Erythromycin Use Before Induction of General Endotracheal Anesthesia.

Abstract

Czarnetzkiandcolleagues1conductedasingle-center,doubleblind, placebo-controlled clinical trial in 132 patientswhounderwentemergent surgery for traumaorconditions suchasappendicitis and cholecystitis. The authors hypothesized that erythromycin given intravenously 15 minutes before intubation decreases the volume of gastric contents, potentially decreasing the risk for aspiration, by creating a clear stomach (<40 mL of liquids and no solid food as determined by endoscopy). Their hypothesis proved true for patients undergoing emergent surgery but not in the trauma population. The findings of this study are similar to those of Asai and colleagues2 who showed that preoperative erythromycin administrationreduces residualgastricvolumeandacidity.Erythromycin has also been used before endoscopy for acute upper gastrointestinal tract bleeding because it reduces the amount of blood present in the stomach.3 However, the conclusions of this study byCzarnetzki and colleagues1 must be interpreted with caution. First, the hypothesis was true only in the nontrauma patient population. Patients who underwent appendectomy or cholecystectomy had been fasting for 15 to 20 hours. Because these conditions rarely causediffuseperitonitiswith aparalytic ileus, thesepatients probably had a normal interdigestive motor complex, and a clear stomach might have been present independently from erythromycin administration. In contrast, trauma patients had been fasting for only 6 hours.We have no information about the type of trauma (extremity vs blunt or penetrating abdominal). Second, to say that themedicationdecreased gastric volume,we should know the volumebefore themedicationwasadministered.Third, the real endpoint shouldhave been the incidenceofaspiration,which thestudywasnotpowered todetect. Finally, erythromycin shouldbeusedwith cautionbecauseofan increasedrisk forcardiacarrhythmias,which predisposepatients to torsadesdepointes and cardiac arrest.4