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ORIGINAL ARTICLE – Comparative study of oral erythromycin- h ttp !"" # # # a p i c a re o n li n ec o m "$

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Anaesthesia, Pain & Intensive Care

An International 5ournal of Anesthesiolo+y6 0ain .ana+ement6 Intensive Care 7 Resuscitation

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ORIGINAL ARTICLE – Comparative study of ora erythromy!in"ranitidine !om#ination and meto!opramide"

ranitidine !om#ination in redu!in$ residua $astri! fuid voume and a!idity in ee!tive sur$ery

LLiikkee  0t 0 1

;hah1ano Af<al6 .=>6 Naseem Ali ;hei?h6 .@@;6 C0;6 Baseem Ismat Chaudhry6 .@@;6 C0;6 =iplomat of The @oard in Anaesthesia IR >>>6 :ahid Ifti?har6 .@@;6 =A>>>>

>C0; Trainee *th yea r6 >>Assistant 0rofessor6 >>>0rofessor7 /ead6 =ept of Anest hesiolo+y6

>>>>Anesthetist =ept of Anesthesiolo+y 9nit-II6 ;hai?h :ayed /oapital6 Lahore 0a?istan

Corresponden!e% =r ;hah1ano Af<al6 *((-6 5ohar To#n66 Lahore 0a?istan 0h No! D2-*2-)&4&,26 Cell: +92-306-4466-718, E-mail! s h a h1 a no42Fy a hoo c om

A'TRACT

a!($round% 0ro?inetic a+ents and /-2 receptor anta+onists are commonly used to decrease the volume and increase the p/ of the +astric fluid This study #as conducted to compare the e ffectof oral erythromycin–ranitidine com1ination and metoclopramide–ranitidine com1ination in reducin+ +astric fluid volume and ac idity in patients under+oin+ elective sur+ery

)ethodoo$y% 3, patients #ere divided into t#o +roups 1y convenient samplin+ techniue after meetin+ inclusion criteriaH Group A #as +iven oral erythromycin 2), m+-ranitidine &), m+

#hile +roup @ #as +iven oral metoclopramide &, m+-ranitidine &), m+ t#o hours 1e fore sur+ery Gastric fluid #as aspirated #ith oro+astric tu1e aft er induction olume and p/ of the +astricfluid #ere determined

Resuts% =ata analysis of our study sho#ed sta tistically si+nificant reduction in mean +astric fluid aspirate volume in +roup A (*mlD2( vs 42mlD(& 0-value % ,,,& and T- value % '2*

There #as no statistically si+nificant difference 1et#een the t #o +roups as far as increase in +astric p/ #as concerned ')D&' vs '2D&( T-value % ,2) " T#o tailed 0-v alue % ,(' In 1oth the +roupsJ +astric p/ #as increased from the avera+e normal value ,(-2

Con!usion% Com1ination of erythromycin-ranitidine is more effective than metoclopramide-ranitidine in reducin+ the +astric aspirate fluid volume and thus in prevention of acid

aspiration syndrome

*ey +ords% Erythromycin6 Ranitidine6 .etoclopramide6 Residual +astric fluid volume6 Residual +astric fluid acidity

Citation% Af<al ;6 ;hei?h AN6 Chaudary IB6 Ifti?har : Comparative study of or al erythromycin-ranitidine com1ination and metoclopramide-ranitidine com1ination in reducin+ residual +astric

fluid volume and acidity in elect ive sur+ery Anaesth 0ain 7 Intensive Care 2,,H&(2H'&-'*

INTRO-CTION

0ulmonary aspiration of +astric contents has 1een one of the maKor causes of anesthesia-related deaths =ifferent methods have 1een advocated to reduce the volume and ac i dity of the residual

