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Anesthetic Implications of the New Guidelines for Button Battery Ingestion in Children

Hoagland, Monica A. MD*; Ing, Richard J. MBBCh, FCA(SA)*; Jatana, Kris R. MD, FACS, FAAP; Jacobs, Ian N. MD; Chatterjee, Debnath MD, FAAP*

Author Information
doi: 10.1213/ANE.0000000000004029
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Abstract

The ingestion of foreign bodies by pediatric patients is a common event. Recently, attention has been drawn to the significant morbidity and mortality associated with button battery ingestions. These ingestions are associated with a spectrum of injury patterns including isolated esophageal injury, as well as damage to adjacent airway, vascular and other mediastinal structures.1,2 Multiple fatalities, mostly due to hemorrhage from a vascular-esophageal fistula, have been reported.3 Due to the rapid development of these injuries, treatment protocols with a standardized approach to triage and management of patients with a suspected button battery ingestion have been published.2,4–6 The common theme in these protocols is emergent removal to limit the damage caused by the button battery. However, it is recognized that this is not always possible due to delays in initial patient presentation or need to transfer to a pediatric facility for removal of the button battery. The most recent guidelines from the National Capital Poison Center continue to stress the importance of prompt button battery removal. However, they also introduce novel mitigation strategies to reduce injury progression during the critical period of time between button battery ingestion and removal.7 The pathophysiology of button battery ingestions has been reviewed in multiple other publications and will only be briefly reviewed here. Instead, this article will focus on the current management guidelines and latest mitigation strategies, with specific attention to their implications on anesthetic management and continued emphasis on rapid button battery removal.

PATIENT POPULATION AND CLINICAL PRESENTATION

The majority of foreign body ingestions occur in young children. The American Association of Poison Control Centers tracks all reported human exposures, including those to environmental agents, toxins, drugs, and foreign bodies. In 2016, 46% of reported exposures involved children ≤5 years old. In this age group, 62% of exposures were unintentional and 6.5% involved foreign bodies. Six percent of fatalities due to any reported exposure in children ≤5 years old are caused by batteries.8 Although the incidence of button battery ingestion has remained stable for 30 years, the rates of emergency department visits and major morbidity and mortality have risen dramatically9,10 (Figure 1). The largest increase in severity of injury occurred after 2006, when 20-mm 3-volt lithium button batteries, which are larger and more powerful than their predecessors, more widely penetrated the market.9 The overall incidence of major morbidity or mortality after button battery ingestion is 0.34%.11 However, rates as high as 12.6% are seen in children <6 years old who ingest batteries >20 mm in diameter.9 All reported fatalities have occurred in children ≤4 years old.3

Figure 1.
Figure 1.:
Incidence of moderate, major, and fatal complications after button battery ingestion in children. Reprinted with permission from data from the National Poison Data System and National Button Ingestion Hotline.7 , 11

The symptoms of foreign body ingestion are nonspecific and may easily be attributed to a respiratory or gastrointestinal illness, particularly when the ingestion is unwitnessed. Dysphagia, fever, and cough are the most frequent presenting symptoms of a button battery ingestion. Infants and toddlers also frequently present with irritability, anorexia, dyspnea, drooling, and vomiting. Older children may present with localized symptoms, such as thoracic or abdominal pain, and may also be able to give a history of foreign body ingestion.12 The nonspecific nature of these symptoms can significantly delay the appropriate diagnosis and management of a button battery ingestion, ultimately worsening the outcome for the patient. New noninvasive, radiation-free button battery/coin detector screening technologies are under development to aid the evaluation of patients with suspected button battery ingestion.13

