Guidelines for Staff who provide Intimate Care for Children and Young People with Disabilities

APPENDIX 9

DRAFT TRAINING PROGRAMME

THE ADMINISTRATION OF RECTAL DIAZEPAM

Prepared by Dr Jane Gray, Medical Director, Services for People with Epilepsy, Quarrier's Village, Bridge of Weir, Renfrewshire and Christine McGarvey, Training Officer, Epilepsy Association of Scotland.

It is recommended that participants undergoing training in the administration of rectal diazepam should have a good basic understanding of epilepsy. In Scotland this is provided in one day workshops "Understanding & Managing Epilepsy" run by the Epilepsy Association of Scotland.

CONTENT OF THE PROGRAMME

What is Diazepam?

Diazepam is a member of the benzodiazepine family of drugs and is used as a sedative, a muscle relaxant and as a hypnotic drug (for sleep disorders) as well as in the treatment of status epilepticus and serial seizures. Previously diazepam had a poor image because of extensive prescribing without sufficient regard to its property of creating and developing dependency. However, it is extremely useful as an emergency treatment for epilepsy and can be administered safely and effectively, using a rectal tube, without specific medical training.

HOW DOES THE BRAIN WORK?

Messages are passed in the brain by neurones (brain cells) firing tiny electrical charges which activate the neurones next to them. These cells then fire, and messages are passed in a chain-like action. There are two types of cerebral neurotransmitters, one which is excitatory (that is, encouraging the brain cell to fire) and one which is inhibitory (that is, it prevents firing).

i) GLUTAMATE - HAS AN EXCITATORY ACTION. Glutamate is released at the post synaptic membrane causing depolarisation of the neurone.

ii) GAMMA AMINO BUTYRIC ACID (GABA) has an inhibitory action. Gaba is released at the post synoptic membrane causing hyperpolarisation of the neurone.

There is either too much excitatory neurotransmitter (glutamate) or too little inhibitory neurotransmitter (gaba) in evidence when a seizure occurs, causing synchronised discharges of electrical impulses.

HOW DOES DIAZEPAM WORK?

Diazepam acts in the same way as the inhibitory neurotransmitters, attaching to the gaba receptor and increasing the amount of gaba thereby inhibiting neuronal firing and preventing seizures. (Diazepam inhibits other actions in the brain such as the respiratory system, therefore care should be taken not to give too much too fast, ie intravenously by a doctor).

Diazepam metabolises in two ways -

i) Desmethylation - it is pharmacologically active and accumulates in the body. For this reason it is not used as routine, daily therapy.

ii) Hydroxylation - makes temazepam and oxazepam. Temazepam is used as a sleep inducer thereby causing drowsiness following the administration of diazepam.

HOW MUCH DIAZEPAM SHOULD BE USED?

The recommended dosage is 0.5 mg/kg

ie. 5mg under 12 years of age

10 mg over 12 years of age

NOTES

i) Dumex ("Stesolid") recommend 10mg for adults

CP Pharmaceuticals ("Rectubes") recommend 20mg for adults

ii) The above guidelines do not take the weight of the individual into account

iii) Diazepam should not be used for babies under 10kg

HOW CAN DIAZEPAM BE ADMINISTERED?

Diazepam is a lipid soluble drug which means that it penetrates the blood barrier rapidly. It can be given in four different ways

i) INTRAVENOUS METHOD

ii) INTRAMUSCULAR METHOD

- unreliable absorption due to precipitation in the tissues

- unsuitable as a rapid therapeutic effect is required

- risk of damage to the muscles

iii) ORAL METHOD

- patient must be able to swallow and cooperate

- effective in serial seizures (with consciousness regained between attacks)

absorption time is 20 minutes (peak concentration 30-90 minutes)

- may be used as a prophylaxis (ie to prevent seizures when a known trigger is likely to cause a seizure - eg when excitement is a trigger and an outing/event is planned).

iv) RECTAL METHOD

- introduced in the UK in 1971

- anti-epileptic effect in 5 minutes (maximum effect in 20 minutes)

