Management of Subcutaneous Infusions in Palliative Care
Transcript of Management of Subcutaneous Infusions in Palliative Care
Management of
Subcutaneous Infusions
in Palliative Care
Centre for Palliative CareResearch and Education
Palliative Care AustraliaPO Box 24Deakin WestACT 2600t: +61 2 6232 4433f: +61 2 6232 4434e: [email protected]: www.palliativecare.org.au
© 2010
Developed in conjunction withCentre for Palliative Care Research and EducationQueensland HealthLevel 7, Block 7Royal Brisbane & Women’s HospitalHerston QLD 4029t: +61 7 3636 1449f: +61 7 3636 7942e: [email protected] w: www.health.qld.gov.au/cpcre
Thanks to the Syringe Driver Replacement Program Advisory Committee for their contribution towards the 'Management of Subcutaneous Infusions in Palliative Care' education materials: Vlad Alexandric, Deputy Chief Executive Officer, Palliative Care AustraliaCathy Bennett, Clinical Services Coordinator – Palliative Care, Country Health SAPatrick Cox, Community Nurse, South Adelaide Palliative ServicesHelen Walker, Program Manager – Palliative Care, WA Cancer and Palliative Care Network
Funded by the Australian Government Department of Health and Ageing
HMMU Nov’10 1287 Griffin_jk
Management of
Subcutaneous Infusions
in Palliative Care
Centre for Palliative CareResearch and Education
Palliative Care AustraliaPO Box 24Deakin WestACT 2600t: +61 2 6232 4433f: +61 2 6232 4434e: [email protected]: www.palliativecare.org.au
© 2010
Developed in conjunction withCentre for Palliative Care Research and EducationQueensland HealthLevel 7, Block 7Royal Brisbane & Women’s HospitalHerston QLD 4029t: +61 7 3636 1449f: +61 7 3636 7942e: [email protected] w: www.health.qld.gov.au/cpcre
Thanks to the Syringe Driver Replacement Program Advisory Committee for their contribution towards the 'Management of Subcutaneous Infusions in Palliative Care' education materials: Vlad Alexandric, Deputy Chief Executive Officer, Palliative Care AustraliaCathy Bennett, Clinical Services Coordinator – Palliative Care, Country Health SAPatrick Cox, Community Nurse, South Adelaide Palliative ServicesHelen Walker, Program Manager – Palliative Care, WA Cancer and Palliative Care Network
Funded by the Australian Government Department of Health and Ageing
HMMU Nov’10 1287 Griffin_jk
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Contents
A Guide To The Training Manual And Learning Package....................................................3 Someadultlearningprinciples..............................................................................5 Somelearningresources.......................................................................................7 Combinedreferencelistfrom ManagementofSubcutaneousInfusionsinPalliativeCare....................................7
Management of Subcutaneous Infusions in Palliative Care.............................................11 Introduction........................................................................................................12 LearningAim......................................................................................................13 LearningObjectives............................................................................................13 Howtousethisself-directedlearningpackage....................................................15 WhyareSubcutaneousInfusionsUsedinPalliativeCare?....................................15 WhataretheAdvantagesandLimitations ofSubcutaneousInfusionDevices?.....................................................................16 IndicationsandContraindications.......................................................................17
Section 1:The Patient and Family/Carer Experience.......................................................19Quiz: Section 1-ThePatientandFamily/CarerExperience..............................................22
Section 2:General Equipment........................................................................................23QUIZ: Section 2 - EquipmentGuidelinesandPrinciples..................................................27
Section 3: Selection and Preparation of the Site.............................................................28QUIZ: Section 3 -Selection,PreparationandMaintenanceoftheSite.............................35
Section 4:Drugs and Diluents........................................................................................37QUIZ: Section 4.1-DrugsandDiluents...........................................................................42QUIZ: Section 4.2 -DrugsandDiluents(Calculations).....................................................45
Section 5: Patient and Family/Carer Education...............................................................47Quiz: Section 5 -PatientandFamily/CarerEducation.....................................................52
Section 6:Patient Assessment and Troubleshooting......................................................54Quiz: Section 6 -PatientAssessmentandTroubleshooting................................................66
Self Assessment............................................................................................................67
Conclusion.....................................................................................................................68
Quiz Answers.................................................................................................................69
Patient and Family/Carer Statements.............................................................................71
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A Guide to the Training Manual and Learning Package
Thismanualprovidesguidancetoparticipantsinthe‘TraintheTrainer’
workshopinuseoftheManagementofSubcutaneousInfusionsinPalliative
Carelearningpackage,aswellassometeachingandlearningprinciples
andresources.