PATHOPHYSIOLOGY OF BUTTON BATTERY INGESTION

The tissue injury produced by button battery is caused by the generation of an electric current leading to liquefaction and necrosis of adjacent tissues. The contact of tissue at the negative and positive poles of the battery effectively completes a circuit that allows current to flow. The electrolytic reaction divides water into hydrogen gas and hydroxide ions, and this generates a highly alkaline environment at the negative pole of the button battery.14 The tissues in direct contact with the negative pole of the button battery are most at risk for severe injury.15–18 Litovitz et al9 have devised a pneumonic of the 3 Ns (“negative pole, narrowest, necrosis”) to identify the negative pole (narrower sider of the battery) on imaging and allow the clinician to anticipate which tissues are at the highest risk of damage.9 This mechanism of injury has been confirmed in several studies all with similar findings. Pressure injury alone and leakage of the internal contents of the button battery, which were historically thought to be contributing factors, have not been found to significantly contribute to tissue damage of the currently available button batteries.17 The extent of tissue injury seen after button battery exposure is dependent on the length of time the battery remains in direct contact with the tissues.4 Visible tissue damage begins within 15 minutes of direct tissue contact with a button battery and the risk of a deep tissue injury with potential for perforation of the intestinal tract, most notably the esophagus, increases after prolonged button battery exposure (Figure 2). Due to the rapid development of tissue injury, the window for injury-free removal is generally considered to be <2 h from ingestion.9 However, tissue injury may continue for days to weeks after button battery removal from ongoing alkali damage, known as liquefactive necrosis of compromised tissues.20,21

Figure 2.
Figure 2.:
Rigid esophagoscopy after button battery removal from a 4-y-old child, showing extent of injury extending into the muscular layer. Reproduced with permission from Jatana.19

Several factors can increase the severity of esophageal tissue injury after button battery exposure. The first is increased duration of tissue exposure to the battery. Button batteries with a diameter >20 mm pose a greater risk of esophageal impaction and therefore longer duration of direct tissue contact. This is especially likely in small children or those with narrower esophageal diameter from previous esophageal pathology. A button battery <20 mm in diameter is less likely to become impacted in the esophagus, but more frequently causes injury in the nasal cavity or ear canal.4 However, the potential for smaller button batteries to get lodged and cause severe esophageal injury exists, and such cases have been documented.9 The voltage of the button battery is also important, as more powerful batteries are able to generate more current and therefore more rapid tissue damage. Although new button batteries are more likely to produce damage than used batteries, any button battery with a residual charge of at least 1.2 volts can cause tissue damage.4 Therefore, even “spent” batteries that are unable to power electronic devices can still cause substantial injury. The damage caused by button batteries is therefore multifactorial and is determined by the duration and location of the impaction; the orientation, size, and voltage of the button battery; and the size of esophagus and any possible underlying esophageal pathology of the patient.

Known complications associated with button battery ingestion throughout the United States are documented in a registry that is maintained by the National Capital Poison Center.11 Since 1977, there have been 59 fatal and 239 severe injury cases associated with button battery ingestion reported to the registry, with 49 (83%) fatalities having occurred since the introduction of lithium batteries in 2006.3 There are likely many more severe or fatal cases that have not been reported and unable to be consistently tracked. Injuries associated with ingested button battery may be limited to the esophagus, causing ulceration and delayed stricture formation or can include perforation and erosion into adjacent structures. This can result in damage to the airway, vasculature, mediastinal structures, or spinal cord. The most severe injuries include tracheo-esophageal fistulae and vascular-esophageal fistulae, which are often associated with a fatal outcome. Of the 59 fatalities compiled by the National Capital Poison Center, 47 (79%) were due to hemorrhage. The most common cause of hemorrhage is aortoesophageal fistula.3 The development of a button battery–associated aortoesophageal fistula is almost uniformly fatal with only 2 reported cases of survival.22,23