- effective in 80% of cases

- peak serum level in 50 minutes

- convenient administration for parents and carers

- useful in children with febrile convulsions

- can be repeated after 5 minutes if necessary

WHEN SHOULD RECTAL DIAZEPAM BE USED

i) FEBRILE CONVULSIONS - seizures in a young child (2-5 years) which are triggered by a high temperature. It is particularly important to prevent a prolonged seizure (more than 5 minutes) because of the risk of damage to neurones, which in turn can lead to established epilepsy.

ii) SERIAL SEIZURES - seizures following on immediately after each other, but with some recovery in between. Diazepam may also be given orally if the person recovers sufficiently to swallow.

iii) STATUS EPILEPTICUS

A DEMONSTRATION OF THE ADMINISTRATION OF RECTAL DIAZEPAM

If possible a demonstration should be given using an anatomically correct model/doll. In addition (or as an alternative) a good demonstration is given in the video Rectal Diazepam, Rapid Solution - Gentle Alternative produced by CP Pharmaceuticals.

NOTE: there are two versions of this video, one for professionals, one for parents and carers.

PRACTICAL EXPERIENCE

Participants should have the opportunity to practice on anatomically correct dolls.

DISCUSSION

Possible problems around administration -

i) constipation - if the administrator is a nurse, evacuate the bowel. If the administrator is medically unqualified, administer rectal diazepam as directed but prepare to call for emergency services (up to 75% may be lost in the faeces). Carers should try to ensure that the recipient has regular bowel movements to avoid problems.

ii) small baby/child - refer to the video demonstration

iii) a heavy young person/adult - ask a colleague to kneel at the recipient's back to retain him/her in the safe recovery position.

iv) fear of damage to the rectum - pass round the tubes to demonstrate that they are soft and pliable. If available, use a model or diagram to show that the tube will naturally follow the line of the rectum. Emphasise the need to twist the top of the yellow "stesolid" tube to remove it, otherwise bleeding from scratched tissue is possible.

ISSUES/PROCEDURES TO CONSIDER

i) Staffing cover - ideally there should always be a trained member of staff available at all times who has been authorised by their employer, the prescribing doctor, the recipient and their relative/guardian. In order of preference the three options are -

a) all staff trained, willing, and acceptable to all interested parties (as above)

b) sufficient staff (trained and willing) to ensure cover at all times

c) A few identified staff members (trained and willing) with emergency procedures in place at all times when cover is not available.

ii) Insurance - any employee who has been trained to carry out the procedure and who follows the guidelines laid down by the prescribing doctor should be covered by Employers' Liability Insurance. However, every employer should ensure that adequate insurance cover exists.

iii) Necessity for individual care plans - to ensure that the interests of all participating parties are protected an individual care plan should be prepared which should include -

• seizure classification and description
• indications for use of rectal diazepam
• contraindications (if appropriate)
• who should administer
• who should witness it
• what the initial dose should be
• when a second dose should be given
• when emergency assistance should be sought
• who should be informed

This document should be signed by the prescribing doctor, the unit manager, the recipient and their relative/guardian. A copy of the individual care plan produced by the Joint Epilepsy Council for the UK and Northern Ireland is attached. (See Appendix 10).

iv) Duty of care issues - staff responsible for the well-being of clients have in the eyes of the law a duty of care to act within their means to prevent unnecessary injury. This may mean that staff have a duty of care to administer rectal diazepam when required if they have been trained to do so.

v) Legal liability - staff can be held responsible for their actions so it is important that they follow the guidelines provided for them. Legal responsibility also lies with (a) the employer to ensure staff are properly trained, (b) the prescribing doctor to ensure that proper guidelines are given and that the staff member is considered competent.

QUESTIONS TO BE ADDRESSED WHEN SETTING UP A TRAINING PROGRAMME

i) Who should provide training? - ideally a doctor, but an experienced nurse may also be appropriate, but certainly someone with wide experience of working with people with epilepsy. Also, someone from a patient representative organisation who is familiar with care issues.

ii) Who should provide accreditation/authorisation? - preferably the health organisation employing the doctor/nurse (Health Board, Hospital Trust, Epilepsy Centre) or an accrediting body which is nationally recognised.

iii) How often should people re-take/update training? - as rectal diazepam is only administered in emergencies it may be many months later that the staff member is required to use their training. 'Enable' require their staff to take a refresher course every 6 months - this may be a useful guideline