Episode #97 Patient Safety Threat: Button Battery Ingestion in Children, Part 2

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We hope you tuned in last week for our discussion of a pediatric patient safety threat related to button battery ingestion and this is a big threat that comes with a high morbidity and mortality. We are returning to this topic today. So, let’s head back to the nearest pediatric ward to review anesthetic considerations and mitigation strategies following pediatric button battery ingestion.

Before we dive into the episode today, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Our featured article today is once again “Perioperative Management of Button Battery Ingestions in Children” by Hoagland and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well. You can also get to the February 2022 APSF Newsletter by clicking on the Newsletter heading and 5^th one down is the Newsletter archives and then scroll down until you get to the February 2022 APSF Newsletter. This is also where you can find all of the APSF Newsletters all the way back to 1986.

Last week we discussed why button battery ingestion is such a serious event since the battery causes an electrolytic current that hydrolyzes tissue fluids with the production of hydroxide ions at the battery’s negative pole. When this happens, there is a very alkaline environment with local tissue pH as high as 12-13 with the resultant liquefactive necrosis of the surrounding tissues. The damage may be extensive with perforation and erosion into nearby structures such as the airway, major blood vessels, mediastinal structures or spinal cord. The most common cause of mortality is hemorrhage from esophageal-vascular fistulae or complications from a tracheoesophageal fistula. Patients who develop an aorto-esophageal fistula are at high risk for mortality.

We mentioned last week that there are standardized protocols for initial triage and management of patients with suspected button battery ingestion to help identify high risk patients and expediate removal of the battery. Today, we are going to head over to the National Capital Poison Center to review their detailed management guidelines. This independent and non-for-profit organization is based in the United States. I will include a link in the show notes as well. Here we go:

• The first step is to keep button battery ingestion on the differential diagnosis especially in these situations. Keep in mind that children under the age of 5 may not be able to tell you what happened.
  • When it is reported that a “coin” has been ingested. Make sure to review the AP Chest X-Ray closely using magnification if necessary, looking for the double rim” or the “halo effect” of the battery. On the lateral x-ray, you can look for a step off.
  • When there is a patient with no history of ingestion, but with these concerning symptoms:
    • Airway obstruction or wheezing
    • Drooling
    • Vomiting
    • Chest discomfort
    • Difficulty swallowing, decreased appetite, refusal to eat
    • Coughing, choking, gagging with eating or drinking
• The next couple of steps are critical when there is a known or suspected battery ingestions.
  • Do not induce vomiting.
  • Keep NPO except for honey administration.
  • Administer commercial honey or Carafate (10mls or 2 teaspoons every 10 minutes) for patients over 12 months old who are able to swallow when there is a suspected lithium battery ingestion that occurred in the past 12 hours. Remember honey is not safe for patients less than 12 months old. In addition, after 12 hours from the battery ingestion there is a high risk that an esophageal perforation has already occurred so it is not safe to administer honey in this situation either.
  • Do not delay going to the emergency room and proceeding with emergent removal of the button battery.

Let’s stop here on the protocol so that we can talk about why honey administration is recommended in these cases. Honey acts to coat the battery and form a protective layer that helps to prevent local generation of hydroxide leading to less liquefactive necrosis and local tissue injury. Literature supports this practice based on the 2018 study by Anfang and colleagues published in Laryngoscope. This study evaluated apple juice, orange juice, Gatorade, Powerade, pure honey, pure maple syrup, and Carafate with a 3V lithium button battery in porcine esophagus models. The authors reported that honey and Carafate were the most protective in vitro and in vivo in live American Yorkshire piglets. These 2 substances were effective in preventing the tissue pH increase that occurs following button battery ingestion with less local tissue injury. The tissue injuries tended to not extend as far and be more superficial. The conclusion from this study is that administration of honey or Carafate as soon as possible after the ingestion with repeat administration followed by endoscopic removal of the button battery may lead to decreased morbidity and mortality.

Now, let’s return to the protocol.

The next step is to take up to 5 minutes to figure out the imprint code of the battery that was ingested. You may be able to do this with a companion or replacement battery, the battery packaging, or product instructions. If this is not available, you may be able to measure that slot that the battery fits into or to estimate the size compared to a US penny which is 19mm or a US nickel which is 21 mm. This is also the time to consult the National Battery Ingestion Hotline at 800-498-8666 for assistance in battery identification and continued patient management.

The next steps depend on the patients age, so let’s look at patients less than 12 years old and patients older than 12 years old with a battery that is larger than 12mm. These patients require an immediate x-ray with emergent removal within 2 hours if the battery is in the esophagus. The location is the important part here, not symptoms. Even asymptomatic patients require emergent removal if the battery is in the esophagus. If the battery was co-ingested with a magnet, then this requires emergent endoscopic or open removal even if it is located in the stomach or beyond. In addition, if patients have symptoms and the location is in the stomach, the battery still needs to be removed with an endoscopic approach.