Useofsubcutaneousinfusiondeviceshasbecomestandardpractice
inpalliativecareandimprovespatientcomfortbyadministrationof
medicationsataconstantratetoassistinsuccessfulcontrolofavarietyof
symptoms.
Therearesomelimitationsandrisksinuseofthesedevicesincluding
inflexibilityofprescription,technicalproblemsandskinreactionsatthe
subcutaneouscannulainsertionsite.Subcutaneousinfusiondevices
shouldbemanagedinaccordancewithlocalpoliciesandprocedures,by
knowledgable,appropriatelytrainedstafftominimiseriskspresentedbythe
limitationsofindividualdevicesandtheiruse.
Informationcontainedinthelearningpackageispresentedtopromotea
standardapproachtoclinicalcareinvolvingasubcutaneousinfusion.It
isnotintendedaseducationinanyspecificdevice.Itprovidesbaseline
informationtobeusedtodevelopknowledgeforbeginnerlevelpractice
withsubcutaneousinfusiondevicesorrevisionforthemoreexperienced
practitioner.
Healthprofessionalsareatalltimesaccountableandresponsiblefortheir
ownactionsandshouldbeawareofthelimitsoftheirknowledge,skillsand
competenceandactwithinthoselimits.
Acquisitionofbasicknowledgeaboutsubcutaneousinfusionsinpalliative
careshouldbefollowedbydemonstrationsandsupervisedpracticeto
attainbeginnerlevelcompetencyinthatdevice.Settingupandmanaging
asubcutaneousinfusiondeviceisaskillthatmaylapseifnotpractised
1CruikshankS,AdamsonE,LoganJ,BrackenridgeK.2010.Usingsyringedriversinpalliativecarewithinarural,communitysetting:capturingthewholeexperience.InternationalJournalofPalliativeNursing;16(3):126-132.
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regularlyandmaintainingcompetencycanbedifficultforpractitionerswho
havevariableexposuretodevicesandtheiruse.1
Thepackageispresentedinthreedifferentforms–website,DVD,andhard
copy–tocaterfordifferentlearningstylesandpreferencesandthefact
thatsomehealthprofessionalswillnothavegoodinternetaccessand/or
webnavigationskills.Thepackagepresentsintroductoryinformationabout
subcutaneousinfusionsanddevicesincludingrecentchangesinAustralia,
andsixsectionsbasedontheCentreforPalliativeCareResearchand
Education’s‘Guidelinesforsubcutaneousinfusiondevicemanagementin
palliativecare’.
Itissuggestedparticipantsworkthrougheachofthesectionsinturn.They
shouldreadtheinformationineachsection,readorwatchgivenlinksand
completeactivities.Attheendofeachmodule,aseriesofquestionsinthe
formofashortquizwillbepresentedtoenableparticipantstotesttheir
understanding.Theanswerstothesequestionsarecoveredbythecontent,
linksandactivitiesineachsection.Thepackagealsorequiresparticipantsto
sourcecertaininformationfromtheirownorganisation.
Completionofallsectionsofthelearningpackageprovidesbaseline
informationforbestpracticeuseofsubcutaneousinfusiondevices,allowing
forcompetencydevelopmentandmaintenance.Completionoftheself
assessmentincludingdiscussionwithaknowledgablehealthprofessionalis
recommended.
Some Adult Learning Principles
Thereisavastamountofinformationavailableaboutteachingandlearning
principles.Aselectionisprovidedheretosupportyouinyoureducationof
healthprofessionalsaboutsubcutaneousinfusiondevices.Knowles’theory
ofadultlearning2isbasedonseveralassumptions:
2KnowlesMS,HoltonEF,SwansonRA(2005).Theadultlearner(Sixthed).London:Elsevier.
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1. Theneedtoknow.Adultsneedtoknowwhytheyneedtolearnsomething beforecommittingtolearnit.
2. Thelearners’self-concept.Adultshaveaself-conceptofbeing responsiblefortheirownlivesanddecisions,andresentsituations wheretheyfeelanotherisimposingtheirwillonthem.Thiscanpresent challengesinadulteducation.Itisimportanttohelpthelearnerbeand feelasself-directedaspossible.
3. Theroleofthelearners’experience.Learnerscomewithalltheirlife experiencewhichmeansthatformanykindsoflearning,theadult learnersthemselvesalreadyhaverichresourcesforlearning.However thatcanproducebiases,mentalhabitsandpreconceptionsthatclose ourmindstofreshperceptions,newideasanddifferentwaysofthinking. “…inanysituationinwhichtheparticipants’experiencesareignored ordevalued,adultswillperceivethisasrejectingnotonlytheir experience,butrejectingthemselvesaspersons.”2
4. Readinesstolearn.Adultsarereadytolearnthethingstheyneedto knowandbeabletodoinordertobeeffectiveinreal-lifesituations, suchastheirwork.
