Name: a novel approach for the administration of medications and fluids in emergency scenarios and settings
Uploaded: 2016-11-09T13:00:00
Duration: 6 min 59 s
Description: Watch this Scientific Journal Video about A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings at JoVE.com

The authors acknowledge the support of the Departments of Emergency Medicine and Pharmacy at the Advocate Christ Medical Center.&#160;

1. Assessment Guidelines Prior to Placement
<ol>
	<li>Prior to insertion, assess rectal opening for contraindications which include: 
	lesions, tumors, abscesses, rectal bleeding, diarrhea&#160;or recent bowel surgery (less than 6 weeks).</li>
	<li>Assess rectum for stool by performing a digital rectal exam prior to placement. 
	NOTE: It is best if the rectum is empty, however, formed stool in the rectum is not a contraindication for use.</li>
</ol>
2. Insertion of the Device
<ol>
	<li>Lubricate catheter from the tip to the blue marker line with water-soluble lubricant.</li>
	<li>Insert the catheter into the rectum to the blue marker line between the two blue arrows.</li>
	<li>Inflate balloon with Luer syringe by injecting&#160;15 mL water or saline.</li>
	<li>Gently tug catheter to assure balloon is positioned against the rectal sphincter.</li>
	<li>Position catheter between the legs and secure to the anterior aspect of the patient&#39;s thigh or lower abdomen with a catheter-securing device.</li>
</ol>
3. Medication Preparation and Administration
<ol>
	<li>Pulverize solid forms of medications.</li>
	<li>Add 10 - 20 mL water to pulverized medication to produce a microenema suspension.</li>
	<li>Pull microenema suspension into enteral syringe and inject quickly into catheter port over about 3 - 5 sec. 
	NOTE: For medication already in liquid form, Step 3.1 and 3.2 are not necessary.</li>
	<li>Quick-flush the Medication Administration Port (over less than one sec) with 3 mL of water using a 3 mL enteral syringe.</li>
</ol>
4. Hydration (Proctoclysis Procedure)
<ol>
	<li>Administer hypotonic solutions only (water, 0.2% Normal Saline, 0.5% Normal Saline, etc.).</li>
	<li>Administer bolus fluids using a large (45 or 60 mL) enteral syringe at a rate of about 60 mL over 15 - 30 sec. 
	NOTE: A hydration infusion via the catheter may be done using a gravity tube feeding bag which attaches readily to the medication port on the Macy Catheter. Infusion at rates of up to 250 - 400 mL/h have been shown to be well tolerated.7</li>
</ol>
5. Catheter Removal
<ol>
	<li>Remove the catheter before defecation. The catheter can remain in the rectum for up to 28 days. 
	NOTE: The catheter is easily expelled with defecation and will not inhibit the passing of stool.</li>
	<li>To remove the catheter deflate balloon with a Luer syringe. Attach 20 mL Luer syringe to balloon inflation valve and gently withdraw the 15 mL water from the balloon. Remove gently from the rectum. 
	NOTE: Contraindication for use. Do not use the catheter for patients with rectal lesions, tumors,&#160;active rectal bleeding or recent bowel surgery (less than 6 weeks). Do not use if rectal mucosa is compromised (ulcers or ischemic proctitis). Do not use for patients with diarrhea.</li>
</ol>

