Erythromycin may speed stomach clearance before emergency surgery

Reuters Health Information: Erythromycin may speed stomach clearance before emergency surgery

Erythromycin may speed stomach clearance before emergency surgery

Last Updated: 2015-06-23

By Anne Harding

NEW YORK (Reuters Health) - Erythromycin can help clear the stomach in non-trauma patients undergoing emergency surgery, according to new findings.

Residual gastric liquid was also less acidic in patients given erythromycin, Dr. Christoph Czarnetzki of Geneva University Hospitals in Switzerland and colleagues report in JAMA Surgery, online June 17.

"Now we have a medication at hand which can empty stomachs in emergency patients when we suspect that they have a full stomach," Dr. Czarnetzki told Reuters Health in a telephone interview.

About 40 million people undergo general anesthesia every year in the U.S., about 12,000 of whom develop bronchoaspiration, Dr. Czarnetzki and his colleagues note. The risk of bronchoaspiration is ten times higher in patients who undergo emergency surgery, they add.

Erythromycin, an antibiotic and motilin receptor agonist, has been shown to induce antral contraction and increase lower esophageal sphincter tone. The drug is given for patients with stomach bleeding before gastroscopy, Dr. Czarnetzki noted, while it also may be used in diabetic patients with gastroparesis.

To investigate whether erythromycin could improve stomach clearance in emergency surgery patients, the researchers randomly assigned 132 patients undergoing emergency surgery to receive 3 mg/kg of erythromycin lactobionate or placebo 15 minutes before intubation. Patients underwent endoscopy immediately after intubation to assess the amount and pH of gastric content.

Sixty-four percent of the patients given placebo had a clear stomach (the study's primary outcome, defined as less than 40 milliliters of liquid and no solids), versus 80% of those who received erythromycin.

Patients undergoing non-trauma surgery had 13.4 times greater odds of having clear stomachs if they received erythromycin, but the association between erythromycin and clear stomach was not significant in the trauma-surgery patients.

The median pH of remaining gastric liquid was 2 for 36 patients given placebo and 6 for 16 who received erythromycin. Patients given erythromycin were more likely to have nausea and stomach cramps, and one patient given erythromycin vomited before undergoing anesthesia.

Patients treated for trauma may have eaten sooner before surgery, Dr. Czarnetzki noted, while they also may have been given opioids for pain, which can slow intestinal motility. One approach to improve stomach clearance in these patients could be to give erythromycin earlier, he noted, while another could be to use low-dose scanners or ultrasound to identify the patients with full stomachs.

A trial including thousands of patients would be necessary to determine if erythromycin actually reduced the risk of bronchoaspiration, Dr. Czarnetzki said. For now, he added, he and his colleagues routinely give erythromycin to patients at his hospital who are undergoing emergency surgery.

"Many, many people said we needed a gastrokinetic agent but nobody did the study, and now we have one," the researcher added. "Erythromycin I think is the most potent gastrokinetic agent we have in medicine."

Finalizing the study protocol took nine years, he said. "We are really lucky to have it done and have good results."

In an editorial accompanying the study, Dr. Marco Patti of the University of Chicago Pritzker School of Medicine says the conclusions of the new study "must be interpreted with caution."

While the non-trauma patients who underwent appendectomy or cholecystectomy had been fasting for 15 to 20 hours, Dr. Patti notes, trauma patients had been fasting for just six hours. The study did not include information on trauma type, he adds, nor did it include the gastric volume before the administration of erythromycin. Also, the editorialist notes, the endpoint should have been the incidence of aspiration, but the study was not powered to detect this.

"Finally, erythromycin should be used with caution because of an increased risk for cardiac arrhythmias, which predispose patients to torsades de pointes and cardiac arrest," Dr. Patti concludes.

The trial did not have commercial funding.

SOURCE: http://bit.ly/1eFB5O7 and http://bit.ly/1JfY2o3

JAMA Surg 2015.

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