MANAGEMENT RECOMMENDATIONS

Due to the serious and time-sensitive nature of esophageal button battery injuries, multiple groups have published management guidelines to standardize the triage and management of these patients.4–6 The central goal of these guidelines is to correctly identify patients who are at high risk of injury from a button battery impaction and to facilitate removal. This requires early recognition of ingestion and transport to a medical facility with the staff and equipment necessary to manage the patient, which may include emergency physicians, radiologists, otolaryngologists, gastroenterologists, general or cardiothoracic surgeons, anesthesiologists, and other subspecialists as clinically indicated. It is imperative that delays are minimized at each step of evaluation and management. A recent study found that activating a trauma protocol for patients suspected of ingesting a button battery significantly decreased the time to arrival in the operating room.6

The current recommendations for triage of a patient with a button battery ingestion are summarized in Figure 3. Any patient with a witnessed or suspected button battery ingestion should be brought immediately to the emergency department for evaluation. The evaluation includes x-rays of the entire neck, chest, and abdomen to locate and identify the ingested object. If a button battery is identified in the esophagus, the patient should undergo immediate removal. In many cases, button battery located in the stomach must also be urgently removed. Although most gastric button battery will continue to pass through the gastrointestinal tract uneventfully, the patient may have occult esophageal damage due to transient esophageal impaction before passing to the stomach.5 Therefore, patients who are symptomatic with an ingestion of a large button battery (≥20 mm) or coingestion with a magnet should undergo urgent removal. It is important to note that coins and button batteries have a similar appearance on x-rays; see Figure 4A, B. Unless the ingestion was witnessed and is known to be a coin, all patients should be presumed to have a battery ingestion and treated accordingly. Criteria for conservative management, including deferring initial x-rays and observation are outlined in Figure 3.

Figure 3.
Figure 3.:
Management of button battery ingestions. (1) Nothing should be given orally if the time from battery ingestion is >12 h due to the risk of underlying esophageal perforation. Honey is not safe in children <12 mo old. Do not administer any other medications or fluids orally prior to battery removal. Neither treatment is a substitute for immediate removal of a button battery lodged in the esophagus. Do not delay battery removal under general anesthesia because the patient has recently had any oral ingestion. (2) X-rays obtained to locate the battery should include the entire neck, chest, and abdomen. Obtain both anterior-posterior and lateral x-rays for batteries in the esophagus to determine orientation of the positive and negative poles. (3) Conservative management criteria: The patient is >12 y old, asymptomatic, and has no history of esophageal pathology, including esophageal surgery or stricture, motility disorder, or other esophageal disease. The ingestion is known to be a single button battery <12 mm with no coingestion of a magnet. The patient (or caregiver) is reliable, mentally competent, and agrees to report symptoms if they develop. (4) Children <5 y old with >20 mm button battery (regardless of symptoms) are at highest risk for esophageal injury while in transit to stomach that need endoscopic evaluation. (5) Magnet coingestion: Immediate endoscopic removal, if cannot, then do surgical removal. Symptomatic: Immediate endoscopic removal and assess esophagus; if beyond reach of endoscope, surgical removal reserved for severe cases (ie, occult bleeding, acute abdomen, etc). Adapted with permission from the National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline.7
Figure 4.
Figure 4.:
Anterior-posterior chest x-ray showing esophageal button battery with double ring or halo sign. Reproduced with permission from Jatana.19

The most recent update from the National Capital Poison Center includes recommendations to mitigate the damage caused by exposure of esophageal mucosa to the alkaline environment created by the button battery.7 These recommendations are based on the results of cadaveric and live piglet studies, which showed that irrigation with weakly acidic solutions neutralized the alkaline environment, ultimately reducing the damage caused by the button battery when compared to irrigation with saline.24,25 The solutions investigated in these studies were common household beverages, including juice, soda and sports drinks, and viscous liquids, such as honey and syrup, which are likely to be easily accessible in most household kitchens in the event of such an emergency.

