Administration of Drugs Via Intracardiac, Intrathecal, Epidural

Administration of Drugs via intracardiac, intrathecal, and epidural routes involves highly specialized techniques used in critical care, anesthesia, and pain management.

A) Intracardiac drug administration

Introduction

Intracardiac injections (ICI) are a medical technique reserved for emergencies. It consists of putting medication directly into the heart. It should be performed in less than 10 seconds and requires no special equipment.

Definition

ICI is the technique of administering medication by inserting the tip of the needle through the myocardium and into a cardiac chamber.

Purposes

• To revive the patient with resuscitative medications.
• To aid in quick response and cardiac survival.

Indications

Patient with

• Asystole.
• Pulseless electrical activity.
• Pulseless ventricular tachycardia.
• Ventricular fibrillation.
• Unobtainable vascular access during resuscitation (cardiac arrest).

Contraindications

There are no absolute or relative contraindications. Certain clinical conditions to be considered are the following:

• Chronic obstructive pulmonary disease can shift the heart from its normal position.
• Dextrocardia and prior lung resection require identification of the position.
• The patient’s over-anticoagulation may result in a hemopericardium and cardiac tamponade.

Articles

Procedure

• As this procedure is performed in a patient who is clinically “dead” and as a last effort at resuscitation, no specific preparation is required.
• The patient will be supine with CPR in progress. If time permits, insert a nasogastric tube.
• Assist the physician by providing povidone-iodine of chlorhexidine solution to the area around the lower sternum, xiphoid process of the sternum, upper epigastric, and left costosternal angles.
• Assist in loading the required dose of epinephrine into a syringe or use prefilled syringes and provide a spinal needle, which should be attached to the syringe containing the epinephrine (epinephrine 1 mg/10 mL).
• Stop performing CPR. Stop ventilating the patient and allow the lungs to passively deflate.
• The physician identifies, by palpation, the anatomic landmarks required to perform the procedure.
• Subxiphoid approach: The spot identified 1 cm to the left of the patient’s xiphoid process in the costosternal angle.
• Left parasternal approach: The left fourth or fifth intercostal space, approximately 1 cm (or one fingerbreadth) lateral to the left sternal border.
• The physician inserts the needle with the bevel up, at a 30°-45° angle to the skin of the abdominal wall, and aimed toward the patient’s left shoulder, and advances the needle while applying negative pressure to the syringe.
• The physician ensures the position, as the blood flows freely into the syringe, signifying that the tip of the needle is within the cardiac chamber, and stops further advancing.
• The physician quickly injects the epinephrine, and then withdraws the needle.
• Resume CPR and ventilation of the patient.

Complications

• Pneumothorax.
• Coronary artery/pulmonary artery laceration.
• Myocardial laceration.
• Hemopericardium.
• Cardiac tamponade.
• Perforation of the stomach or liver.
• Intractable ventricular fibrillation.

B) Intrathecal Drug Administration

Introduction

Several drugs that act on the nervous system are administered by the intrathecal route, as it bypasses the blood-brain barrier. Intrathecal drug administration, also called a “pain pump,” is usually provided by a programmable infusion pump, a small machine implanted in patients’ bodies, which allows the drug to be stored in the reservoir.

Definition

Intrathecal or intraspinal drug administration is the introduction of a therapeutic substance into the cerebrospinal fluid (CSF) by injecting it into the subarachnoid space of the spinal cord through a drug delivery system made up of a pump and catheter.

Purposes

• To relieve pain sensation as a part of palliative care, post neural surgery for its advantages of low dose and fewer side effects.
• To administer certain medications such as opioids, local anesthesia drugs, adrenergic agonists, and N-methyl-D-aspartate (NMDA) antagonists

Indications

Patient with:

• Surgical anesthesia (spinal).
• Pain management for cancer and noncancer pain (neuropathic, e.g., lumbar post-laminectomy syndrome).
• Chemotherapy (metastatic malignancy of the CNS).
• Unresponsive to oral opiates.

Contraindications

• Coagulopathies.
• Immunocompromised.
• Epidural metastasis.
• Drug allergy.

Modes of Intrathecal Infusions

• Continuous (fixed) infusion mode: It will enable administering the drug continuously throughout the 24 hours.
• Flexible infusion mode: It permits the clinician to change the daily dosage of the drug, increasing or decreasing it at any time during the 24 hours, based on the patient’s needs.
• PCA infusion mode: It allows, in addition to continuous administration, the administration of prefixed doses “on-demand” by the patient, such as in case of incident pain (e.g., breakthrough cancer pain).

