Promoting Excellence in Symptom Management Case Series: Case Study: A New Intervention for Rapid End-of-Life Symptom Control in the Home Setting

Current Updates in Rectal Infusion of Fluids and Medications

Purpose of Review

Rectal infusion is a feasible alternative for the immediate administration of medication and fluids when intravenous access is delayed, contraindicated, or unnecessary. Advances in medical device technology have made rectal infusion more practical and easier for medical care providers, and more comfortable for patients. This paper briefly reviews the history of therapeutic rectal infusion, including recent improvements in technology and the existing evidence for the use of this technique.

Recent Findings

While ultrasound-guided peripheral intravenous (PIV) access techniques and other alternatives to landmark-based PIV catheter insertion have recently improved the ability of providers to overcome challenges related to difficult vascular access (DVA), these challenges are increasingly affecting patient outcomes, emergency department throughput, and the cost of medical care. In recent years, waves of parenteral drug, fluid, and supply shortages have affected hospitals. Concurrently, advances in rectal infusion technology have made rectal infusion easier, more comfortable, and more cost-effective than many parenteral options.

Summary

The infusion of resuscitative fluids and medications via the rectal route has previously fallen out of favor due to concurrent improvements in IV access devices. However, this technique demonstrates the potential for a reemergence considering the current challenges facing healthcare providers and systems. Improvements in rectal infusion devices, coupled with an aging population, increased incidence of DVA, shortages in parenteral drugs, fluids, supplies and skilled staff, and the need for care improvements in the post-acute setting have contributed to a greater need for easy, safe and effective alternatives to IV infusion.

Field Notes From the Frontline of a COVID-19 Outbreak: Dyspnea Management for Hospitalized Patients at End-of-Life

Northern New Jersey was inside one of the worst initial coronavirus disease 2019 pandemic epicenters in the United States. At the peak of the pandemic surge in mid-April 2020, New Jersey saw 8045 hospitalized patients with severe coronavirus disease 2019 symptoms, of which 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of critically ill patients, the national opioid shortage, and transmission prevention measures for standard palliative care treatment protocols in place for refractory and/or end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the following Notes From the Field is to provide concise, pragmatic, and experiential reflection by 3 palliative care advanced practice nurses from 3 different hospital systems within the pandemic epicenter. The novel methods and opioid strategies implemented by their respective palliative care teams to ensure continued effective and appropriate treatment for end-of-life dyspnea are described. These accounts include Lessons Learned in order to assist others who may need to quickly implement changes in the future due to pandemic resurgence or second-wave events.

Macy Catheter: Integration and Evaluation in a Hospice Setting to Provide Symptom Relief During End-of-Life Care

Provision of high-quality end-of-life care in a cost-effective work environment is the aim of all hospice organizations. This opportunity can be negatively affected when there is a limited supply of parenteral narcotics or administration routes are either not functional or fail to control symptoms. To combat these challenges, including a shortage of available parenteral narcotics, staff at a hospice organization adopted the use of a rectal catheter to deliver oral medications that were readily available. The implementation of a rectal catheter resulted in better control of symptoms, fewer titrations, and improvement in pain control and/or symptom management needs during end-of-life care management.

Transmucosal drug administration as an alternative route in palliative and end-of-life care during the COVID-19 pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has led to a surge in need for alternative routes of administration of drugs for end of life and palliative care, particularly in community settings. Transmucosal routes include intranasal, buccal, sublingual and rectal. They are non-invasive routes for systemic drug delivery with the possibility of self-administration, or administration by family caregivers. In addition, their ability to offer rapid onset of action with reduced first-pass metabolism make them suitable for use in palliative and end-of-life care to provide fast relief of symptoms. This is particularly important in COVID-19, as patients can deteriorate rapidly. Despite the advantages, these routes of administration face challenges including a relatively small surface area for effective drug absorption, small volume of fluid for drug dissolution and the presence of a mucus barrier, thereby limiting the number of drugs that are suitable to be delivered through the transmucosal route. In this review, the merits, challenges and limitations of each of these transmucosal routes are discussed. The goals are to provide insights into using transmucosal drug delivery to bring about the best possible symptom management for patients at the end of life, and to inspire scientists to develop new delivery systems to provide effective symptom management for this group of patients.

Evaluation of the Macy Catheter®: a rectal catheter for rapid medication and fluid administration

INTRODUCTION

Health care providers are increasingly challenged to balance cost considerations for devices, drugs, and staffing all while continuing to provide excellent care. Patients in both the post-acute and acute care settings often require fluid and/or medication when their oral route is compromised and vascular access may not be warranted or immediately accessible. The rectum is an underutilized administration point that can be accessed with speed and relative ease. Areas Covered: Literature reviews of pharmaceutical, medical, and nursing references reveal current and historical science that validates the rectal route as a means of alternative administration for fluids and medications. Expert Commentary: Historically the rectum has been used for medication and fluid delivery but in more recent times, use has waned due to many factors. The physiology of the rectum allows for rapid and reliable administration of a variety of medications as well as hydration. This serves as an introduction to a novel, simple, cost effective device that allows for discreet and painless rectal administration of fluids and medications when the oral route is compromised and/or intravenous access is difficult or unnecessary. This device is used in a variety of patients in many care settings.