<ol>
	<li>Chiang, L. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rectal+diazepam+solution+is+as+good+as+rectal+administration+of+intravenous+diazepam+in+the+first-aid+cessation+of+seizures+in+children+with+intractable+epilepsy.">Rectal diazepam solution is as good as rectal administration of intravenous diazepam in the first-aid cessation of seizures in children with intractable epilepsy.</a> Pediatr Neonatol. 52 (1), 30-33 (2011).</li><li>Pasero, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Perioperative+rectal+administration+of+nonopioid+analgesics.">Perioperative rectal administration of nonopioid analgesics.</a> J Perianesth Nurs. 25 (1), 5-6 (2010).</li><li>Fouad, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preparation+and+investigation+of+acetyl+salicylic+acid-caffeine+complex+for+rectal+administration.">Preparation and investigation of acetyl salicylic acid-caffeine complex for rectal administration.</a> Pharm Dev Technol. 15 (3), 249-257 (2010).</li><li>Zweig, S. B., Schlosser, J. R., Thomas, S. A., Levy, C. J., Fleckman, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rectal+administration+of+propylthiouracil+in+suppository+form+in+patients+with+thyrotoxicosis+and+critical+illness:+case+report+and+review+of+literature.">Rectal administration of propylthiouracil in suppository form in patients with thyrotoxicosis and critical illness: case report and review of literature.</a> Endocr Pract. 12 (1), 43-47 (2006).</li><li>Nabil, N., Miner, D. J., Amatruda, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methimazole:+an+alternative+route+of+administration.">Methimazole: an alternative route of administration.</a> J Clin Endocrinol Metab. 54 (1), 180-181 (1982).</li><li>Needham, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proctoclysis+for+hydration.">Proctoclysis for hydration.</a> Lancet. 345 (8949), 596 (1995).</li><li>Bruera, E., Schoeller, T., Pruvost, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proctoclysis+for+hydration+of+terminal+cancer+patients.">Proctoclysis for hydration of terminal cancer patients.</a> Lancet. 344 (8938), 1699 (1994).</li><li>Trout, H. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proctoclysis:+Some+clinical+and+experimental+observations.">Proctoclysis: Some clinical and experimental observations.</a> Journal of the American Medical Association. LVIII. 58 (18), 1352-1354 (1912).</li><li>Murphy, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=PRoctoclysis+in+the+treatment+of+peritonitis.">PRoctoclysis in the treatment of peritonitis.</a> Journal of the American Medical Association. 52 (16), 1248-1250 (1909).</li><li>Tremayne, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+rectal+infusion+of+fluid+in+rural+or+remote+settings.">Emergency rectal infusion of fluid in rural or remote settings.</a> Emerg Nurse. 17 (9), 26-28 (2010).</li><li>Lam, Y. W., Lam, A., Macy, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pharmacokinetics+of+Phenobarbital+in+Microenema+Via+Macy+Catheter+Versus+Suppository.">Pharmacokinetics of Phenobarbital in Microenema Via Macy Catheter Versus Suppository.</a> J Pain Symptom. , (2016).</li><li>de Boer, A. G., Moolenaar, F., de Leede, L. G., Breimer, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rectal+drug+administration:+clinical+pharmacokinetic+considerations.">Rectal drug administration: clinical pharmacokinetic considerations.</a> Clin Pharmacokinet. 7 (4), 285-311 (1982).</li><li>Honasoge, A., Parker, B., Wesselhoff, K., Lyons, N., Kulstad, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+Use+of+a+New+Device+for+Administration+of+Buspirone+and+Acetaminophen+to+Suppress+Shivering+During+Therapeutic+Hypothermia.">First Use of a New Device for Administration of Buspirone and Acetaminophen to Suppress Shivering During Therapeutic Hypothermia.</a> Ther Hypothermia Temp Manag. , (2016).</li><li>Lyons, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+alternative+for+rapid+administration+of+medication+and+fluids+in+the+emergency+setting+using+a+novel+device.">An alternative for rapid administration of medication and fluids in the emergency setting using a novel device.</a> Am J Emerg Med. 33 (8), e1115-e1116 (2015).</li><li>Davis, M. P., Walsh, D., LeGrand, S. B., Naughton, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Symptom+control+in+cancer+patients:+the+clinical+pharmacology+and+therapeutic+role+of+suppositories+and+rectal+suspensions.">Symptom control in cancer patients: the clinical pharmacology and therapeutic role of suppositories and rectal suspensions.</a> Support Care Cancer. 10 (2), 117-138 (2002).</li><li>Fields, J. M., Piela, N. E., Au, A. K., Ku, B. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+associated+with+difficult+venous+access+in+adult+ED+patients.">Risk factors associated with difficult venous access in adult ED patients.</a> Am J Emerg Med. 32 (10), 1179-1182 (2014).</li></ol>

The authors have nothing to disclose.