5. Orientationtolearning.Adultsarelife-centred,ortask-centredor problem-centredintheirlearningorientation.Theyaremotivatedto learntotheextenttheyperceivethelearningwillhelpthemsolve problemsorperformtasksinreallife.Adultslearnnewknowledge mosteffectivelywhenpresentedinthecontextofareallifesituation.
6. Motivation.Themostpotentmotivatorsforadultsareinternal,such asthedesireforincreasedjobsatisfaction,qualityoflife,andself- esteem.Externalmotivatorssuchasbetterjob,promotion,highersalary areimportantbutlessso.Adultsaremotivatedtokeepgrowingand developingbutthismaybeblockedbynegativeself-concept,time constraints,andeducationalprogramsthatviolateadultlearning principles.
Adultlearnershavearichbackgroundoflifeexperiences,bothpersonaland
workrelated.Trytotapintothatexperiencewhenteaching–forexample
• whatexperiencedoesthepersonalreadyhavewithinfusiondevices?
• dotheyhaveanyconcernsaboutusingthedevicese.g.apre-
conceptionthatasubcutaneousinfusionwillhastendeath?
2KnowlesMS,HoltonEF,SwansonRA(2005).Theadultlearner(Sixthed).London:Elsevier.
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Forthesesortsofreasons,startwithidentifyingthebeginninglevelof
knowledgeofyourparticipants.
Adultsenjoytheopportunitytoapplynewknowledge–apractical
demonstrationaccompaniedbythechancetoactuallyusethedeviceallows
themthatopportunity.
Some learning resources
EgleC(2007).Adultlearningprinciplesforfacilitators.RuralHealth
EducationFoundation.Availablefromhttp://www.rhef.com.au/wp-content/
uploads/userfiles/716_alp_lr.pdf
KnowlesMS,HoltonEF,SwansonRA(2005).Theadultlearner(Sixthed).
London:Elsevier.
Combined reference list from ‘Management of Subcutaneous Infusions in Palliative Care’
AbbasS,YeldhamM,BellS.Theuseofmetalorplasticneedlesincontinuoussubcutaneousinfusioninahospicesetting.AmericanJournalofHospiceandPalliativeMedicine2005;22(2):134-138.
BreckenridgeA.Reportoftheworkingpartyontheadditionofdrugstointravenousinfusionfluids[HC(76)9][Breckenridgereport].London:DepartmentofHealthandSocialSecurity;1976.
BritishNationalFormulary.Syringedrivers.<www.bnf.org>.Accessed26January2005.
CentreforPalliativeCareResearchandEducation.Guidelinesforsubcutaneousinfusiondevicemanagementinpalliativecare(RevisedEdition).Brisbane,Queensland:QueenslandHealth;2010.
CHRISP(CentreforHealthcareRelatedInfectionSurveillanceandPrevention).Occupationalexposurestobloodandbodyfluids:Recommendedpracticesforpreventinghollow-boreneedlestickinjuries(Recommendation2:Wingedinfusionsetsforsubcutaneousandintravenousinfusions).QueenslandGovernment(QueenslandHealth);2007.<http://www.health.qld.gov.au/chrisp/resources/hollbore_rec_prac.pdf>.Accessed28June2010.
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Coleridge-SmithE.TheuseofsyringedriversandHickmanlinesinthecommunity.BritishJournalofCommunityNursing1997;2(6):292,294,296.
GovernmentofWesternAustralia,DepartmentofHealth.Palliativecaremedicineandsymptomguide.WACancerandPalliativeCareNetwork;2010.Availablefrom:http://www.healthnetworks.health.wa.gov.au/cancer/docs/Consumer_Book.pdf
CruikshankS,AdamsonE,LoganJ,BrackenridgeK.Usingsyringedriversinpalliativecarewithinarural,communitysetting:capturingthewholeexperience.InternationalJournalofPalliativeNursing2010;16(3):126-132.
DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneousinfusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
DickmanA,SchneiderJ,VargaJ.Thesyringedriver:continuoussubcutaneousinfusionsinpalliativecare.2nded.Oxford:OxfordUniversityPress;2005.
DriscollA.Managingpostdischargecareathome:ananalysisofpatients’andtheircarer’sperceptionsofinformationreceivedduringtheirstayinhospital.JournalofAdvancedNursing2000;31(5):1165-1173.