+astric fluid6 includin+! overni+ht fastin+6 use of pro?inetic dru+s6 /-2 receptor anta+onists6 proton pump inhi1itors and antac ids& The pro?inetics a+ents availa1le include erythromycin2 and

metoclopramide(6 and this property has led these to 1e used in patients #ith dia1etic +astroparesis Erythromycin* in lo# doses reduces +astric f luid volume #hen +iven as a premedication dru+

 prior to sur+ery ;tudies sho# that metoclopramide alone or in com1ination #ith /-2 receptor anta+onists causes reduction in +astric fluid volume and acidity ) @ut unfortunately it has etra pyramidal side effects Ranitidineis /-2 receptor anta+onist and increases the p/ of +astric fluid It is in use as chemoprophylais 1efore induction of anesthesia to reduce the ri s? of acidaspiration syndrome

In this study #e aimed t o compare the ef fect of oral e rythromycin-ranitidine com1ination #ith metoclopramide-ranitidine com1ination in reducin+ residual +astric fluid volume and ac idity in

 patients under+oin+ elective sur+ery

)ET.OOLOG/

The study #as conducted after the approval of ethical committee in the =epartment of Anaesthesia and Intensive Care 9nit6 ;hai?h :ayed /ospital6 Lahore It #as a uasi e perimental study A

total of 3, patients6 A;A I and II #ere enrolled from either se6 a+ed 2, – ), years6 scheduled to under+o elec tive sur+ery under +eneral anesthesia It #as convenient sa mplin+ 0re+nant patients6 those #ith history of +astrointestinal disease or etra pyramidal si+ns6 patients ta?in+ /2 1loc?ers6 proton pump inhi1itors6 antacids or other dru+s #ith ?no#n effects o n +astric fluid

volume and p/ #ere ecluded Britten informed consent #as o1tained from each patient durin+ preoperative visit 0atients #ere selected on preoperative visit6 no routine premedication # as+iven and patients #ere as?ed to 1e nil 1y mouth at least si hours 1efore sur+ery On operation day6 in the preoperative area patients #ere divided into t#o +roupsH Group A received co

m1ination I ta1let erythromycin 2), m+ #ith ta1let ranitidine &), m+6 #hile Group @ patients received com1ination II ta1let metoclopramide &, m+ #ith ta1let ranitidine &), m+ #ith &, mlof #ater t#o hours 1efore sur+ery

In the operatin+ room6 a standardi<ed anesthesia techniue #as follo#ed for each patient ECG6 heart rate and 1lood pressure #as monitored Induction of anesthesia #as do ne 1y inKection sodiumthiopentone )m+"?+6 inKection atracurium ,'m+"?+ After intu1ation6 anesthesia #as maintained #ith isoflorane ,) – &M6 *, M oy+en and ',M nitrous oide Then a multi-orificed oro+astrictu1e &3 rench #as passed and its correct location #as confirmed 1y pushin+ air #ith ), ml syrin+e and auscultation over the epi+astrium @efore the commencement of the sur+ery6 +astric fluid#as aspirated and measured #ith a ), ml syrin+e in the head do#n position The p/ of the aspirate6 collected in a sterile 1o#l #as measured #ith p/ meter Those patients #ith incomplete

measurements #ere ecluded from the study

The data #as entered and analy<ed throu+h statistical soft#are ;0;; version &, =ata analysis consisted of t#o steps The mean fluid volume and mean p/ #ith standard deviation #as calculatedfor each com1ination of dru+ .ean +astric fluid volume and p/ #ere compared #ith each com1ination and statistica l test ANOA #as applied or comparison of proportions of ca te+ories offluid volumes Chi–suare test #as applied

RE'-LT'

3, patients #ere included in our study They #ere divided in t#o +roups ie *, pat ients to each +roup Group A #as of Erythromycin–Ranitidine com1ination #hile +roup @ #as of

.etoclopramide– Ranitidine com1ination =ata analysis of our study sho#ed statistically si+nificant reduction in +astric fluid aspirate volume in +roup A #here mean volume #as (* ml as

compared to +roup @#here mean volume #as 42 ml 0-value % ,,,& and T-value % '2* There #as no statistically si+nificant difference 1et#een the t#o +roups as far as increase in +astric p/ #as concerned T-value

% ,2) " T#o tailed 0-value % ,(' #hich is +reater than ,,) In 1oth the +roupsJ +astric p/ #as increased from the normal value ,(-2 Analysis of the demo+raphic profile .ean a+e "