The administration of medications and fluids via rectal mucosal absorption has been utilized in various environments over a long time period, with the provision of fluids by this route specifically given the term proctoclysis or rectoclysis6-9.&#160;Nevertheless, despite the effectiveness of this route, practical use has been limited by the availability of a convenient, and easy-to-use device to leverage it. The initial reports of use in the ED have shown that the catheter is easy to place, and the onset of effects from medications administered via the catheter appears quickly. Since the time to place the device is minimal, the catheter appears to be a valuable medications and fluids administration device in emergency and critical care settings.
Because the device is non-sterile, and is placed in the rectum in a similar fashion to a standard Foley catheter placed in the urethra, minimal skill is required, and almost no advanced training is necessary. The most critical component in rectal delivery of medication is an understanding of dosing via the rectal route. Most opiates, benzodiazepines, and NSAIDs are well absorbed and dosing is comparable to the oral route. An extensive review of the literature on rectal absorption of medications used in the palliative setting has been compiled15. It is important to note that hypotonic fluids should be used for proctoclysis, as absorption through the rectal mucosa occurs by passive diffusion and isotonic and hypertonic fluids may have a cathartic effect. With the use of hypotonic fluids, rectal hydration via infusing water at a rate of up to 400 mL/h&#160;has been demonstrated, with a mean rate of 224&#160;mL/h7.
Due to the simplicity of the device there is minimal need for troubleshooting. It is important to note that the medication port on the catheter mates only with an enteral syringe. Luer syringes cannot connect to the medication port. This feature was designed to avoid misconnection errors between parenteral devices (Luer syringe) and gastrointestinal device (enteral syringe). For this reason, an IV bag cannot be attached directly to the catheter for administration of fluids as IV tubing is fitted with Luer connectors. A &#34;Luer to Enteral&#34; adaptor can be purchased for this purpose, or hydration can be performed by bolusing the patient with fluids using a 60 mL enteral syringe that comes with the catheter in the kit supplied by the manufacturer.
Critical situations such as shock, sepsis or cardiac arrest need parenteral access either by IV or intraosseous methods, as rectal medication and fluid administration does not provide immediate absorption; however, a rectal catheter can provide an additional rapidly accessible route in these situations. For example, in the incidence of sepsis, when protocols demand large volumes of fluids in a short period of time, multiple IV access points are necessary, and rectal fluid delivery can be a way to increase vascular volume rapidly while multiple IVs are being implemented. In addition, the catheter can provide a route of access for medications that cannot be instilled intravenously, such as Buspirone for the control of shivering in hypothermia induction and aspirin for platelet inhibition and fever reduction.
Difficult IV access is an increasingly common problem in the ED setting. Fields et al. found that 1 in 10 patients admitted into an urban ED were considered to be &#39;difficult IV access&#39;16. For patients in whom vascular access is difficult, delayed&#160;or unnecessary, this new method of medication and fluid delivery may prove invaluable in the ED. Medications and fluids can be administered in minutes while awaiting ultrasound placement, central venous placement, or during repeated attempts at peripheral placement. In these cases, the rectal catheter can allow for hydration or management of a patient&#39;s condition that may be complicating IV access, by decreasing the difficulty of placement. In pediatric patients, who are well known to have difficult IV access (and generally fear invasive or painful procedures), this technique may be a good alternative.
Intraosseous infusion is painful and pre-medication with lidocaine can be time consuming. For alert patients that are not critically ill, the use of this catheter may be preferable from a cost, time, and patient comfort perspective, since the cost of the device offers significant savings over alternatives such as a popular intraosseous needle delivery system in widespread use. The catheter may be a good alternative to nasogastric placement for fluid and medication therapy since no imaging, such as X-ray confirmation of placement, is necessary and it less likely to cause discomfort or injury during placement. Even with ultrasound guidance technology, IV placement can be significantly delayed and treatment can be initiated and even completed without IV access offering additional savings in time and money. Significant savings can be realized in the use of lower cost oral medications (such as tablets that can be crushed and administered via the catheter) compared to intravenous formulations of the same medication. Finally, this device has less potential for complications compared to IV access, decreasing the incidence of infections, infiltration, and embolism associated with intravenous treatment.
Patient types that commonly present as difficult peripheral IV access and may benefit from this method include patients with diabetes, obesity, renal failure, edema, IV drug use&#160;or those receiving chemotherapy. Most pediatric and elderly patients may also benefit. Specific clinical needs for which the catheter may be used in the emergency setting may include hydration, fever, pain, agitation, seizures, migraine, sickle cell crisis, gastroparesis&#160;or nausea and vomiting.
The catheter can also be used for instillation of retention enemas such as lactulose for elevated ammonia, Kayexalate for elevated potassium, and saline or other preparations for severe constipation, or to assist for disimpaction. It is an alternative option for retention enemas than the currently utilized bowel management systems which employ a larger diameter shaft and balloon, and it is easier to insert and use.
There are several other benefits of using of the catheter in the ED setting, including decreased wait times, decreased staff burden, and decreased iatrogenic complications related to intravenous therapy. Patient satisfaction can be improved with reduced wait times, and patient symptoms such as pain or vomiting could be relieved quickly without having to wait for IV access.