The steps may be a little different for patients older than 12 years old with a battery that is smaller than 12mm if all of the following conditions apply.

• Patient is asymptomatic
• Only 1 battery ingested
• There is no magnet that has been co-ingested
• You are certain that the ingested battery is less than 12 mm in diameter
• There is no pre-existing esophageal disease
• The patient or caregiver is reliable and mentally competent and agrees to seek immediate further evaluation if symptoms develop. This is so important. If symptoms develop later the patient will require further evaluation and endoscopic removal of the battery.

Before we discuss the management for button batteries that are located in the esophagus, let’s review the protocol for batteries that are in the stomach and beyond. If a magnet was co-ingested, then the patient requires emergent endoscopic removal if possible or open removal of the battery and magnet.

For batteries alone, if there are signs or symptoms, then proceed with endoscopic removal of the battery. If the button battery cannot be reached by the endoscope, then open removal may be indicated for patients with bleeding, severe abdominal pain, acute abdomen, fever, or decreased appetite.

When the button battery larger than 15mm is located in the stomach and the patient is greater than 6b years old and remains asymptomatic, then a wait and see approach may be reasonable with an x-ray 4 days after ingestion. If the battery remains in the stomach at this time, then endoscopic removal is necessary. Don’t forget if the patient develops symptoms, then you will need to move back on to the symptomatic pathway and remove the battery.

Now is the moment you have been waiting for – what do we need to do when the button battery is found to be in the esophagus. This is when immediate removal is required. Don’t delay removal for NPO status, but keep in mind that the patient may have been given honey or Carafate prior to coming to the OR. Endoscopic removal is the preferred technique.  Prior to battery removal, it is important to note the battery location and the direction the negative pole faces. After battery removal, direct visualization of the esophageal tissue to evaluate for location, extent, and depth of tissue damage is critical. The last step during the procedure if there is no evidence of esophageal perforation is for irrigation of any damaged areas with 50-150mls of 0.25% sterile acetic acid. This helps to further neutralize the esophageal tissue surface. This is a newer recommendation that may help decrease the risk for progressive esophageal injury from the alkaline environment caused by the button battery.

Following the procedure, patients may require ICU level care. Be on the lookout for these complications:

• tracheoesophageal fistula
• esophageal perforation
• mediastinitis
• vocal cord paralysis
• tracheal stenosis or tracheomalacia
• aspiration pneumonia
• empyema
• lung abscess
• pneumothorax
• spondylodiscitis
• exsanguination from perforation into a large vessel

There may be a delay in the development of complications of days to weeks to months for perforation, fistula, and stricture formation. So, you will need to remain vigilant.

It’s time to return to the conclusion of the APSF Newsletter article. The authors remind us that anesthesia professionals need to be prepared for these patients to come to the operating room for emergent endoscopic removal. Do not delay the case for adequate NPO time for patients who receive honey or Carafate. This is an emergent procedure and any delays may lead to worsening esophageal injury.

The authors created 2 infographics, one for parents, and one for anesthesia professionals related to button battery ingestion that we are going to review now. I hope that you will take a look at them as well, plus, they are available on the Society for Pediatric Anesthesia website and I will include a link in the show notes. That way, you can make these available in your department and hospital to help keep pediatric patients safe.

First up, the infographic for parents with the title: Button Batteries can be deadly. Then, there are 4 boxes that tell parents What a button battery is, Why are they dangerous, How can I avoid accidents, and What to do if your child swallows a button battery.

The next infographic is for anesthesia professionals with the title Button Battery Ingestions for Anesthesia Professionals. The first box provides information about The Problem with over 3,500 ingestions each year and 12.6% of child less than 6 years old developing serious or fatal complications. The next box reveals The Mechanism with the button battery creating an electric current that causes tissue injury and necrosis that is related to the duration and location of impaction as well as the size and voltage of the battery.  The next box provides information about high risk patients which includes age less than 5, battery greater than 20mm, prior bleed, negative pole or narrow side facing posteriorly, impacted at the level of the aorta. On the other side of the infographic is a box with anesthetic considerations that includes the following:

• Extraction is emergent. Goal is removal within 2 hours.
• Do not delay for NPO time.
• Consider appropriate staff, equipment, and location for removal.
• Assess risk factors for bleeding and be prepared for blood loss and hemodynamic instability.
• Patients may require inpatient monitoring and repeat procedures.

These Infographics provide a lot of information about how to keep pediatric patient safe. We hope that you will check them out and share them with parents of young children as well as any anesthesia and other healthcare professionals that you work with who may be involved in the care of pediatric patients following button battery ingestions.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We are almost at our 100^th episode and we hope that you will share this podcast with anyone you know who is interested in anesthesia patient safety including your surgical and procedural colleagues, nurses, and hospital administrators. Plus, you can connect with us on twitter @APSForg and using the hashtag #APSFpodcast. You can also find us on Facebook, Instagram, and linked in. We would love to hear from you as we work towards improved anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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