Endotracheal bretylium tosylate in a canine model

Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration

Difficulties and delays in establishing intravenous access are not uncommon in emergency situations in pediatrics. Alternatives to venous cannulation exist, including intraosseous access, intratracheal drug administration, sublingual and intralingual injection, the intrapenile route, and intracardiac injection. Each of these emergency alternatives to intravenous access is discussed from the historical, technical, utilitarian, and risk-benefit aspects. It is concluded that the intraosseous effective alternative to intravenous access in emergency situations.

Pharmacologic controversies in CPR

Since the 1985 Emergency Cardiac Care Conference, numerous controversies about the pharmacology of CPR have arisen (eg, questions about the pharmacokinetics and pharmacodynamics of drugs during CPR, the optimal vehicle for delivery of medications, and the dose of atropine in brady-asystolic cardiac arrest). This article has three objectives: 1) to critically explore these controversies, 2) to provide recommendations for clinical practice, and 3) to identify areas for future study. The ideal route is one which combines rapid access with quick delivery of drug to the central circulation. Because of hemodynamic changes during CPR, administration of drugs into the central circulation is preferable when compared with peripheral venous injection. Whenever drugs are administered from a peripheral i.v. site, the extremity should be elevated, and a 20-mL bolus of i.v. fluid should be given to facilitate access of the agent to the central circulation. If there is a delay in obtaining venous access, epinephrine, lidocaine, and atropine may be administered through the endotracheal tube at 2.5 times the i.v. dose. When administering these drugs through the endotracheal tube, dilute the drug in 10 mL of saline or water and inject it through a long catheter beyond the tip of the endotracheal tube. Dextrose 5% water is the primary vehicle for drug delivery during CPR. However, the administration of glucose during CPR is controversial because of the potentially detrimental effects of hyperglycemia on neuronal function during periods of ischemia. Data are inconclusive regarding the effects of glucose levels on neurologic outcome following resuscitation. Hyperglycemia may be a marker for prolonged resuscitation with subsequent impairment in insulin release.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversies in cardiopulmonary resuscitation: pediatric considerations

This article addresses some therapeutic controversies concerning medications that may be needed during advanced pediatric life support (APLS) and the routes of administration that may be selected. The controversies that are discussed include the appropriateness and selection of various routes for drug administration during APLS; the determination of whether epinephrine hydrochloride is the adrenergic agent of choice for APLS and its appropriate dose; treatment of acidosis associated with a cardiopulmonary arrest; recommendations for atropine sulfate doses; and the role, if any, of calcium in APLS. Background information differentiating pediatric from adult cardiopulmonary arrest is presented to enable the reader to have a better understanding of the specific needs of children during this life-threatening emergency. The article also presents an overview of various drugs used for APLS and a table of their typically recommended doses and routes of administration.

Differences in plasma lidocaine levels with endotracheal drug therapy secondary to total volume of diluent administered

Endotracheal drug therapy provides an effective alternative method for the administration of drugs in the numerous clinical settings in which intravenous access is difficult or impossible to obtain. However, the specific factors affecting endotracheal drug absorption and thus, the drug's plasma levels and effectiveness, has not yet been fully determined. Lidocaine alone or lidocaine mixed with normal saline was given endotracheally in four volumes (Volume I = undiluted with less than or equal to 5.5 cc total volume; Volume II = diluted to 6 cc total volume; Volume III = diluted to 12 cc total volume; Volume IV = diluted to 25 cc total volume) by the same technique of administration and in the same dosage of 4 mg/kg. Each dog served as its own control and received all four volumes of endotracheal lidocaine on different occasions. Plasma lidocaine levels at all four volumes and at all four time periods (5, 15, 30 and 60 min after giving endotracheal lidocaine) were obtained in each of the six dogs for a total of 96 plasma lidocaine levels measured in the study. Mean plasma lidocaine levels (micrograms/ml) at 5 min were: Volume I = 1.9, Volume II = 10.0, Volume III = 3.2 and Volume IV, = 4.3. These results were highly significant (P less than 0.001). The highest plasma lidocaine levels were obtained in the diluted volume, Volume II and the lowest plasma lidocaine levels in the undiluted volume, Volume I, with Volumes III and IV being intermediate.(ABSTRACT TRUNCATED AT 250 WORDS)

Endotracheal drug administration in the critical care setting

Administration of drugs through an endotracheal tube has been evaluated in a number of animal models. In addition, the technique has been utilized in humans as reported in several published cases. A review of endotracheal drug administration with emphasis on application to the critical care setting is presented.

Effect of technique of administration on plasma lidocaine levels

There are many clinical situations in which IV access is unavailable, and the endotracheal route is a valuable alternative route for drug therapy. The optimal technique of endotracheal drug administration, however, has not been determined. Twenty-nine dogs were divided into five groups and given endotracheal lidocaine at two doses, 2 mg/kg and 4 mg/kg, by differing techniques: control, undiluted lidocaine in a syringe was given as a bolus; needle, the drug was given through a needle attached to the syringe; dilution, lidocaine was diluted approximately 1:1 with normal saline and the entire dilution was given as a bolus; normal saline (NS) followup, lidocaine in a syringe was given as a bolus, followed immediately by an equal bolus of normal saline; and catheter, the drug was given through a catheter that was placed inside and extended just beyond the endotracheal tube. Mean plasma lidocaine levels (microgram/mL) at five minutes were as follows (at a 2-mg/kg endotracheal lidocaine dose): control, 0.64; needle, 0.0; dilution, 3.1; and (at a 4-mg/kg endotracheal lidocaine dose) control, 1.0; needle, 0.6; dilution, 6.2; NS followup, 1.9; and catheter, 1.9. At all time periods with either dose of lidocaine (2 or 4 mg/kg), the highest plasma lidocaine levels occurred with dilution and the lowest with the needle method. These results were highly significant (P less than .001). The highest plasma lidocaine levels may be attained by diluting the drug with normal saline. Higher levels were achieved when the drug was given through a catheter or when the drug was followed with a bolus of normal saline.(ABSTRACT TRUNCATED AT 250 WORDS)