The most common routes of administration for medications and fluids in the emergency care setting are generally oral (if the patient can tolerate oral intake), intravenous (for more rapid administration, or provision of medications not orally bioavailable), or intraosseous (in the case where intravascular access is difficult to obtain). Nevertheless, in many cases, patients who are too ill to tolerate oral intake are also dehydrated, with poor vascular access that prevents placement of intravascular (IV) lines. In most cases, intraosseous placement is not an ideal option, since the discomfort of administration in an awake patient can be significant.
A new device, the catheter, offers an alternative route via rectal mucosal absorption, which is a route long-known to be effective and easy to access1-11. Absorption through the rectal mucosa is generally rapid, with blood levels of many drugs attaining therapeutic levels rapidly, in part as a result of avoiding the first-pass effect.12 The catheter has a silicone tube that is 14 Fr in diameter and has a 15 mL balloon at the tip. The balloon provides for secure retention of the catheter for retention of administered medications and fluids, yet also allows elimination through passage via defecation. The catheter has multiple exit ports at the distal tip for fluid and medication passage, and an internal one-way check valve at the proximal end to prevent backflow of fluids (Figure 1). A description of the components of the device is shown in Table 1.
This catheter, which became available in 2014, was originally intended for palliative care and hospice patients, being designed to meet the needs of family members taking care of patients in the home setting, eliminating the need for hospitalizations and more invasive care. The product design particularly enables the preservation of the patient dignity while being easy enough for those without a medical background to use. However, because of its appeal for use with emergency department and critical care patients, the device has been increasingly utilized in this setting recently. In particular, case reports and case series describing the novelty of this approach in the emergency setting first appeared just in the last year13,14.
The features and benefits of the catheter enable easier and more efficient use of the rectal mucosal administration route than has been available previously. Placement of the catheter is easy, with no need for sterility. Use of the device requires no advanced training, since it is placed in a manner similar to a standard Foley catheter. Because placement is simple, repeat attempts at vascular access can be avoided, which increases satisfaction of both providers and patients. Indications for the device are to provide rectal access to administer liquids/medications.
Case Presentation
A number of examples of use of the catheter in emergency settings, including emergency departments and intensive care units, have been recently reported13-14. Examples of these include:
Case 1
An 80-year-old male with multiple medical comorbidities, including obesity, chronic leg wound, skin grafts, HTN, CAD, and COPD, presented to the Emergency Department (ED) via ambulance with fever, decreased mental status, and cough. Attempts at IV access by ambulance personnel, and subsequently by ED personnel after arrival, were unsuccessful. The patient&#39;s initial vital signs were:&#160;BP 124/68, HR&#160;98, T 38.4 &#176;C, O2 saturation of 92% on 2L NC, and GCS of 14 (due to confusion).
Case 2
A 41-year-old female presented via ambulance in alcohol withdrawal with vital signs of BP 110/78, HR 120, T 36.9 &#176;C, and oxygen saturation of 98% on room air. Her Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score was 9. Attempts at obtaining IV access for administration of fluids and benzodiazepines were unsuccessful, and the patient was deemed too disoriented and agitated to safely tolerate oral administration.
Case 3
A 25-year-old female presented via ambulance with acute confusion, agitation, and tachycardia resulting from substance abuse, including cocaine and heroin. She had an underlying untreated hyperthyroidism for which the patient was previously taking methimazole. Her vital signs were BP 118/73, HR 117, T 37.4 &#176;C, and oxygen saturation of 97% on room air. IV access was established with some difficulty; however, the patient remained too confused and agitated to safely tolerate methimazole tablets (the medication is only available in oral form).
Case 4
A 59-year-old male was brought into the ED&#160;after a cardiac arrest followed by return of spontaneous circulation after defibrillation, but persistent coma. Therapeutic hypothermia was instituted, but despite maximum cooling power provided by external surface pads, the patient&#39;s temperature was noted to be climbing, likely as a consequence of ongoing shivering. Because an NG tube placed to suction revealed gastric contents to be similar in appearance to coffee grounds, GI bleeding was suspected, and NG tube administration of medications, including acetaminophen and buspirone was felt to be contraindicated.
Diagnosis, Assessment, and Plan
In all of the above patients, this method of medication delivery provided a useful alternative treatment modality to address challenging medication and fluid administration conditions.

