Bicitra

allnurses Guide · Aug 16, 2009

There are different preparations (tablets, solution or crystals) doses and preparation depending if one is using to decrease citrate content to prevent kidney stones or to decrease PH content prior to surgery (to prevent aspiration pneumonia).

For preop preparation there is only one acceptable dosage range: 15-30cc po. The whole idea is to prevent mendelson's syndrome/aspiration pneumonia. The two most important aspects for risk in aspiration pneumonia are having greater than 25cc in the stomach and having a pH less than 2.5. Giving more than 30cc of bicitra and some would say more than 15cc increases the risk of apsiration and there are a lot of anesthesia providers that would delay the surgery or possibly cancel the surgery depending on how much dilutent was used.

Try these references for more information:

Clinical Anesthesiology: Morgan et al.

Basics of Anesthesia: Stoelting

http://books.google.com/books?id=YgP11R7IKOsC&pg=PA279&lpg=PA279&dq=bicitra+anesthesia&source=bl&ots=_ANWsbfjmd&sig=0fqP_rWy8wtqbUToxZ6qQRxNJXA&hl=en&ei=QsuHSqfqCKCntgeWgNnnDA&sa=X&oi=book_result&ct=result&resnum=4#v=onepage&q=bicitra%20anesthesia&f=false

jenrninmi, MSN, RN · Aug 17, 2009

No, we give it like it is...I tell them to take it like a they're drinking a shot.

Sandwitch883RN · Aug 18, 2009

Not an OR nurse, but doesn't diluting it in 500 - 1000ml fluid sort of defeat the purpose of being NPO pre-op?

Not to mention....how would you drink 500-1000 mls of fluid at one time? And on an empty stomach to say the least? Can you imagine someone vomiting or aspiration 1000mls of fruit punch during surgery???!!! HOLY CRAP!!! :eek:

bmcm2girls · Aug 19, 2009

We have one anesthesiologist who insists that we dump half the bicitra out and then mix half and half with water. I didn't do it that way one time and he threw a computer across the room, lol. I have no clue what his rational for that is. He claims that straight bicitra makes them vomit. Typically, we do the "take it like a shot" though.

Papercutz · Mar 21, 2010

This thread popped up on my google search of 'bicitra and aspiration'. Unfortunately my mother just had a lumpectomy and was given the liquid bicitra prior to surgery by the anesthesiologist. Not being a nurse, I thought nothing of this (i mean, this was the anesthesiologist giving it!). Post op she developed hypoxia/hypotension and the anesthesiologist was saying 'she's got mild congestion, not sure why'. After a Chest CT/perfusion scan to r/o pulm embolism, a pulmonologist told my mother "you aspirated the medication you were given prior to surgery'. When we told the anesthesiologist what the pulmonologist said (imagine the catfight that caused), she said "no, there's no scientific evidence not to give the bicitrate. in fact, i'm glad i gave it because otherwise you would have aspirated pure acid into your lungs. you have a hiatal hernia which we didn't know about pre op which caused the aspiration. If we would have known about it, we would have intubated you instead of the iv sedation".

Thoughts?

allnurses Guide · Mar 21, 2010

This thread popped up on my google search of 'bicitra and aspiration'. Unfortunately my mother just had a lumpectomy and was given the liquid bicitra prior to surgery by the anesthesiologist. Not being a nurse, I thought nothing of this (i mean, this was the anesthesiologist giving it!). Post op she developed hypoxia/hypotension and the anesthesiologist was saying 'she's got mild congestion, not sure why'. After a Chest CT/perfusion scan to r/o pulm embolism, a pulmonologist told my mother "you aspirated the medication you were given prior to surgery'. When we told the anesthesiologist what the pulmonologist said (imagine the catfight that caused), she said "no, there's no scientific evidence not to give the bicitrate. in fact, i'm glad i gave it because otherwise you would have aspirated pure acid into your lungs. you have a hiatal hernia which we didn't know about pre op which caused the aspiration. If we would have known about it, we would have intubated you instead of the iv sedation".
Thoughts?

It is against the terms of service on this forum to give medical advice. By the way there is no way to tell from CT what someone aspirated on...meds, gastric juices, leftover food/chyme from a slow digestive process etc.

Papercutz · Mar 21, 2010

It is against the terms of service on this forum to give medical advice. By the way there is no way to tell from CT what someone aspirated on...meds, gastric juices, leftover food/chyme from a slow digestive process etc.