In an in vitro study, button batteries were placed on cadaveric piglet esophagi and serial irrigation with 10 mL of acidic solutions was performed every 10 minutes for 2 h. Honey and sucralfate best neutralized the highly alkaline pH at the battery application site to clinically optimal and statistically significant levels compared to saline controls25 (Figure 5). A subsequent in vivo study was performed in which button batteries were placed in live piglet esophagi and irrigated every 10 minutes for 1 h with 10 mL of honey, sucralfate, or saline control. Gross and histological examination at 7 days showed that honey was the most effective, followed by sucralfate, at neutralizing the alkaline pH associated with button battery exposure. The injuries in the honey and sucralfate groups were more localized and superficial, with minimal extension beyond the surface ulcer and shallower depths of necrotic and granulation tissue observed. Half of the saline-treated piglets developed a delayed esophageal perforation, but none of the piglets in the honey or sucralfate groups developed this complication.25 Honey is a palatable, highly viscous, weak acid found in most households. Sucralfate is a cherry-flavored, weakly acidic suspension with mucosal protective effects. It is used for the treatment of duodenal ulcer and found in hospitals. Both solutions form a viscous physical barrier between the button battery and tissue surface, in addition to the neutralization of the alkaline environment. It is possible that future studies may find that more frequent irrigation further improves outcomes.25 However, voluntary ingestion of these solutions will likely be limited by the child’s symptoms and the palatability of the solution.

Figure 5.
Figure 5.:
Mucosal surface of cadaveric piglet esophagus exposed to a lithium button battery with serial irrigations of (A) saline, (B) honey, and (C) carafate. Reproduced with permission from John Wiley and Sons: Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. Laryngoscope. 2019;129:49–57. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.25

A separate in vitro study by Jatana et al24 evaluated the effect of pH neutralization after removal of the button battery. In this study, button batteries were placed on cadaveric piglet esophagi for 24, 36, or 48 h. After removal, the tissue was irrigated 3 times with 50–150 mL of acetic acid (0.25% or 3%) or normal saline. Irrigation with 50–150 mL of either 0.25% or 3% acetic acid was effective at reducing the visible eschar and neutralizing the pH of exposed esophageal tissue at all time points. Using the more dilute, commercially available, medical grade 0.25% sterile acetic acid was just as effective as 3% acetic acid. Household cooking vinegar (5% acetic acid) is not sterile and is not recommended for use after button battery removal. On the other hand, minimal pH change was seen after saline irrigation. This 0.25% acetic acid irrigation could decrease the common progression of tissue injury and delayed complications seen after button battery removal, and this has been reported to be beneficial in human application.26

Based on these findings, the most recent guidelines from the National Capital Poison Center include recommendations to mitigate tissue damage caused by exposure to a button battery. Honey and/or sucralfate should be administered orally to patients (10 mL every 10 minutes) from the time of ingestion until button battery removal. No honey should be administered to patients <1 year of age. These interventions should not be performed if the time from suspected or witnessed button battery ingestion is >12 h due to the risk of underlying esophageal perforation. This guideline is based on a recent retrospective review of 189 esophageal perforations associated with button battery ingestion. Only 2% of perforations (3 cases) occurred <24 h after button battery ingestion. Based on these data, the likelihood of esophageal perforation within 12 h of ingestion is thought to be very low.27 In addition, clinical assessment is important. If there is suspicion for existing perforation, mediastinitis, or sepsis, these interventions should not be performed, regardless of time frame. No other medications or fluids should be administered orally before button battery removal. Neither of these interventions is a substitute for prompt button battery removal. Therefore, transportation to the emergency department should not be delayed to administer these substances and button battery removal should not be delayed due to the patient’s oral intake. After button battery removal, the esophagus should be irrigated with acetic acid solution to neutralize residual alkali substances and help prevent progression of tissue damage.7 Other elements of the management guideline, including risk stratification and criteria for emergent removal versus observation are unchanged from previous guidelines.4,5 The administration of sucralfate and acetic acid as button battery mitigation strategies are considered an “off-label” use of these medications.