<table border="0" cellpadding="0" cellspacing="0" width="688">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Macy Catheter</td>
			<td style="width:115px;">Hospi Corp.</td>
			<td style="width:119px;">MAC 1001</td>
			<td style="width:239px;">Single Macy catheter device</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Macy Catheter Bedside Care Kit</td>
			<td style="width:115px;">Hospi Corp.</td>
			<td style="width:119px;">MCK 1001</td>
			<td>Kit with syringes, Liqui-Pill grinder</td>
		</tr>
	</tbody>
</table>

a novel approach for the administration of medications and fluids in emergency scenarios and settings

The available routes of administration commonly used for medications and fluids in the acute care setting are generally limited to oral, intravenous, or intraosseous routes, but in many patients, particularly in the emergency or critical care settings, these routes are often unavailable or time-consuming to access. A novel device is now available that offers an easy route for administration of medications or fluids via rectal mucosal absorption (also referred to as proctoclysis in the case of fluid administration and subsequent absorption). Although originally intended for the palliative care market, the utility of this device in the emergency setting has recently been described. Specifically, reports of patients being treated for dehydration, alcohol withdrawal, vomiting, fever, myocardial infarction, hyperthyroidism, and cardiac arrest have shown success with administration of a wide variety of medications or fluids (including water, aspirin, lorazepam, ondansetron, acetaminophen, methimazole, and buspirone). Device placement is straightforward, and based on the observation of expected effects from the medication administrations, absorption is rapid. The rapidity of absorption kinetics are further demonstrated in a recent report of the measurement of phenobarbital pharmacokinetics. We describe here the placement and use of this device, and demonstrate methods of pharmacokinetic measurements of medications administered by this method.

Initial reports of the use of this method of medication and fluid delivery in the emergency or critical care setting demonstrate rapid effects from the medications and fluids administered in the variety of conditions described13,14.&#160;In addition, these patients tolerated the procedure well with no complaints of discomfort. The average time taken for placement of the catheter was about 1 min. Furthermore, the procedure was well accepted and the patients who were awake and alert verbalized satisfaction with this mode of fluids and medications delivery. The clinical outcomes for the four cases presented are shown below.
Clinical Outcomes
Case 1
The 80-year-old male with multiple medical comorbidities was provided a total of 50 mL of fluids and medications, including water, aspirin tablets dissolved in water, and acetaminophen (oral formulation), for the treatment of fever, dehydration, and elevated troponin. Approximately 90 min later, the patient was afebrile, alert, and oriented (Figure 2).
Case 2
The 41-year-old female in alcohol withdrawal and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 9 was given 2 mg of lorazepam, resulting in immediate improvement of the patient&#39;s agitation, orientation, and tachycardia. The patient was then given 4 mg of ondansetron along with multiple aliquots of tap water at a rate of 10 mL every 2 -&#160;10 min over the subsequent hour, resolving her tachycardia and eliminating her nausea, while bringing her CIWA score to zero.
Case 3
The 25-year-old female with acute confusion, agitation, and tachycardia resulting from substance abuse (cocaine and heroin) with an underlying untreated hyperthyroidism, was given methimazole tablets after being crushed and suspended in water. The catheter remained in place in the Intensive Care unit (ICU) for subsequent administrations every six hours until the patient improved sufficiently to begin tolerating oral intake the day after admission.
Case 4
The 59-year-old cardiac arrest patient was given liquid acetaminophen (650 mg) and Buspirone (30 mg) via the catheter, which was then flushed with normal tap water. Shortly after the administration of these medications, the patient&#39;s previously rising core temperature effectively plateaued at 36.9 &#176;C and he clinically stopped shivering.
<img alt="Figure 1" src="/files/ftp_upload/54622/54622fig1.jpg" /> 
Figure 1. Diagram of Catheter. Reprint with permission from manufacturer. <a href="https://www.jove.com/files/ftp_upload/54622/54622fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" src="/files/ftp_upload/54622/54622fig2.jpg" /> 
Figure 2. Temperature Profile of an 80-year-old Male Patient Provided Antipyretics via Catheter. <a href="https://www.jove.com/files/ftp_upload/54622/54622fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Catheter Part </td>
			<td>Description</td>
			<td>Purpose</td>
		</tr>
		<tr>
			<td>Medication Administration Port</td>
			<td>Clear Plastic Port Marked &#34;MEDS&#34;</td>
			<td>Connects with an enteral/oral syringe to deliver medications and liquids to the rectum</td>
		</tr>
		<tr>
			<td>Balloon Inflation Port</td>
			<td>Red Plastic Port Marked &#34;Inflate w 15 mL&#34;</td>
			<td>Connects with Luer type syringe to inflate balloon with 15 mL water</td>
		</tr>
		<tr>
			<td>Placement Marker Lines</td>
			<td>Two black arrow markers between black line towards the tip of the catheter</td>
			<td>Assists in proper placement of the catheter in the distal 1/3 of the rectum</td>
		</tr>
		<tr>
			<td>Balloon</td>
			<td>Inflatable balloon towards the tip of the catheter</td>
			<td>Holds the medication and device in the rectum and is easily expelled by defecation.</td>
		</tr>
		<tr>
			<td>Medication Delivery Holes</td>
			<td>Four holes near the tip of the catheter</td>
			<td>Allow for transmission of medications and fluids from the catheter to the rectum.</td>
		</tr>
	</tbody>
</table>
Table 1: Catheter - Parts/Description/Purpose.