Understood; wasn't really looking for med advice, just thoughts on bicitra; sorry if it was misleading. I'm just doing research about this medication and looking for input.

Thanks for the info about the CT.

jctiabecerra · Mar 21, 2010

Nope, I tell them to take it like a shot.

Guruofgas · Dec 7, 2011

I am an anesthesiologist and am alarmed at the rather cavalier attitude about Bicitra. For years I wondered why on the 30cc dose cups it said "dilute as directed". Well, on the bottle of Bicitra it says dilute the 30cc with 30cc of water in a 1:1 dilution. A much greater dilution as an antiacid. This is the manufacturers label. In my many years of experience with it many patients threw it up a while after ingestion. Since now I inform the nurses to dilute the Bicitra, it is better tolerated and not as many vomit. One nurse told me later she had called the pharmacy and they said it didn't matter. Well, yes it does and I'm currently addressing that matter.

Addressing the quantity of stomach contents, NPO patients frequently have over 100-150cc of gastric fluid. The extra 30cc water will have minimal to no effect on the "NPO" status of the patient.

To finish this off, it is probably just better to give a PPI with enough time and avoid the Bicitra altogether unless it is an emergency. Nuff said.:)

allnurses Guide · Dec 7, 2011

I am an anesthesiologist and am alarmed at the rather cavalier attitude about Bicitra. For years I wondered why on the 30cc dose cups it said "dilute as directed". Well, on the bottle of Bicitra it says dilute the 30cc with 30cc of water in a 1:1 dilution. A much greater dilution as an antiacid. This is the manufacturers label. In my many years of experience with it many patients threw it up a while after ingestion. Since now I inform the nurses to dilute the Bicitra, it is better tolerated and not as many vomit. One nurse told me later she had called the pharmacy and they said it didn't matter. Well, yes it does and I'm currently addressing that matter.
Addressing the quantity of stomach contents, NPO patients frequently have over 100-150cc of gastric fluid. The extra 30cc water will have minimal to no effect on the "NPO" status of the patient.
To finish this off, it is probably just better to give a PPI with enough time and avoid the Bicitra altogether unless it is an emergency. Nuff said.:)

The common dosing is 30ml of bicitra prior to surgery/c-section. http://books.google.com/books?id=TZbnM0nPbk8C&pg=PA401&lpg=PA401&dq=sodium+citrate+prior+to+cesarean+section+15+ml&source=bl&ots=41t8j2KxcX&sig=kkXD2loUIdibgDn5nfb8ftCqGn4&hl=en&ei=AiHfTvO4GazViALhhpC6CA&sa=X&oi=book_result&ct=result&resnum=2&ved=0CCsQ6AEwAQ#v=onepage&q=sodium%20citrate%20prior%20to%20cesarean%20section%2015%20ml&f=false

Furthermore, it has been shown that this dose is not effective in up to 17% of C-section possibly d/t increased gastric volumes and/or decreased gastric motility. Adding another 30ml of fluid on top of 30ml of bicitra given is only going to increase the chances that the dose of Bicitra is going to be inadequate to neutralize all the stomach contents. One dose of 30ml of bicitra is enough to neutralize 255ml of gastric contents. Patients that are in active labor, as we well know, have decreased gastric motility and increasing the amount of fluid/gastric contents only increases overall risk of pulmonary aspiration. What you are suggesting is not the normal that most anesthesia providers do for the reasons listed above, if you have some research to provide to back up your statements I am sure we would all be happy to review it. Just being an anesthesiologist doesn't necessarily make you right.

Nuff said.

DebblesRN, ASN, BSN, RN · Dec 8, 2011

One place I used to work gave a dose of PPI IVP and a 30ml dose of Bicitra PO right before the patient was wheeled into the OR. We never diluted it. Told patients to take it like a shot. I never had a problem with a patient aspirating in the OR, or throwing up the Bicitra.

The place I work now, they like to give IV PPI, no oral meds before OR. You get the PPI in pre-op about an hour before your surgery.

I'm guessing the above Anesthesiologist does not work with obstretrical patients, and is relaying his/her experience in another type of surgery.

I personally have had 2 c-sections, the first I had to take the Bicitra (yuck) and the 2nd, I didn't. Didn't see much of a difference other than the happiness that I didn't have to choke down the sour nasty crap with the second one. Why not give the med IV prior to OR and bypass it altogether?? Works just as well. :)

strn96 · Dec 9, 2011

We give ours straight. I usually give a few ice chips to "chase it down", but our anesthesiologists would throw a fit if we diluted it.