Putting Drugs down an ET Tube ============================= þ Which Drugs can go down the ET Tube? - not NAVEL (Narcan, Atropine, Valium, Epinephrine, Lidocaine): see below - LANE (Lidocaine, Atropine, Narcan, Epinephrine) - LEAN (same, different order) - Can Valium Be Given Down the ET tube? No. þ Do you need to use a feeding tube to give ET drugs? - don't need to use feeding tube or IV catheter as in PALS text [Jasani MS, Nadkarni VM, Finkelstein MS, Mandell GA, Salzman SK, Norman ME. Effects of different techniques of endotracheal epinephrine administration in pediatric porcine hypoxic-hypercarbic cardiopulmonary arrest. Crit Care Med 1994;22:1174-1180.] [H„hnel J; Lindner KH; Ahnefeld FW. Endobronchial administration of emergency drugs. Resuscitation, 17: 3, 1989 Jun, 261-72.] Abstract: þ What dosage of Epi must you give to get it to work ET? 1) TITLE: Haemodynamic effects of tracheally administered adrenaline in anaesthetised patients. AUTHOR: Kestin IG; McCrirrick AB AUTHOR Department of Anaesthesia, Derriford Hospital, Plymouth. AFFILIATION: SOURCE: Anaesthesia 1995 Jun;50(6):514-7 NLM CIT. ID: 95343958 ABSTRACT: Ten patients undergoing arterial surgery in the leg received a combined general anaesthetic, which included muscle relaxation and intubation of the trachea, and a regional anaesthetic using a lumbar extradural catheter. The radial arterial pressure was measured. Adrenaline 0.1 micrograms.kg-1 was administered intravenously and the heart rate, arterial pressure and oxygen saturation were recorded every 15 s for 10 min. Adrenaline in 5 ml of saline was given into the trachea at 10 min intervals. The first was saline only, and successive injections contained 0.5 micrograms.kg-1, 1 microgram.kg-1, 2 micrograms.kg-1, and 3 micrograms.kg-1 of adrenaline. The mean maximum rise in systolic arterial pressure after adrenaline given intravenously was 30 (SD 11) mmHg, and 15 (SD 16) mmHg after the maximum dose of adrenaline given into the trachea (p < 0.05). The mean systolic arterial pressure was significantly increased between 45 s and 4.5 min after the adrenaline given intravenously, and 2 min after adrenaline given into the trachea. Of seven patients who received adrenaline 3 micrograms.kg-1 into the trachea, six had no noticeable effect and in the other patient, the increase in arterial pressure was less than 90% of the maximum rise after the adrenaline. We conclude that adrenaline given into the trachea is unreliable in humans with very large doses necessary in some patients to produce a clinically useful haemodynamic effect. 2) Title: Comparison of endotracheal and peripheral intravenous adrenaline in cardiac arrest. Is the endotracheal route reliable? Lancet Date of Pub: 1987 Apr 11 Author: Quinton DN; O'Byrne G; Aitkenhead AR; Issue/Part/Supplement: 8537 Volume Issue: 1 Abstract: Twelve patients presenting to an accident and emergency department in asystolic cardiac arrest were randomly allocated to treatment with endotracheal adrenaline (five patients) or peripheral intravenous adrenaline (seven patients). Femoral-artery blood samples were taken for assay of adrenaline and noradrenaline. After intravenous adrenaline there was a good clinical and biochemical response, but after endotracheal adrenaline there was no change in serum adrenaline and no measurable clinical response. The endotracheal route of adrenaline administration is not reliable in out-of-hospital cardiac arrest. 3) Authors Ralston SH. Tacker WA. Showen L. Carter A. Babbs CF. Title Endotracheal versus intravenous epinephrine during electromechanical dissociation with CPR in dogs. Source Annals of Emergency Medicine. 14(11):1044-8, 1985 Nov. Abstract The dose-response curves of epinephrine given either IV or endotracheally (ET) were compared during resuscitation from electromechanical dissociation (EMD). Ten anesthetized dogs were subjected to a two-minute period of electrically induced ventricular fibrillation (VF) followed by defibrillation without CPR to produce EMD. Mechanical CPR was followed by injection of either ET or IV epinephrine. Successful response was defined as a return of pulsatile blood pressure within two minutes of drug administration. Using log-dose increments of epinephrine, experimental trials were repeated in each animal. The IV and ET median effective doses were 14 and 130 micrograms/kg, respectively. When the trials were successful, the time between drug administration and either arterial blood pressure increases or return of spontaneous circulation did not differ significantly for the ET and IV groups. These results show that the dosage for epinephrine delivered ET must be higher than the IV dosage to achieve the same response during CPR. 4) Crespo SG. Schoffstall JM. Fuhs LR. Spivey WH. Title Comparison of two doses of endotracheal epinephrine in a cardiac arrest model. Source Annals of Emergency Medicine. 