Watch this Scientific Journal Video about A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings at JoVE.com

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings

This study presents a novel device that offers an easy route to quickly provide medications and fluids in patients with limited or difficult IV access. This small-diameter device is placed in the distal third of the rectum, allowing for ongoing medication and fluids administration.

The available routes of administration commonly used for medications and fluids in the acute care setting are generally limited to oral, intravenous, or ...

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Inclusion body myositis (IBM) is a rare idiopathic inflammatory myopathy. It is known to produces remarkable muscle weakness and to greatly compromise ...

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Bronchial thermoplasty is performed during bronchoscopy with the patient under moderate sedation. All accessible airways distal to the mainstem bronchi between 3 and 10 mm in diameter, with the exception of the right middle lobe, are treated under bronchoscopic visualization. Contiguous and non-overlapping activations of the device are used, moving from distal to proximal along the length of the airway, and systematically from airway to airway as described previously. Although conceptually straightforward, the actual execution of bronchial thermoplasty is quite intricate and procedural duration for the treatment of a single lobe is often substantially longer than encountered during routine bronchoscopy. As such, bronchial thermoplasty should be considered a complex interventional bronchoscopy and is intended for the experienced bronchoscopist. Optimal patient management is critical in any such complex and longer duration bronchoscopic procedure. This article discusses the importance of careful patient selection, patient preparation, patient management, procedure duration, postoperative care and follow-up to ensure that bronchial thermoplasty is performed safely.
Bronchial thermoplasty is expected to complement asthma maintenance medications by providing long-lasting asthma control and improving asthma-related quality of life of patients with severe asthma. In addition, bronchial thermoplasty has been demonstrated to reduce severe exacerbations (asthma attacks) emergency rooms visits for respiratory symptoms, and time lost from work, school and other daily activities due to asthma.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled ...

A Novel Surgical Approach for Intratracheal Administration of Bioactive Agents in a Fetal Mouse Model

