A 2-year-old child presents for endoscopic removal of a button battery lodged in the esophagus. The patient was transported from a location two hours away and received 60 mL of honey en route. The battery ingestion occurred approximately one hour prior to transport. According to a recent review article, which of the following statements is MOST likely true for this patient?
  • □ (A) Ingested button battery should be removed emergently despite her nil per os status.
  • □ (B) Tissue injury will halt once the battery is removed.
  • □ (C) Honey should not have been administered.
Ingestion of button batteries can be difficult to diagnose in children because the symptoms are often nonspecific and the ingestion may not have been witnessed. The rates of major morbidity and mortality after button battery ingestion have increased markedly since 2006, when 3-volt, 20-mm lithium batteries were introduced. These rates have been reported to be as high as 12.6% in children younger than 6 years. When lithium batteries come in contact with tissue, current flows through the tissue between the positive and negative poles of the battery, splitting water into hydrogen and hydroxide ions. The dissociation of water molecules creates a highly alkaline environment, which in turn causes liquefactive necrosis of the adjacent tissue. Most damage occurs to tissues in contact with the negative pole of the battery (the narrower pole, usually visible on a radiograph). Damage begins within 15 minutes. Injury-free removal can be expected if done within two hours of ingestion. A battery lodged in a small child’s upper esophagus for more than 12 hours with the negative pole facing posteriorly may increase the risk of an aortoesophageal fistula, or a tracheoesophageal fistula if the negative pole was directed anteriorly. The timing of removal, as well as the location and resources available, could determine the outcome.

Aortoesophageal fistulas are the most common cause of fatal hemorrhage from the ingestion of a button battery. They are almost always fatal, with only two instances of survival having been reported. Depending on their location, button batteries can also cause nasal septal perforation, intranasal synechiae, periorbital cellulitis, tympanic membrane perforation, hearing loss, facial nerve paralysis, vocal cord paralysis (unilateral or bilateral) from recurrent laryngeal nerve dysfunction, thyroid parenchymal damage, spondylodiscitis, mediastinitis, and bronchial stenosis.

Emergent removal of esophageal button batteries is critical. However, the resources necessary for removal (e.g., pediatric anesthesiologists, gastroenterologists, pediatric endoscopes) may not be present at all health care facilities. The National Capital Poison Center updated its button battery ingestion triage and treatment guideline in June 2018, which continues to emphasize the emergent removal of button batteries. It also provides mitigation strategies that can be employed while awaiting transport to a medical facility. Honey and sucralfate have been proven to decrease the damage substantially by neutralizing the alkalinity. Administration of 10 mL of honey is recommended every 10 minutes only in children older than 12 months, and only if ingestion occurred within 12 hours. A maximum of six doses of honey is recommended.

If the ingestion is suspected to have occurred more than 12 hours earlier, esophageal perforation may have occurred, and esophageal rest is recommended until perforation is ruled out by endoscopy. If the esophagus is intact after removal of the battery, the guideline also recommends irrigation of the esophagus with 50 to 150 mL of 0.25% acetic acid to neutralize the alkali. Inspection of the airway with laryngoscopy or bronchoscopy may be required. Patients with esophageal injury may need to be admitted and observed with serial imaging and repeat endoscopy. Continued and progressive tissue damage caused by ongoing alkali injury after battery removal is the hallmark of button battery-induced esophageal damage, with tracheoesophageal fistulas occurring up to nine days after removal and aortoesophageal fistulas occurring as late as 28 days after removal. Esophageal strictures or spondylodiscitis may manifest weeks, or even months, later.

Immediate radiographic evaluation to locate the battery is advised. If the battery is in the esophagus, immediate removal is emphasized. Risk stratification based on duration, size, orientation, and location will determine the safest way to remove the battery. One institution did an aortic arteriogram in the cardiac catheterization suite to determine the proximity of the ingested battery to the aorta before deeming it safe for endoscopic removal. The need for specialists to be present at the time of removal (e.g., pediatric general surgeon, cardiothoracic surgeon, interventional cardiologist) must be determined on a case-by-case basis. Blood products may need to be immediately available.

If the battery is in the stomach, it may still be removed emergently even if the patient is asymptomatic. If the battery has passed into the intestine, the patient may be managed conservatively as long as there is only one battery and a magnet has not been coingested (coingestion with a magnet requires consideration for emergent removal regardless of where the battery is located). In older children, outpatient management may be an option depending on the size and quantity of ingested batteries, provided no magnet has been coingested.

Anesthetic implications include the need to proceed regardless of the nil per os status of the child. If there is risk for a vascular-esophageal fistula, the patient will need adequate vascular access for monitoring and receiving blood products. Personnel required and the location for the procedure are dependent on the likelihood of serious complications. Anesthesiologists may need to provide anesthesia in non-OR locations. Spontaneous ventilation and I.V. anesthesia may be required for airway evaluation. Patients may return for repeat procedures and imaging in the following weeks to months.

Anesthesiologists are familiar with different areas of the hospital, including the endoscopy suite, cardiac catheterization laboratory, interventional radiology suite, and OR. Thus, anesthesiologists may be able to advise the team regarding the best location for the procedure. Familiarity with the latest guidelines and possible risks and complications of button battery ingestion will enable the anesthesia provider to be a valuable team player in achieving a favorable outcome for these patients.

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Answer: A