Administration of Drug via Intrathecal Delivery System

• Explain the procedure and obtain informed consent.
• Patients are screened for epidural or intrathecal injection.
• The test is performed with single intrathecal injections of the drug at L2-L3 via a 27-gauge spinal needle, while the patient is in prone position with a pillow under the chest, to keep the spine stretched.
• Agents used for this include either morphine 0.1 mg or isobaric bupivacaine (0.5%).
• 0.125 mg, or saline solution (2 mL).
• Patients responding positively to the test (reduction in pain) are scheduled for implantation of the infusion system (catheter implanted and connected to an external pump CADD) under aseptic precautions under the abdominal skin.
• General surgical protocols such as lab investigations and NPO from 12 am should be followed.
• Post implantation, monitor for occlusion, seroma, pump displacement, granuloma, infection, etc.
• Observe the level of pain using a pain scale while administering analgesic agents and drug-related side effects related to opioids (constipation, respiratory depression. urinary retention, immune suppression, nausea, vomiting, myoclonus, etc.).
• Assess the need for refilling the port and patients’ response to the therapy. Follow the aseptic technique in handling the port and follow the 10 rights for medication administration.
• Instruct the patients not to sleep in prone position, and avoid strenuous activity 6-8 weeks postprocedure to prevent catheter displacement.
• Ommaya reservoir is a ventricular access device with an intraventricular catheter system with a reservoir for the medications injected into the intrathecal space.
• It is placed for the purpose of repetitive access to the intrathecal space for the administration of antimicrobials, antifungals, antineoplastics, and analgesic medications directly into the brain.
• Monitor for infection (fever, swelling, pus discharge), failure, displacement, and signs of increased intracranial pressure (headache, vomiting, blurring of vision).

C) Epidural Drug Administration

Introduction

Epidural injections of steroid, local anesthetic, and/or opioid were the most common procedures associated with neuraxial chronic pain claims.

Definition

An epidural administration is a procedure that involves injecting a medication into the epidural space around the spinal cord.

Purposes

• To minimize the pain sensation.
• To aid in quick recovery from postsurgical anesthesia effect.

Types

• Continuous epidural infusion (CEI).
• Epidural catheter (anesthesia).
• Epidural PCA
• Intermittent epidural bolus (IEB).
• Epidural steroidal injection.

Indications

Patient with:

• Radicular pain (herniated discs, spinal stenosis, chemical discs, chronic pain secondary to post-cervical surgery syndrome, and chronic neck pain).
• Surgical intervention (anesthesia).
• Postoperative epidural analgesia.

Contraindications

Absolute contraindications

• Coagulopathies.
• Immunocompromised.
• Sepsis.
• Hemorrhage.
• Cardiovascular instability (hypovolemia).
• Increased ICP.
• Epidural metastasis.
• Allergy to drug.

Relative contraindication

• Spinal deformity.

Nursing Care for Administration of Epidural Drug

• Instruct the patient that while injecting the drug (anesthesia) in the epidural space, he or she may experience pressure, tingling, a burning sensation, or momentary shooting pain.
• Inform him or her that it will take 20-30 minutes for the drug’s full effect.
• In case of epidural steroid injection administration, the effect will start working within 2-7 days.
• Epidural injections in the cervical spine are performed via either an interlaminar or a transforaminal approach.
• The injection is always given in theater conditions; access to the epidural space is obtained under sterile conditions with loss of resistance techniques under fluoroscopic visualization.
• For epidural cervical injection, the epidural space is entered between C7 and T1, and 10 mL of either a steroid solution or a mixture of local anesthetics and steroids is injected.
• Ensure that the 10 rights for medication administration are followed.
• Post procedure, monitor for a complication such as infection (epidural abscess and/or meningitis), urinary retention, nausea, vomiting, pruritus, hypotension, leg weakness, and respiratory depression.
• Removal of the epidural catheter will depend on the patient’s pain tolerance and the physician’s order.

Special Considerations for Administration of Drugs

Administering drugs via intracardiac, intrathecal, and epidural routes requires specialized techniques and precautions to ensure patient safety and effectiveness. Here are some special considerations for each route:

1. Intracardiac Administration of Drugs

• Used in emergencies such as cardiac arrest when IV access is unavailable.
• Requires precise needle placement to avoid complications like cardiac tamponade.
• Sterile technique is critical to prevent infection.
• Typically used for epinephrine or other life-saving medications.

2. Intrathecal Administration of Drugs

• Delivers medication directly into the cerebrospinal fluid (CSF).
• Used for chemotherapy, pain management, and spinal anesthesia.
• Requires strict aseptic technique to prevent meningitis.
• Medications must meet low endotoxin standards to avoid neurotoxicity.

3. Epidural Administration of Drugs

• Injects medication into the epidural space for pain relief.
• Commonly used for labor analgesia and post-surgical pain management.
• Requires careful monitoring to prevent hypotension and respiratory depression.
• Epidural solutions should meet similar endotoxin limits as intrathecal drugs.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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