Endotracheal Med Administration...Help!

Nurses Medications

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Specializes in Med-Surg/Oncology, Psych.

So, it's Saturday night and my date for the evening is my ACLS book. I'm going for initial certification, and I'm a new nurse with relatively little experience in the types of situations that ACLS covers (I'm starting on a med surg floor and fortunately, we don't have intubated patients). As I'm going through the material, I'm reading about how narcan, atropine, vasopressin, epi, and lidocaine can be given through the ETT if IV/IO access can't be established. What I'm trying to understand is, wouldn't putting medications into a patient's trachea put them at risk for aspiration or pneumonia? I realize that someone with an ETT and no IV/IO access probably has bigger fish to fry, but I just don't really understand how ETT med administration is done and whether or not it sets patients up for respiratory problems as they recover. Thank you to anyone who can help clear this up for me!

-Erin

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Specializes in Pediatric Critical Care, Cardiac, EMS.

Here ya go.

"endotracheal (ET) tube. Instilling some resuscitation drugs via an ET tube results in lower circulating blood levels of the medication and lower survival rates compared with I.V. administration. Use this method only if I.V. or IO access can't be established. Only naloxone, atropine, vasopressin, epinephrine, and lidocaine can be administered via ET tube. The recommended dosing is two to two and a half times the I.V. dose, although little evidence supports this practice. After diluting the recommended drug dose in 5 to 10 mL of sterile water or 0.9% sodium chloride solution, instill the drug directly into the ET tube, followed by ventilations via a bag-valve—mask device."

Ultimately, survival of the patient depends far less on what drugs we give and when than on how well we maintain central perfusion. Patients who have taken an anoxic hit from a code, been aggressively resucitated, and are post-code in your unit will have fluid balance issues, neurological issues, respiratory issues, and post-resucitation arrythmias. 50-60 cc's of total fluid volume into their lungs isn't going to push the balance one way or the other.

Ultimately, if you're looking at spraying drugs down someone's ET tube, you're reaching the "something is better than nothing" stage - do we need to say much more?

IOW - a little aspiration pneumonia is the LEAST of their worries - and yours.

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Specializes in Med-Surg/Oncology, Psych.

Thanks for the clarification, TD. So after administering the meds, I assume you'd want to make sure you ventilate the pt well so that the meds can get into the alveoli and then absorbed by the capillaries, right? Thanks again!

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Specializes in Critical Care.

Correct.

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http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-58

American Heart Guidelines from "Circulation" circa 2005. Medications in an arrest situation are not all that important. Endotracheal medication administration have been highly de-emphasized due to the fact that IV medications do not seem to make much if any difference, and ETT medications appear to do the same, while potentially leading to additional complications in some cases.

I would not worry too much about the details of giving meds down the tube.

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Specializes in Critical Care.

The last time I put meds down a tube was in a code back in 2005, I really havent seen it done in quite a while. Personally It'd be the last route I'd be giving meds...But then again as someone above me said..something is better than nothing, and when you're in the crap, ya gotta go what ay gotta do.

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Specializes in Oncology.

I've always kinda wondered about this too. I figured in the code situation it may be indicated if there's not any alternative. However, ET route is often used for anesthesia as well. A person undergoing anesthesia always has IV access. What's up with that?

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I've always kinda wondered about this too. I figured in the code situation it may be indicated if there's not any alternative. However, ET route is often used for anesthesia as well. A person undergoing anesthesia always has IV access. What's up with that?

Lots of things happen during surgery. The primary induction agent and paralytic prior to inhaled anesthesia is given IV, medications to control hemodynamics are given IV, volume expanders and blood products are given IV, and multiple other therapeutic agents and diagnostic agents are given IV during surgery as well. Therefore, IV access is mandatory for multiple reasons related and unrelated to the administration of inhaled general anesthetic gasses.

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Specializes in Oncology.
Lots of things happen during surgery. The primary induction agent and paralytic prior to inhaled anesthesia is given IV, medications to control hemodynamics are given IV, volume expanders and blood products are given IV, and multiple other therapeutic agents and diagnostic agents are given IV during surgery as well. Therefore, IV access is mandatory for multiple reasons related and unrelated to the administration of inhaled general anesthetic gasses.

I get that. My question was if ET med administration is such a bad thing that should be avoided whenever possible, why are anesthetic agents given this route?

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Because anesthetic agents are inhaled gasses. ACLS medications down the tube are liquids. Even aerosolized liquid solutions such as albuterol are not guaranteed to have optimal inertial impaction and deposition to target areas of the lungs.

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So helpful, even 6 years later. Thanks :)

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Specializes in critical care, ER,ICU, CVSURG, CCU.
Here ya go.

"endotracheal (ET) tube. Instilling some resuscitation drugs via an ET tube results in lower circulating blood levels of the medication and lower survival rates compared with I.V. administration. Use this method only if I.V. or IO access can't be established. Only naloxone, atropine, vasopressin, epinephrine, and lidocaine can be administered via ET tube. The recommended dosing is two to two and a half times the I.V. dose, although little evidence supports this practice. After diluting the recommended drug dose in 5 to 10 mL of sterile water or 0.9% sodium chloride solution, instill the drug directly into the ET tube, followed by ventilations via a bag-valve—mask device."

Ultimately, survival of the patient depends far less on what drugs we give and when than on how well we maintain central perfusion. Patients who have taken an anoxic hit from a code, been aggressively resucitated, and are post-code in your unit will have fluid balance issues, neurological issues, respiratory issues, and post-resucitation arrythmias. 50-60 cc's of total fluid volume into their lungs isn't going to push the balance one way or the other.

Ultimately, if you're looking at spraying drugs down someone's ET tube, you're reaching the "something is better than nothing" stage - do we need to say much more?

IOW - a little aspiration pneumonia is the LEAST of their worries - and yours.

and dexamethasone, and some antibiotic, gentamicin I think, grannyRRT will know for sure.

there are millions of capillary beds in millions of alveoli for the absorption

aspiration sequel a not an issue, as what you are pulling down tube in volume, and nature, are not caustic, as gastric secreations would be....we instill similar volume of just saline, to loosen mucus plugs

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