使用挤压瓶喷雾器对仰卧位的病人实施鼻腔内给药将会导致用药剂量过量
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Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients
背景与目的
血管收缩药和局麻药，通常是经挤压瓶喷雾器喷洒于鼻粘膜以起到消肿、止血、镇痛的作用。尽管使用广泛，但很少有相关技术安全实施细节的临床指南。本研究的目的是通过模拟量化当患者处于仰卧位和直立位置时输送到鼻粘膜的液体量，以及可以可靠地提供每次喷雾所需的药量的给药参数。
方 法
研究了10例麻醉患者的便利样本。要求实施者使用一个25毫升的喷雾浸管鼻挤压瓶，将测试溶液（无菌水）以垂直（90°仰角）和仰卧（0°仰角）位置施用于人体模型。在人体模型试验的基础上，分别在0°、15°、30°、45°和90°的条件下对喷雾瓶进行了附加试验，确定了喷头工作角度与液体分配量的关系。
结 果
与直立位置（0.041±0.02mL，差异= 0.52mL，5％置信区间[CI]，0.37-0.67mL P <0.001）相比，当以仰卧位（0.56±0.22mL）施用时，每次喷雾的平均体积显着增加。 将给药体积转换为使用标准的0.25％去氧肾上腺素溶液的给药剂量，与直立位置相比，仰卧位每次喷雾输送增加1300mcg（95％CI，925-1675mcg，P <.001）。 递送角度≤30°比以90°角定向时每喷分配体积更多。 在45°角时的分配体积与90°（0.032±0.006mL对比0.030±0.005mL，P = 0.34）输送的体积没有差异。
结 论
对人体模型使用挤压瓶喷雾器鼻腔给药时，与直立位置相比，仰卧位时每次喷雾输送的体积（即剂量）增加14倍。 鉴于文献报道的鼻内用药的毒性和在临床实践中使用挤压瓶雾化器时发生的意外过量，我们的数据明，所有滴鼻药物都应以精确的计量剂量给药。如果计算剂量的设备不可用，则药物应以≥45°的角度递送; 然而，我们推荐患者采取坐卧位且与喷雾瓶呈90度角给药，因为45度以下的小角度给药将导致药物输送量大幅增加。
原始文献摘要
Goldhammer JE, Dobish MA, McAnulty JT, et al.Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients.Anesth Analg. 2017 Aug;125(2):453-457. doi: 10.1213/ANE.0000000000001686.
BACKGROUND:Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray.
METHODS:A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasalsqueeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90° elevation) and supine (0° elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0°, 15°, 30°, 45°, and 90° to determine the relationship between the angles of administration and the amount of liquid dispensed.
RESULTS:The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 ± 0.22 mL) compared with the upright position (0.041 ± 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37-0.67 mL, P < .001). Converting the administered volume to the dose of phenylephrine that would be administered using our standard 0.25% solution, an estimated additional 1300 mcg is delivered per spray in the supine position compared with the upright position (95% CI, 925-1675 mcg, P < .001). Administration with a delivery angle of ≤30° resulted in significantly more volume than when the bottle was oriented at a 90° angle. The volume dispensed at 45° was not different from the volume delivered at 90° (0.032 ± 0.006 mL vs 0.030 ± 0.005 mL, P = .34).
CONCLUSIONS:We found a 14-fold increase in the volume (ie, dose) delivered per spray when a nasal squeeze bottle was used with a mannequin in the supine position compared with the upright position. Given the reported toxicity from the use of intranasal medication and the inadvertent overdosing that occurs when squeeze bottle atomizers are used in clinical practice, our data suggest that all intranasal drugs should be administered with a precise, metered-dose device. If a metered-dose device is unavailable, the medication should be delivered at an angle of ≥45°; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90° because only a small change in angle below 45° will result in a substantial increase in medication delivered.
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