ANESTHETIC CONSIDERATIONS

The anesthetic considerations for management of button battery ingestions have recently been published and are only briefly reviewed here (Table).2 It is imperative that the anesthesiologist is aware of the potential complications associated with button battery ingestion to provide appropriate perioperative management and care coordination for the patient. The appropriate timing, location, and medical staff required for button battery removal are dependent on risk stratification of the patient. The patients at highest risk for major morbidity and mortality are those who are <5 years of age with a button battery ≥20 mm in diameter impacted in the esophagus at the level of the aortic arch or those who have had a sentinel bleed with hematemesis or hemoptysis. Patients with an esophageal battery impaction not fitting severe criteria or symptomatic gastric button battery who have not had a sentinel bleed are at intermediate risk. Those who are >5 years of age with a smaller (<20 mm in diameter), asymptomatic gastric button battery and no history of esophageal pathology are at lower risk.2 When possible, patients with an esophageal button battery impaction, particularly those at high risk, should be cared for in a facility with pediatric subspecialists, including anesthesiologists, otolaryngologists, gastroenterologists, general and cardiothoracic surgeons, interventional cardiologists, intensivists, and appropriate support staff available. However, the benefit of transferring patients to such a facility must be weighed against increased esophageal damage expected when there is a significant time delay for button battery removal.2

Table. - Anesthetic Considerations for Button Battery Ingestion
Risk assessment High: patient <5 y old, button battery ≥20 mm diameter, impaction at the level of the aortic arch, negative pole facing posteriorly, and/or previous bleed
Intermediate: esophageal or symptomatic gastric button battery not fitting high-risk criteria
Low: asymptomatic gastric button battery <20 mm diameter AND patient >5 y old with no prior esophageal pathology
Preoperative planning Appropriate location and staff for removal
Appropriate lines, monitors, and blood products
Intraoperative management Rapid sequence induction (do NOT delay for nil per os status)
Airway vigilance during endoscopy and button battery removal
Bronchoscopy for airway assessment (will likely require spontaneous ventilation with unprotected airway)
Preparation for hemodynamic and/or respiratory instability
Postoperative management Duration and acuity level of inpatient care depends on esophageal injury at time of removal
Repeated anesthetics may be required for serial imaging studies or endoscopic evaluation

Patients at intermediate or low risk for complications may be cared for in the general operating room by gastroenterologists with or without pediatric surgeons on standby. For those at highest risk who have had sentinel bleeding event or chronic impaction at level of aorta, consideration should be given to removing the button battery in a specialized operating room with interventional cardiologists or cardiothoracic surgeons immediately available. These patients may also require more invasive vascular access, hemodynamic monitoring, volume resuscitation, and blood product administration. The need for postoperative intensive care as well as subsequent imaging or endoscopic procedures will depend on the extent of esophageal injury noted at the time of battery removal.2

As previously stated, the emergent removal of button battery should not be delayed due to any recent oral intake, including those now recommended by the National Capital Poison Center.7 Based on the latest guidelines from the National Poison Control Center, children are going to be presenting to the operating room having ingested significant amounts of honey and/or sucralfate before endoscopic removal. In our opinion, the risk of ongoing esophageal injury from an impacted button battery ingestion far outweighs the risk of pulmonary aspiration in this situation and therefore nil per os guidelines should not be followed. A recent multicenter prospective survey of specialist pediatric centers in the United Kingdom revealed a very low incidence of 2.2 cases of pulmonary aspiration per 10,000 cases of nonelective surgery. There were no deaths, and serious morbidity occurred only in 5 cases.28