.ean #ei+ht " Gender sho#ed no statistically si+nificant difference

.ean Gastric fluid aspirate volume

=ata analysis of our study sho#ed that mean +astric fluid volume #as si+nificantly reduced #ith erythromycin–ranitidine com1ination as compared t o metoclopramide–ranitidine +roup .ean

aspirate volume #ith +roup A erythromycin–ranitidine #as (* ml standard deviation % 2( as compared to +roup @ metoclopramide – ranitidine #here mean aspirate volu me #as 42mlstandard deviation % (&This #as sho#n to 1e statistically si+nificant difference p value less than ,,,& and t value '2* 8ualitative analysis of t he data also con firmed our o1servation In

+roup A erythromycin–ranitidine +astric fluid aspirate volume less than or eual to &, ml #as o1served in ( patients 4)M #hile only & patient had +astric fluid aspirate volume +reater than&,ml 2)M Bhile analy<in+ +roup @ metoclopramide–ranitidine (* patients 3)M had +astric fluid aspirate volume up to &,mls and ' patients &) M had +astric fluid volume +reate r than &,

ml Comparison of 1oth +roups a+ain sho#ed statistically si+nificant difference fisher eact one tailed 0 value #as ,,) 0roportion of more than &, ml +astric aspirate #as si+nificantly hi+herin +roup @ as compared to +roup A

.ean +astric p/

Our study sho#ed that there #as no si+nificant difference in +astric p/ 1et#een the t#o +roups t-value % ,2) " t#o tailed 0-value % ,(' #hichis +roup A standard deviation % &' #hile for +roup @ mean +astric p/ #as '( standard deviation % &( ;o no statistically si+nificantdifference in

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e<iol Reanimatol 2,,3!3-&2! a retrospective study @.C Gastroenterol

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Erythromycin-ranitidine com1ination #ith .etoclopramide-Ranitidine com1ination as pre-anaesthetic medication to increase +astric p/

8ualitative analysis of the data sho#ed that in +roup A erythromycin–ranitidine p/ of less t han or eual to ) #as o1served in ( patients 4)M #hile the remainin+ (4 p atients 2)M had p/+reater than or eual to ) Bhere a s in +roup @ metoclopramide–ranitidine ) patients &,,M had p/ less than or eual to ) and () patients ,,M had p/ +reater than or eual to )

Comparison of 1oth the +roups sho#ed no statistically si+nificant difference in hi+h or lo# p/ of +astric fluid aspirate fisher eact one t ailed 0 value #as ,()'

Comparison of mean a+es

Bhile considerin+ the demo+raphic profile6 no statistically si+nificant difference #as o1served #hile comparin+ the mean a+es 1et #een the t#o +roups t-value % ,23) " t# o tailed p-value %,44' #hich is +reater than ,,) .ean a+e in +roup A erythromycin-ranitidine #as (,3 years standard deviation % &,' #hile in +roup @ metoclopramide-ranitidine #as (&* yearsstandard deviation % '

Gender status under study

Gender status of the patients under study also did not sho# any statistically si+nificant difference Chi-suare value % ,2'4 " T#o tailed p-value % ,',' #hich is +reat er than ,,) In+roup A erythromycin-ranitidine patients 22))M #ere f emales #hile (& patients 44)M #ere males In +roup @ && patients 24)M #ere f emales #hile 2 patients 42)M #er emales

Comparison of mean #ei+hts

Comparison of mean #ei+ht 1et#een the t#o +roups did not reveal any statistical si+nificant difference t-value % ,(,3 " t#o tailed p value % ,))& #hich is +reater than ,,) .ean #ei+htin +roup A #as '( ?+ standard deviation % &&* #hile in +roup @ #as '2( + standard deviation % &2,'

Ta#e 0% Comparison of mean $astri! fui d voume and p.