20(3):230-4, 1991 Mar. Abstract STUDY OBJECTIVE: The objective of this study was to measure plasma catecholamine levels and the cardiovascular response before and after endotracheal administration of epinephrine in a swine cardiac arrest model. DESIGN: Prospective, controlled laboratory investigation. TYPE OF PARTICIPANTS: Twenty-one swine weighing 10 to 12 kg, anesthetized with ketamine and alpha-chloralose and ventilated with room air. INTERVENTIONS: Ventricular fibrillation was induced with 90 V of 60 Hz current delivered to the right ventricle by transvenous pacemaker. Blood samples for epinephrine were drawn before arrest and every two minutes thereafter. At five minutes, external mechanical cardiac compressions were initiated. Nine animals received no further therapy and served as controls. Two groups of six animals received either 0.01 mg/kg or 0.1 mg/kg of epinephrine through the endotracheal tube at ten and 20 minutes. Blood samples were assayed for epinephrine. MEASUREMENTS: Arterial blood pressure, lead II ECG, and plasma epinephrine. MAIN RESULTS: Swine receiving epinephrine 0.01 mg/kg had an increase in epinephrine levels after drug administration, but these were not significantly different from control levels. The 0.1-mg/kg dose group had a significant increase in plasma epinephrine levels compared with controls and the 0.01-mg/kg dose group after receiving epinephrine at ten and 20 minutes. These increases were from 14 +/- 3 to 215 +/- 40 ng/mL (+/- SEM) at 12 minutes after arrest and from 151 +/- 56 to 402 +/- 80 ng/mL at 22 minutes after arrest. CONCLUSION: These data suggest that standard dosing of epinephrine through the endotracheal tube during arrest does not produce significant increases in plasma catecholamines or blood pressure. Epinephrine 0.1 mg/kg produces a significant increase in plasma epinephrine levels, but it is not sufficient to produce a significant change in blood pressure. 5) Comparison of i.v. and intra-tracheal administration of adrenaline [see comments] McCrirrick A; Monk CR Br J Anaesth, 1994 May, 72:5, 529-32 Abstract Adrenaline is the single most important therapeutic agent used in advanced cardiac life support (ACLS). Ideally it should be given into a large central vein but the European Resuscitation Council, the American Heart Association and the Resuscitation Council (U.K.) advise that adrenaline may be given into the trachea if i.v. access is not available. We have studied the effects of intra-tracheal and i.v. adrenaline in 16 patients undergoing mechanical ventilation. Log dose-response curves were constructed for systolic arterial pressure and heart rate responses. Intra-tracheal doses of adrenaline up to 10 micrograms kg-1, approximately one-third of that recommended for resuscitation, had no effect on arterial pressure or heart rate, whereas adrenaline 0.1 microgram kg-1 i.v. produced a mean increase in systolic pressure of 24 mm Hg. The intra-tracheal doses recommended for resuscitation (2-3 mg) are likely to be ineffective and consideration should be given to abandoning the tracheal route for adrenaline in ACLS. 6) Haemodynamic effects of tracheal compared with intravenous adrenaline [see comments] McCrirrick A; Kestin I Lancet, 1992 Oct 10, 340:8824, 868-70 Abstract If intravenous access is not available during cardiopulmonary resuscitation, tracheal administration of adrenaline 0.02 mg/kg, twice the intravenous dose, is recommended. In a randomised crossover study we investigated the haemodynamic effects of low doses of tracheal versus intravenous adrenaline. 12 anaesthetised patients having a hip replaced received one dose of adrenaline intravenously (0.1 microgram/kg) and the other tracheally (0.5 microgram/kg). There was a mean increase in systolic arterial pressure of 40.5 mm Hg (range 16-81) after the intravenous injection, with little effect on heart rate. Tracheal adrenaline had no effect on arterial pressure or heart rate. Thus low doses of tracheal adrenaline have no haemodynamic effects. We believe that the recommended tracheal dose of twice the intravenous dose is likely to be ineffective for the treatment of cardiac arrest. Animal studies suggest that a tracheal dose at least ten times the intravenous dose is required.