Rectal drug administration

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23.12 Rectal drug administration

Ronald A. Dieckmann

Background

Status epilepticus is a major paediatric medical emergency that requires emergency treatment. Although the first priority is airway and breathing, additional therapy includes termination of the seizure. Cannulating a peripheral vein in a child in status epilepticus limits timely delivery of essential advanced life support (ALS) drugs, especially in infants and toddlers. However, intravenous (IV), intramuscular (IM), or intraosseous drug administration is not necessary because rectal benzodiazepine administration is probably as effective and has no added complications. Rectal drug administration is a time-honoured drug-delivery technique in children and is useful for many medications, including antipyretics and anticonvulsants. The rectum is highly vascularised, and lipid-soluble drugs are rapidly absorbed when correctly administered (Fig. 23.12.1). Diazepam is a lipid-soluble benzodiazepine that is reliably absorbed through the rectum and will terminate most seizures without further treatment. Lorazepam is an effective alternative drug choice.

Fig. 23.12.1 Anatomy of the rectum.

Rectal drug administration is a technique that allows delivery of an absorbable benzodiazepine in the setting of status epilepticus. The relative effectiveness and safety of rectal diazepam versus IM midazolam, lorazepam or other benzodiazepines for treatment of status epilepticus are not known. Rectal diazepam or lorazepam administration may take a few minutes longer to stop the seizure, compared to IV administration, and drug levels may be more variable. Occasionally, as with the IV diazepam preparation, more than one dose of rectal diazepam is necessary.

Indications

• Repetitive seizures.

• Status epilepticus.

Contraindications

• Newborn age (a month or less).

• Recent prior rectal surgery (e.g. for Hirschsprung’s disease, imperforate anus).

Equipment

Diazepam gel preparation or IV solution of diazepam or lorazepam.

Tuberculin syringe, or 14–20-gauge over-the-needle catheter with 3–5-mL syringe.

Tape (optional).

Procedure

Position the patient in the decubitus position, knee–chest position, or supine position (Fig. 23.12.2) and have a second person hold the legs apart.

Carefully introduce the rubber tip of the gel container, or the syringe or over-the-needle catheter approximately 5 cm (2 inches) into the rectum.

Inject the gel or solution into the rectum. Remove the syringe.

Hold buttocks closed for 10 seconds.

Tape buttocks closed (optional).

Fig. 23.12.2 Administering rectal drugs.

Complications

• The most serious potential complication of rectal diazepam is respiratory depression, which is usually from the drug, but may be from the prolonged seizure, or the underlying cause of the seizure.

• Administration of diazepam too high or too proximal into the rectum may decrease its anticonvulsant effect. When the drug is delivered too proximal in the rectum, absorption may occur into the superior haemorrhoidal veins, which drain into the portal system instead of the middle and inferior haemorrhoidal veins, which drain into the systemic venous system. The drug will then undergo hepatic metabolism, which will significantly reduce brain concentrations.

• Rectal tearing.

Tips

• The rectal dose of diazepam is 0.5 mg kg^–1, or five-times the IV dose, to a maximum dose of 10 mg. Onset of action for rectal diazepam is slower.

• Do not give additional rectal diazepam until approximately 5 minutes after the first dose, to avoid ‘stacking’ doses and increasing the risk of respiratory depression.

• Rectal lorazepam may be at least as effective as rectal diazepam in status epilepticus.

• Do not perform endotracheal intubation on every child with diminished breathing after rectal diazepam. Most will not need it if bag–valve–mask is effectively performed for a few minutes until the child begins breathing again spontaneously.

• Do not use the benzodiazepine reversal agent flumazenil when respiratory depression occurs after diazepam administration. The drug may precipitate seizures by interfering with the effect of the diazepam in the brain.

Further reading

Appleton R., Martland T., Phillips B. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev. 4, 2002. CD001905

Dieckmann R.A., Brownstein D., Gausche M. Textbook for paediatric education for prehospital professionals. Sudbury, MA: Jones & Bartlett. 2001:291-292.

Dieckmann R.A., Fiser D., Selbst S. Illustrated textbook of paediatric emergency and critical care procedures. St Louis, MO: Mosby. 1997:274-278.

Dieckmann R.A. Rectal diazepam for prehospital paediatric status epilepticus. Ann Emerg Med. 1994;23(2):216-224.

Fitzgerald B.J., Okos A.J., Miller J.W. Treatment of out-of-hospital status epilepticus with diazepam rectal gel. Seizure. 2003;12(1):52-55.

Mitchell W.G., Conry J.A., Crumrine P.K., et al. An open-label study of repeated use of diazepam rectal gel (Diastat) for episodes of acute breakthrough seizures and clusters: Safety, efficacy, and tolerance. North American Diastat Group. Epilepsia. 1999;40(11):1610-1617.

Related

Textbook of Paediatric Emergency Medicine