IV access should be obtained preoperatively and a rapid sequence induction is highly recommended to facilitate endotracheal intubation. At least 2 large bore IV catheters should be placed after intubation for volume resuscitation and administration of blood products, if necessary. During endoscopy, attention must be paid to prevent accidental extubation and compression of the endotracheal tube. After endoscopic removal of the button battery, the esophagus should be reexamined to assess the degree of mucosal injury and rule out any perforating injury. In the absence of a perforating injury, the surgeon or endoscopist may consider irrigating the esophagus with 50–150 mL of 0.25% acetic acid to neutralize the alkaline tissue injury. A flexible or rigid bronchoscopy should be considered to rule out tracheal injury, particularly if the negative pole of the button battery was facing anteriorly, which can more likely lead to a trachea-esophageal fistula. Such complications must be kept in mind from an anesthetic standpoint, as it is possible that removing the button battery in the presence of a trachea-esophageal fistula could lead to acute respiratory compromise. Spontaneous ventilation and topicalization of the trachea with local anesthetic may be considered if bronchoscopy is performed. In cases of moderate or severe esophageal injury, a soft nasogastric feeding tube is inserted under direct vision for esophageal rest and enteral nutrition. The patient may be extubated when fully awake and following commands. Stridor present either preoperatively or postoperatively is a sign of vocal cord paresis or paralysis, which can also be a complication of upper esophageal button battery.29 After button battery removal, the patient should be observed postoperatively as an inpatient. Since the ongoing alkali damage may continue for days to weeks, the duration of inpatient observation depends on the severity of esophageal injury. Serial imaging with computed tomography angiography and/or magnetic resonance imaging may be considered for surveillance.5

CONCLUSIONS

Anesthesiologists play a critical role in the care of pediatric patients presenting for aerodigestive foreign body removal. The ingestion of button battery is a particularly concerning phenomenon due to the risk of rapid injury to the esophagus and surrounding structures, including the risk of death.

Multiple guidelines have been published in the medical literature reinforcing the importance of emergent removal of these button batteries, as well as outlining important aspects of care including risk stratification, procedural and anesthetic considerations, and postoperative management. The most recent guidelines have also described the importance of esophageal pH neutralization mitigation strategies, both before and after button battery removal. These include the serial ingestion of honey and/or sucralfate before button battery removal, and esophageal irrigation with 50–150 mL 0.25% sterile acetic acid in the operating room after button battery removal to reduce the progression of esophageal injury. The recommendations for preoperative, protective (honey or sucralfate) oral intake, violating typical nil per os parameters, may slightly increase the risk of pulmonary aspiration in these patients, so rapid sequence induction techniques should be performed. However, this risk is clearly outweighed by severity of the button battery hazard and the benefit of preremoval neutralization strategies. It is strongly recommended that interventions involving oral intake should not delay the emergent removal of button batteries.

DISCLOSURES

Name: Monica A. Hoagland, MD.

Contribution: This author helped write and revise the manuscript.

Conflicts of Interest: None.

Name: Richard J. Ing, MBBCh, FCA(SA).

Contribution: This author helped write and revise the manuscript.

Conflicts of Interest: None.

Name: Kris R. Jatana, MD, FACS, FAAP.

Contribution: This author helped write and revise the manuscript.

Conflicts of Interest: K. R. Jatana serves in a leadership position on the National Button Battery Task Force, financially supported by and affiliated with the American Academy of Pediatrics and American Broncho-Esophagological Association. He serves as a general product safety medical consultant for Intertek Inc. He receives royalties for a patented, commercially available tracheostomy-related medical device from Marpac Inc. He is a shareholder of Landsdowne Labs, LLC and is a shareholder of Zotarix, LLC.

Name: Ian N. Jacobs, MD.

Contribution: This author helped write and revise the manuscript.

Conflicts of Interest: I. N. Jacobs serves in a leadership position on the National Button Battery Task Force, financially supported by and affiliated with the American Academy of Pediatrics and American Broncho-Esophagological Association.

Name: Debnath Chatterjee, MD, FAAP.

Contribution: This author helped write and revise the manuscript.

Conflicts of Interest: D. Chatterjee represents the American Academy of Pediatrics Section on Anesthesiology on the National Button Battery Task Force.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

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