Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

An alternative for rapid administration of medication and fluids in the emergency setting using a novel device?,??

Abstract

Routes of administration for medications and fluids in the acute care setting have primarily focused on oral, intravenous, or intraosseous routes, but, in many patients, none of these routes is optimal. A novel device (Macy Catheter; Hospi Corp) that offers an easy route for administration of medications or fluids via rectal mucosal absorption (proctoclysis) has recently become available in the palliative care market; we describe here the first known uses of this device in the emergency setting. Three patients presenting to the hospital with conditions limiting more typical routes of medication or fluid adminis- tration were treated with this new device; patients were administered water for hydration, lorazepam for treatment of alcohol withdrawal, ondansetron for nausea, acetaminophen for fever, aspirin for antiplate- let effect, and methimazole for hyperthyroidism. Placement of the de- vice was straightforward, absorption of administered medications (judged by immediacy of effects, where observable) was rapid, and use of the device was well tolerated by patients, suggesting that this device may be an appealing alternative route to medication and fluid administration for a variety of indications in acute and critical care settings.

Routes of administration for medications and fluids in the acute care setting, such as emergency departments (EDs) and Intensive care units have primarily focused on oral, intravenous (IV), or intraosseous routes, but, in many patients, none of these routes is optimal. Patients who are volume depleted, with difficult vascular access, and poor oral tolerance are often not sick enough to require central line placement or sedated enough to tolerate intraosseous placement.

A novel device (Macy Catheter; Hospi Corp) that offers an easy route for administration of medications or fluids via rectal mucosal absorption (proctoclysis) has recently become available in the palliative care mar- ket. The catheter is a thin silicone tube 14F in diameter with a 15-mL balloon at the tip (sized to allow secure retention yet also provide for ready elimination in the event of need for defecation), multiple exit ports for fluid and medication passage, and an internal 1-way check valve to prevent backflow of fluids. Hypothesizing the potential benefits of this approach in a wider patient population, we describe here the first known uses of this device in the acute care (ED and ICU) setting.

? Funding: None.

?? Conflicts of interest: None.

An 80-year-old man with multiple medical comorbidities (obesity, chronic leg wound, Skin grafts, hypertension, coronary artery disease, and chronic obstructive pulmonary disease) presented to the ED via ambulance with fever, decreased mental status, and cough. Attempts at IV access by ambulance personnel were unsuccessful. Initial vital signs were Blood pressure , 124/68 mm Hg; heart rate (HR), 98 beats per minute; temperature (T), 38.4?C; oxygen saturation of 92% on 2-L nasal cannula; and Glasgow Coma Scale of 14 (due to confu- sion). Because the patient’s mental status was felt to preclude oral administration, but his BP and clinical condition did not warrant central IV access, we began treatment via placement of the Macy Catheter, where- as laboratories were drawn, and peripheral IV access was attempted in the ED. After the Macy Catheter was placed in the rectum, the balloon was inflated with water, and we administered a total of 50 mL of fluids and medications, including water, aspirin tablets dissolved in water, and aceta- minophen (Oral formulation), whereas peripheral IV access was established. Approximately 90 minutes later, the patient was afebrile (36.5?C), alert, and oriented, with laboratories showing an elevated white blood cell count and chest x-ray demonstrating pneumonia. After demonstrating the ability to tolerate oral liquids, the Macy Catheter was removed.

A 41-year-old woman presented via ambulance in alcohol withdrawal with vital signs of BP, 110/78 mm Hg; HR, 120 beats per minute; T, 36.9?C; and oxygen saturation of 98% on room air. Her Clinical Institute Withdrawal Assessment of Alcohol 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. The Macy Catheter was consequently placed without difficulty, and 2 mg of loraze- pam were administered, resulting in immediate improvement of the patient’s agitation, orientation, and tachycardia. The patient was then given 4 mg of ondansetron via the Macy Catheter, along with multiple ali- quots of tap water at a rate of 10 mL every 2 to 10 minutes over the subse- quent hour, resolving her tachycardia and eliminating her nausea. Her Clinical Institute Withdrawal Assessment of Alcohol score decreased to zero. A 25-year-old woman presented via ambulance with acute confu- sion, agitation, and tachycardia resulting from substance abuse (cocaine and heroin) with an underlying untreated hyperthyroidism for which the patient was previously taking methimazole. Her vital signs were BP, 118/73 mm Hg; HR, 117 beats per minute; T, 37.4?C; and oxygen saturation of 97% on room air. Intravenous access was established with some difficulty; however, the patient remained too confused and agitated to safely tolerate methimazole, which is only available in tablet form. To administer her methimazole, the Macy Catheter was easily placed; the methimazole tablets were administered after being crushed and

