RESUMO
BACKGROUND: Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods. METHODS: A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies. RESULTS: "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources). CONCLUSION: This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.
RESUMO
BACKGROUND: A retrospective utilization study was performed to evaluate utilization patterns for enteral nutrition in a university teaching hospital. METHODS: Enteral nutrition was divided into three types according to the nitrogen source, ie, total protein type [Nutrison Fibre(®), Fresubin Energy Fibre(®), Fresubin(®), Supportan(®) (a special immunonutrition for cancer patients or patients with increased demands for omega-3 fatty acids), Fresubin Diabetes(®) (a diabetes-specific formula), Ensure(®)]; short peptide type (Peptison(®)); and amino acid type (Vivonex(®)). A pharmacoeconomic analysis was done based on defined daily dose methodology. RESULTS: Among hospitalized patients taking enteral nutrition, 34.8% received enteral nutrition alone, 30% concomitantly received parenteral nutrition, and 35.2% received enteral nutrition after parenteral nutrition. Combined use of the different formulas was observed in almost all hospitalized patients receiving enteral nutrition. In total, 61.5% of patients received triple therapy with Nutrison Fibre, Fresubin Diabetes, and Supportan. Number of defined daily doses (total dose consumed/defined daily dose, also called DDDs) of formulas in descending order were as follows: Nutrison Fibre, Fresubin Energy Fibre, Fresubin Diabetes > Supportan > Peptison, Ensure > Vivonex, Fresubin. The ratio of the cumulative DDDs for the three types of enteral nutrition was 35:2.8:1 (total protein type to short peptide type to amino acid type). Off-label use of Fresubin Diabetes was also observed, with most of this formula being prescribed for patients with stress hyperglycemia. Only 2.1% of cancer patients received Supportan. There were 35 cases of near misses in dispensing look-alike or sound-alike enteral nutrition formulas, and one adverse drug reaction in an elderly malnourished patient who did not receive vitamin K1-enriched enteral nutrition during treatment with cefoperazone. After 4 months of the trial intervention, off-label use of Fresubin Diabetes was no longer endorsed by the Drug and Therapeutics Committee for nondiabetic patients, and the proportion of this formula prescribed for patients with stress hyperglycemia decreased by 20%, with a 10-fold increase in the amount of Supportan prescribed for cancer patients. Near misses in dispensing look-alike or sound-alike enteral nutrition were successfully abolished, and no severe coagulation disorders occurred after prophylactic administration of vitamin K1-enriched enteral nutrition in elderly malnourished patients receiving cefoperazone. CONCLUSION: This utilization study indicates that continuous quality improvement is necessary and that a Drug and Therapeutics Committee can play an important role in promoting rational and safe use of enteral nutrition. Appropriateness of this therapy still needs to be improved, especially in addressing the issues of non-evidence-based combined use of multiple enteral nutrition formulas, the relatively high rate of concomitant use of enteral and parenteral nutrition, off-label use of diabetes-specific Fresubin Diabetes, insufficient use of Supportan in cancer patients, and unnecessary use of Supportan in intensive care patients not suffering from cancer.