essential before performing lavage in patients with decreased consciousness 4
• Use appropriate volumes of fluid for each lavage cycle to minimize risk of aspiration 4
• Ensure proper monitoring during the procedure 4
• Only trained individuals with proper expertise should perform gastric lavage 7

Special Considerations

• In elderly patients with acute diverticulitis and peritonitis, laparoscopic lavage is not recommended due to higher risk of failure to control sepsis 6
• For inflammatory bowel disease complications, laparoscopic peritoneal lavage and drainage should only be considered in very selected patients 6
• When percutaneous drains are used alongside lavage, they should be clamped between lavages to maintain appropriate pressure gradients 6