0735-6757/(C) 2015 The Authors. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

suspended in water. The Macy Catheter remained in place in the ICU for subsequent administrations every 6 hours, until the patient improved sufficiently to begin tolerating oral intake the day after admission.

The absorption of fluids and a wide variety of medications by the rectal mucosa is well described [1-5]. In fact, the administration of fluids for hydration is specifically referred to as proctoclysis or rectoclysis and has a long history of use, dating back to at least the early 1900s [6-9]. A recent report highlights the potential of this ap- proach in emergent and remote settings because no sterility or complex training is required [10]. However, practical use of this route has been limited due to the lack of a simple, effective means of administration with the ability to ensure secure retention of the administered fluids or medications.

The Macy Catheter became available in 2014, intended for pal- liative care and hospice patients. Because of its simplicity and po- tential attractiveness for use with our acute care patient population, our hospital recently began trialing the Macy Catheter for emergency and intensive care patients and has identified a number of benefits to this approach. Placement is easy and fast, with no need for sterility or advanced training, as the device is placed analogously to a standard Foley catheter but in the rectum rather than bladder. Absorption through rectal mucosa is rapid, with blood levels of many drugs (aqueous and alcoholic solutions in particular) becoming therapeutic very rapidly (potentially due to avoidance of the first-pass effect) [11]. Our experience has found that noticeable effects of lorazepam occurred less than 1 minute after rectal administration via the Macy Catheter and that the antipyretic effects of acetaminophen and antiemetic effects of ondansetron also appeared soon after administration. The avoidance of the need for repeated attempts at difficult vascu- lar access or placement of central venous access is appreciated by nurses, physicians, and patients alike.

Limitations of this report include the inherent retrospective nature of a case series. We did not perform a formal measurement of the total volumes of fluids administered or obtain a robust quan- tification of the timing between administration and observation of effects. We did not perform any pharmacokinetic laboratory mea- sures to determine efficacy of administered medications and relied solely on Clinical response. As recommended by the manufacturer, we used plain tap water for all of our flushes and to dissolve the oral formulations of aspirin and methimazole. Absorption from suppositories is generally slower than aqueous solutions and is dependent on the nature of the suppository base [11], but subtle influences on absorption rates from other unmeasured factors may influence our findings.

In summary, a novel rectal administration device appears to offer an appealing alternative route to medication and fluid administration for a variety of indications in acute and critical care settings.

Neal Lyons, PharmD

Department of Pharmacy Services Advocate Christ Medical Center, Oak Lawn, IL 60453

Daniel Nejak, MD

Department of Emergency Medicine Advocate Christ Medical Center, Oak Lawn, IL 60453

Nadine Lomotan, PharmD Robert Mokszycki PharmD Department of Pharmacy Services

Advocate Christ Medical Center, Oak Lawn, IL 60453

Stephen Jamieson, MD

Department of Emergency Medicine Advocate Christ Medical Center, Oak Lawn, IL 60453

Marc McDowell, PharmD

Department of Pharmacy Services Advocate Christ Medical Center, Oak Lawn, IL 60453

Erik Kulstad, MD, MS^?

Department of Emergency Medicine Advocate Christ Medical Center, Oak Lawn, IL 60453

?Corresponding author. Tel.: +1 708 684 3889;

fax: +1 708 684 1028

E-mail address: kulstad@uic.edu http://dx.doi.org/10.1016/j.ajem.2015.01.028

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