Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation

Lam, Samuel H.F.; Li, David R.; Hong, Christian E.; Vilke, Gary M.

doi:10.1016/j.jemermed.2018.04.025

Cited by 12 publications

(22 citation statements)

References 30 publications

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“…As the rectal mucosa is highly vascularised, this route of administration is useful for rapid systemic drug absorption, particularly in an emergency or when the oral route is unavailable. Rectal formulations have been used in pain management [ 102 , 103 ], sedation [ 104 ] and treatment of seizures [ 105 ]. Compared to other transmucosal routes of administration, one of the distinct advantages of rectal delivery is that it is not limited by vomiting which patients commonly experience as they approach the ends of their lives.…”

Section: Rectal Deliverymentioning

confidence: 99%

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

Lam

Cheung

Chow

et al. 2020

Advanced Drug Delivery Reviews

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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.

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Section: Rectal Deliverymentioning

confidence: 99%

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

Lam

Cheung

Chow

et al. 2020

Advanced Drug Delivery Reviews

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“…The rectal (transmucosal) route is particularly convenient for PPS, especially for infants, because it is not invasive, does not pose any choking risks, and does not need to be taste-masked [ 8 ]. It also has the advantage of a rapid and more predictable onset than the oral route [ 9 ]. Rectally administered drugs, which are described in the literature as being possible to use for PPS, are benzodiazepines, chloral hydrate, ketamine, and barbiturates; however, according to Lam et al [ 9 ] in their 2018 systemic review, rectal midazolam (the main benzodiazepine used for PPS) was the least effective of these drugs, and ketamine induced very common adverse effects (hypersalivations and hallucinations, for example).…”

Section: Introductionmentioning

confidence: 99%

“…It also has the advantage of a rapid and more predictable onset than the oral route [ 9 ]. Rectally administered drugs, which are described in the literature as being possible to use for PPS, are benzodiazepines, chloral hydrate, ketamine, and barbiturates; however, according to Lam et al [ 9 ] in their 2018 systemic review, rectal midazolam (the main benzodiazepine used for PPS) was the least effective of these drugs, and ketamine induced very common adverse effects (hypersalivations and hallucinations, for example). They reported a sedating efficacy of 60–75% for midazolam in most trials versus 80–95% for the other drugs.…”

Section: Introductionmentioning

confidence: 99%

Development and Stability of a New Formulation of Pentobarbital Suppositories for Paediatric Procedural Sedation

et al. 2023

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Pentobarbital is a drug of choice to limit motion in children during paediatric procedural sedations (PPSs). However, despite the rectal route being preferred for infants and children, no pentobarbital suppositories are marketed, and therefore they must be prepared by compounding pharmacies. In this study, two suppository formulations of 30, 40, 50, and 60 mg of pentobarbital sodium were developed using hard-fat Witepsol® W25 either alone (formulation F1) or with oleic acid (formulation F2). The two formulations were subjected to the following tests described in the European Pharmacopoeia: uniformity of dosage units, softening time, resistance to rupture, and disintegration time. The stability of both formulations was also investigated for 41 weeks of storage at 5 ± 3 °C using a stability-indicating liquid chromatography method to quantify pentobarbital sodium and research breakdown product (BP). Although both formulae were compliant to uniformity of dosage, the results were in favour of a faster disintegration of F2 compared to F1 (−63%). On the other hand, F1 was found to be stable after 41 weeks of storage unlike F2 for which several new peaks were detected during the chromatographic analysis, suggesting a shorter stability of only 28 weeks. Both formulae still need to be clinically investigated to confirm their safety and efficiency for PPS.

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“…Chemical immobilization can be required for blood sampling, X-rays, biopsy, or other procedures [ 1 ]. The intrarectal route (IR) is widely used in human medicine for the sedation of uncooperative patients, such as children, and has wide safety margins [ 3 ]. Common routes of sedation in cats are intramuscular (IM), intravenous (IV), and oral (OS).…”

Section: Introductionmentioning

confidence: 99%

“…Thus, IR administration can provide significant local and systemic levels for various drugs, despite the relatively small surface area of the rectal mucosa [ 6 , 7 ]. In human medicine, IR administration is used for the treatment of epileptic seizures [ 3 , 6 ], during pediatric sedation, for burn wounds [ 8 ], for vomiting, and for dysphagia patients [ 9 ]. In veterinary medicine, IR administration is extensively investigated for the control of epileptic seizures in dogs, but less so in cats [ 10 , 11 ].…”

Section: Introductionmentioning

confidence: 99%

Comparison of Certain Intrarectal versus Intramuscular Pharmacodynamic Effects of Ketamine, Dexmedetomidine and Midazolam in Cats

Paolini

Vignoli

Falerno

et al. 2022

Veterinary Sciences

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The aim of this clinical trial was to evaluate the impacts of administration via the intrarectal route (IR) in cats on their heart and respiratory rates, blood pressure, body temperature, and sedation quality compared to the intramuscular route (IM). The intramuscular group (IMG) received 0.003 mg kg−1 dexmedetomidine, 2 mg kg−1 ketamine, and 0.2 mg kg−1 midazolam while the intrarectal group (IRG) protocol was 0.003 mg kg−1 dexmedetomidine, 4 mg kg−1 ketamine, and 0.4 mg kg−1 midazolam. Cardiorespiratory values, temperature, and sedation score were measured 2 min after administration and then every 5 min up to the 40th minute. Cats belonging to IRG reacted less strongly to the drug, as opposed to those receiving intramuscular administration (2/10 in IRG vs. 8/10 in IMG). Average time between drug administration and standing position was 44.9 ± 5.79 in IRG and 57 ± 9.88 min in IMG. In IRG, maintenance of SpO₂ values is > 95% at each time point. Median and range peak of sedation {7 (5)} in IMG occurs at 20th, 25th, and 30th minutes post drug administration while was lower in IRG. Cardiorespiratory values were slightly lower in IMG than in IRG, but always constant in both treatments. Temperature did not differ between groups. At this dosage, although sedation score was higher in IMG, intrarectal route could be efficacious for performing minimally invasive clinical and diagnostic procedures in cats.

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Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation

Cited by 12 publications

References 30 publications

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

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

Development and Stability of a New Formulation of Pentobarbital Suppositories for Paediatric Procedural Sedation

Comparison of Certain Intrarectal versus Intramuscular Pharmacodynamic Effects of Ketamine, Dexmedetomidine and Midazolam in Cats

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