A p"vaue

.ean Aspirate volume

ml D ;=

(*D2( 42D(& ,,,&

.ean +astric 0/ml D;=

')D&' '2D&( ,('

Ta#e 1% 2uaitative anaysis of !omparison of voume of $astri! fuid aspirate

Groups

3o of

$astri!aspirates

A 4Erythromy!in"Ranitidine 5

N 465

4)eto!opramide"Ranitidine5

N 465

7ishers E8a!t onetaied p vaue

9p to &, ml ( 4)M (*3),M ,,)

.ore than &, ml &2)M '&),M ,,)

Ta#e 9% 2uaitative anaysis !omparison of p. of $astri! fuid aspirate

Groups

p. ran$e

A 4Erythromy!in

"Ranitidine 5 N465

4)eto!opramide"

Ranitidine5 N465

7ishers E8a!t one

taied p"vaue

0/ ) (4)M )&,M ,()'

0/ P ) (42)M (),M ,()'

I'C-''ION

The results of our study sho# that erythromycin-ranitidine +roup si+nificantly decreased the volume of +astric fluid aspirate a s compared to metoclopramide-ranitidine +ro up No si+nificant

difference in p/ #as noted 1et#een the t#o +roups6 yet it #as si+nificantly increased in 1oth +roups from the normal +astric p/ ,(-2 ' /ence com1ination of erythromycin-ranitidine #asfound to 1e more efficacious as it caused more decrease in the +astric residual fluid volume as compared to metoclopramide-ranitidine +roup

The volume and acidity of the +astric contents are a r esult of +astric secretion6 oral inta?e and +astric emptyin+ Traditionally a value of 2) for +astric p/ and 2) ml or,* ml"?+ for +astric fluid

volume has 1een ta?en as a cut off value for development of aspiration syndrome4-3 it has 1een reported from animal studies that a very lo# p/ less than &6 and 1reast mil? or a dairy formula6

 predisposed to an increased severity of aspiration pneumonitis compared #ith less acidic content or a soya-1ased mil? .ore recently ;oreide E et al reported that for passive re+ur+itation and pulmonary aspiration to occur durin+ anaesthesia more than 2,, ml of +astric fluid volume is needed in adult patients6 #hile in a healthy patient for elective sur+ery only &,-(, ml of +astric fluid

are present They also reported that in patients #ith +astro-oesopha+eal reflu or if vomitin+ occurs6 even smaller +astric volumes may 1e pushed into the trachea In 1oth th e +roups that #estudied the values #ere si+nificantly lo#er than the values reuired for causin+ aspiration syndrome

The pro?inetic effects of erythromycin and metoclopramide is #ell esta1lished no#&,6 && Com1ination of erythromycin and metoclopramide therapy has 1een sho#n to 1e more effec tive than

erythromycin alone in improvin+ the delivery of naso+astric nutrition&2 .claren R et al&( in their study sho#ed that 1oth erythromycin and metoclopramide can 1e used to facilitate +astric

emptyin+ and erythromycin seemed to 1e more effective than metoclopramide for enhancin+ +astric motility Our results are consistent #ith the a1ove mentioned studies confirmin+ th eeffectiveness of erythromycin over metoclopramide #hen used as a pro?inetic a+ent

Althou+h there #as no statistically si+nificant difference noted in 1oth our study +roups in mean p/ value yet in 1oth the +roups the +astric p/ #as #ell a1ove the cut of f value of 2) A p/ Q2)

#as o1served in * cases ( 1elon+ed to erythromycin-ranitidine +roup #hile only & to metoclopramide-ranitidine +roup /on+ 5 et al&* in their study evaluated the effect of I metoclopramide

and ranitidine on preoperative +astric contents in patients receivin+ I anaesthesia for laproscopic +ynaecolo+ic sur+ery They found mean +astric p/ of '3 in patients +iven ranitidine thusconcludin+ that ranitidine #as useful in increasin+ p/ of +astric contents The litera ture thus supports our findin+s as mean +astric p/ #as increased in 1oth our study +roups and t he uantitativeincrease #as almost similar to the findin+s reported in the literature

In our study 1lind aspiration throu+h naso+astric tu1e #as done to measure the volume of +astric content Althou+h this method is commonly employed6 it results in incomplete emptyin+ of the

stomach and therefore underestimates +astric fluid volume This may also eplain #hy in our study #e found mean +astric aspirate fluid volume to 1e much less than that re ported in theliterature 2D&, ml .odern methods for measurin+ +astric emptyin+ e+ paracetamol a1sorption test6 +astric emptyin+ scinti+raphy etc can accura tely uantify the pro?inetic eff ect ofthese dru+s