Prenatal pulmonary delivery of cells, genes or pharmacologic agents could provide the basis for new therapeutic strategies for a variety of genetic and acquired diseases. Apart from congenital or inherited abnormalities with the requirement for long-term expression of the delivered gene, several non-inherited perinatal conditions, where short-term gene expression or pharmacological intervention is sufficient to achieve therapeutic effects, are considered as potential future indications for this kind of approach. Candidate diseases for the application of short-term prenatal therapy could be the transient neonatal deficiency of surfactant protein B causing neonatal respiratory distress syndrome1,2 or hyperoxic injuries of the neonatal lung3. Candidate diseases for permanent therapeutic correction are Cystic Fibrosis (CF)4, genetic variants of surfactant deficiencies5 and &alpha;1-antitrypsin deficiency6.
Generally, an important advantage of prenatal gene therapy is the ability to start therapeutic intervention early in development, at or even prior to clinical manifestations in the patient, thus preventing irreparable damage to the individual. In addition, fetal organs have an increased cell proliferation rate as compared to adult organs, which could allow a more efficient gene or stem cell transfer into the fetus. Furthermore, in utero gene delivery is performed when the individual's immune system is not completely mature. Therefore, transplantation of heterologous cells or supplementation of a non-functional or absent protein with a correct version should not cause immune sensitization to the cell, vector or transgene product, which has recently been proven to be the case with both cellular and genetic therapies7.
In the present study, we investigated the potential to directly target the fetal trachea in a mouse model. This procedure is in use in larger animal models such as rabbits and sheep8, and even in a clinical setting9, but has to date not been performed before in a mouse model. When studying the potential of fetal gene therapy for genetic diseases such as CF, the mouse model is very useful as a first proof-of-concept because of the wide availability of different transgenic mouse strains, the well documented embryogenesis and fetal development, less stringent ethical regulations, short gestation and the large litter size.
Different access routes have been described to target the fetal rodent lung, including intra-amniotic injection10-12, (ultrasound-guided) intrapulmonary injection13,14 and intravenous administration into the yolk sac vessels15,16 or umbilical vein17. Our novel surgical procedure enables researchers to inject the agent of choice directly into the fetal mouse trachea which allows for a more efficient delivery to the airways than existing techniques18.

We developed a novel surgical approach for intratracheal administration of bioactive agents into the mouse fetus. The delivery route is more efficient in targeting the fetal mouse lungs than the commonly used intra-amniotic injection. This procedure has to date not been described in a mouse model.

Prenatal pulmonary delivery of cells, genes or pharmacologic agents could provide the basis for new therapeutic strategies for a variety of genetic and ...

Isolation and Excision of Murine Aorta; A Versatile Technique in the Study of Cardiovascular Disease

Cardiovascular disease is a broad term describing disease of the heart and/or blood vessels. The main blood vessel supplying the body with oxygenated blood is the aorta. The aorta may become affected in diseases such as atherosclerosis and aneurysm. Researchers investigating these diseases would benefit from direct observation of the aorta to characterize disease progression as well as to evaluate efficacy of potential therapeutics. The goal of this protocol is to describe proper isolation and excision of the aorta to aid investigators researching cardiovascular disease. Isolation and excision of the aorta allows investigators to look at gross morphometric changes as wells as allowing them to preserve and stain the tissue to look at histologic changes if desired. The aorta may be used for molecular studies to evaluate protein and gene expression to discover targets of interest and mechanisms of action. This technique is superior to imaging modalities as they have inherent limitations in technology and cost. Additionally, primary isolated cells from a freshly isolated and excised aorta can allowing researchers to perform further in situ and in vitro assays. The isolation and excision of the aorta has the limitation of having to sacrifice the animal however, in this case the benefits outweigh the harm as it is the most versatile technique in the study of aortic disease.

Pathology of the aorta can lead to severe morbidity and mortality, therefore research of disease progression and potential therapies is warranted. Here, we present a protocol to isolate and excise the murine aorta to aid researchers in their investigation of cardiovascular disease.

Cardiovascular disease is a broad term describing disease of the heart and/or blood vessels. The main blood vessel supplying the body with oxygenated ...

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can be&#160;achieved by either&#160;thrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient&#39;s outcome.
This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency.
This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital.
A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

Use of a Central Venous Line for Fluids, Drugs and Nutrient Administration in a Mouse Model of Critical Illness

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce sepsis with the use of a central venous line for fluids, drugs and nutrient administration to mimic the human clinical setting. Critically ill patients require intensive medical support in order to survive. While the majority of patients will recover within a few days, about a quarter of the patients need prolonged intensive care and are at high risk of dying from non-resolving multiple organ failure. Furthermore, the prolonged phase of critical illness is hallmarked by profound muscle weakness, and endocrine and metabolic changes, of which the pathogenesis is currently incompletely understood. The most widely used animal model in critical care research is the cecal ligation and puncture model to induce sepsis. This is a very reproducible model, with acute inflammatory and hemodynamic changes similar to human sepsis, which is designed to study the acute phase of critical illness. However, this model is hallmarked by a high lethality, which is different from the clinical human situation, and is not developed to study the prolonged phase of critical illness. Therefore, we adapted the technique by placing a central venous catheter in the jugular vein allowing us to administer clinically relevant supportive care, to better mimic the human clinical situation of critical illness. This mouse model requires an extensive surgical procedure and daily intensive care of the animals, but it results in a relevant model of the acute and prolonged phase of critical illness.