CONCL-'ION

Be conclude that erythromycin-ranitidine com1ination is more effec tive than metoclopramide-ranitidine com1ination in reducin+ the +astric fluid volume @oth com1inations si+nificantlyincrease p/ from the values uoted to cause acid aspiration inKury

RE7ERENCE'

& Levichev EA6 Nedash?ovs?iS E 0revention of re+ur+itation and aspiration durin+ emer+ency care of patients under +eneral anesthesia Anest

2 en?atasu1ramani N6 Rudolph C=6 ;ood .R Erythromycin lac?s colon pro?inetic effect in children #ith functional +astrointestinal disorders2,,3H3!(3

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( I1al .;6 Ashfaue .6 A?ram . Gastric luid olume 7 p/! A Comparison of Effects of Ranitidine Alone #ith Com1ination of Ranitidine and .etoc lopramide in 0atients 9nder+oin+

Elective Caesarean ;ection Ann in+ Ed#ard .ed Coll 2,,,H2!&3-&* an+ .echanism and clinical a pplication of erythromycin as a +astrointestinal pro?inetic a+ent in children :hon++uo =an+ =ai Er e :a :hi 2,,3H&,!&,2-*

) ;yed AA6 Rattansin+h A6 urtado ;= Current perspectives on the mana+ement of +astroparesis 5 0ost+rad .ed 2,,)H)&!)*-',' Aya<i ;6 Leers 5.6 Oe<celi? A6 A1ate E6 0eyre CG6 /a+en 5A .easurement of +astric p/ in am1ulatory oesopha+eal p/ monitorin+ ;ur+ Endosc 2,,3 =ec ' Epu1 ahead of printU

4 .or+an G E6 .i?hail . ;6 .urray . 5 AdKuncts to Anesthesia in Clinical Anesthesiolo+y6 *th ed2,,'!23'

3 ;mith G6 N+ A Gastric reflu and pulmonary aspiration in anaesthesia .inerva Anestesiol 2,,(H'!*,2-'

;Vreide E6 Eri?sson LI6 /irle?ar G6 Eri?sson /6 /enne1er+ ;B6 ;andin R6 Raede r 5 Tas? orce on ;candinavian 0re-operative astin+ Guidelines6 Clinical 0ractice Committee ;candinavian

;ociety of Anaesthesiolo+y and Intensive Care .edicine 0re-operative fastin+ +uidelines! an update Acta Anaesthesiol ;cand 2,,)H*!&,*&-4&, ;chapira .6 /enrion 56 /eller R  The current status of +astric pro?inetic dru+s Acta Gastroente rol @el+ &,H )(!**'-)4

&& Chicella .6 @atres LA6 /eesters .;6 =ice 5E 0ro?inetic dru+ therapy in children! a revie# of current options Ann 0harmacother 2,,)H(!4,'-&&&2 N+uyen N86 Chapman .6 raser R56 @ryant L 6 @ur+stad C6 /ollo#ay R/ 0ro?inetic therapy for feed intolerance in critical illness! one dru+ or t#o$ Crit Care .ed 2,,4H()!2)'&-4

&( .acLaren R 6 iser T/6 ish =N6 Bischmeyer 0E Erythromycin vs metoclopramide for facilitatin+ +astric emptyin+ and tolerance to intra+astric nutrition in critically ill patients

50EN 5 0arenter Enteral Nutr 2,,3H(2!*&2-&* /on+ 5 Effects of metoclopramide and ranitidine on preoperative +astric contents in day-case sur+ery onsei .ed 5 2,,'H*4!(&)-3

W ORIGINAL ARTICLE – ;afety of Tramadol as a 0re-InductionA+ent

ORIGINAL ARTICLE – O;CE as an Assessment Tool! 0erceptions of 9nder+raduate .edical ;tudentsX Cate+ory! Ori+inal Article Y R;; 2, Y Give a Comment Y trac?1ac? 

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