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce sepsis with the use of a central venous line for fluids, drugs and nutrient administration to mimic the human clinical setting.

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce ...

Cardiopulmonary Bypass in a Mouse Model: A Novel Approach

As prolonged cardiopulmonary bypass becomes more essential during cardiac interventions, an increasing clinical demand arises for procedure optimization and for minimizing organ damage resulting from prolonged extracorporal circulation. The goal of this paper was to demonstrate a fully functional and clinically relevant model of cardiopulmonary bypass in a mouse. We report on the device design, perfusion circuit optimization, and microsurgical techniques. This model is an acute model, which is not compatible with survival due to the need for multiple blood drawings. Because of the range of tools available for mice (e.g., markers, knockouts, etc.), this model will facilitate investigation into the molecular mechanisms of organ damage and the effect of cardiopulmonary bypass in relation to other comorbidities.

This paper describes how to perform cardiopulmonary bypass in mice. This novel model will facilitate the investigation of the molecular mechanisms involved in organ damage.

As prolonged cardiopulmonary bypass becomes more essential during cardiac interventions, an increasing clinical demand arises for procedure optimization ...

A Novel Approach to Monitoring Graft Neovascularization in the Human Gingiva

Laser speckle contrast imaging (LSCI) is a novel method for measuring superficial blood perfusion over large areas. Since it is non-invasive and avoids direct contact with the measured area, it is suitable for monitoring blood flow changes during wound healing in human patients. Vestibuloplasty is periodontal surgery to the oral vestibule, aiming to restore vestibular depth with simultaneous enlargement of the keratinized gingiva. In this special clinical case, a split thickness flap was elevated at the first upper premolar and a xenogenic collagen matrix was adapted to the resulting recipient bed. LSCI was used to monitor the re- and neovascularization of the graft and the surrounding mucosa for one year. A protocol is introduced for the correct adjustment of microcirculation measurement in the oral mucosa, highlighting difficulties and possible failures.
The clinical case study presented demonstrated that &#8212; following the appropriate protocol &#8212; LSCI is a suitable and reliable method for following up microcirculation in a healing wound in the human oral mucosa and gives useful information on graft integration.

This study introduces a protocol for measuring microcirculation in human oral mucosa by laser speckle contrast imaging. The monitoring of wound healing after vestibuloplasty combined with a xenogenic collagen graft is presented on a clinical case.

Laser speckle contrast imaging (LSCI) is a novel method for measuring superficial blood perfusion over large areas. Since it is non-invasive and avoids ...

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

Orthotopic Rat Kidney Transplantation: A Novel and Simplified Surgical Approach

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of renal replacement therapy. Over the past few decades, the rat kidney transplantation model has been used to study the immunological phenomena of rejection and tolerance. This model has become an indispensable tool to test new immunomodulatory pharmaceuticals and regimens prior to proceeding with expensive preclinical large animal studies.
This protocol provides a detailed overview of how to reliably perform orthotopic kidney transplantation in rats. This protocol includes three distinctive steps that increase the probability of success: perfusion of the donor kidney by flushing through the portal vein and the use of a cuff system to anastomose the renal veins and ureters, thereby decreasing cold and warm ischemia times. Using this technique, we have achieved survival rates beyond 6 months with normal serum creatinine in animals with syngeneic or tolerant kidney transplants. Depending on the aim of the study, this model can be modified by pre- or posttransplant treatments to study the acute, chronic, cellular, or antibody-mediated rejection. It is a reproducible, reliable, and cost-effective animal model to study different aspects of kidney transplantation.

The purpose of this manuscript and protocol is to explain and demonstrate in detail the surgical procedure of orthotopic kidney transplantation in rats. This method is simplified to achieve the correct perfusion of the donor kidney and shorten the reperfusion time by using the venous and ureteral cuff anastomosis technique.

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of ...