FletcherC.ReportoncomparativeevaluationofGrasebysyringedriverreplacements.Auckland,NZ:NorthShoreHospiceTrust;2009.Retrieved4October2010fromhttp://www.cme-infusion.com/documents/pub/Report%20on%20Comparative%20Evaluation%20of%20Graseby%20Syringe%20Driver%20Replacements.pdf
FlowersC,McLeodF.Diluentchoiceforsubcutaneousinfusion:asurveyoftheliteratureandAustralianpractice.InternationalJournalofPalliativeNursing2005;11(2):54-60.
GomezY.Theuseofsyringedriversinpalliativecare.AustralianNursingJournal2000;(2):suppl1-3.
GrahamF.Thesyringedriverandthesubcutaneousrouteinpalliativecare:theinventor,thehistoryandtheimplications.JournalofPainandSymptomManagement2005;29(1):32-40.
JointTherapeuticsCommission.Asurveyofdoctorsontheirpreferredmedicationsforvarioussymptomsinpalliativecare.Brisbane:Unpublisheddata;2005.
LichterI,HuntE.Drugcombinationsinsyringedrivers.TheNewZealandMedicalJournal1995;108(1001):224-226.
Lloyd-WilliamsM,RashidA.Ananalysisofcallstoanout-of-hourspalliativecareadviceline.PublicHealth2003;117(2):125.
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McNeillyP,PriceJ,McCloskeyS.Theuseofsyringedrivers:apaediatricperspective.InternationalJournalofPalliativeNursing2004;10(8):399-404.
MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions.InternationalJournalofPalliativeNursing2001;7(2):75-85.
MorganS,EvansN.Asmallobservationalstudyofthelongevityofsyringedriversitesinpalliativecare.InternationalJournalofPalliativeNursing2004;10(8):405-412.
NegroS,SalamaA,SanchezY,AzuaratM,BarciaE.Compatibilityandstabilityoftramadolanddexamethasoneinsolutionanditsuseinterminallyillpatients.JournalofClinicalPharmacyandTherapeutics2007;32:441-444.
O’DohertyC,HallE,SchofieldL,ZeppetellaG.Drugsandsyringedrivers:asurveyofadultspecialistpalliativecarepracticeintheUnitedKingdomandEire.PalliativeMedicine2001;15:149-154.
PalliativeCareExpertGroup.Therapeuticguidelines:palliativecare.Version3.Melbourne:TherapeuticGuidelinesLtd;2010,p.292.
PalliativeCareMatters.<www.pallcareinfo>.Accessed10August2010
PalliativeCareOutcomesCollaborative(PCOC)websitehttp://chsd.uow.edu.au/pcoc/
PalliativeCareOutcomesCollaborative.<http://chsd.uow.edu.au/pcoc/>.Accessed13August2010.
PalliativeDrugs.com.‘Syringedrivers.’<www.palliativedrugs.com>.Accessed25January2005.
PetersonG,MillerK,GallowayJ,DunneP.Compatibilityandstabilityoffentanyladmixturesinpolypropylenesyringes.JournalofClinicalPharmacyandTherapeutics1998;23:67-72.
RatcliffeN.Syringedrivers.CommunityNurse1997;3(6):25-26.
ReymondE,CharlesM.Aninterventiontodecreasemedicationerrorsinpalliativepatientsrequiringsubcutaneousinfusions:BrisbaneSouthPalliativeCareServiceandAdverseDrugEventPreventionProgram;unpublishedreportpresentedtoClinicalServicesEvaluationUnit;PrincessAlexandraHospital.Brisbane,Queensland;2005
ReymondL,CharlesMA,BowmanJ,TrestonP.Theeffectofdexamethasoneonthelongevityofsyringedriversubcutaneoussitesinpalliativecarepatients.MedicalJournalofAustralia2003;178:486-489.
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RossJR,SaundersY,CochraneM,ZeppetellaG.Aprospective,within-patientcomparisonbetweenmetalbutterflyneedlesandTefloncannulaeinsubcutaneousinfusionofdrugstoterminallyillhospicepatients.PalliativeMedicine2002;16:13-16.
WorldHealthOrganization.http://www.who.int/cancer/palliative/definition/en/Accessed28July2010.
Yatesetal.2004inCruikshankS,AdamsonE,LoganJ,BrackenridgeK.Usingsyringedriversinpalliativecarewithinarural,communitysetting:capturingthewholeexperience.InternationalJournalofPalliativeNursing2010;16(3):126-132.
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Management of Subcutaneous Infusions in Palliative Care
Introduction
Thisinformationispresentedtopromoteastandardisedapproachto
clinicalcareinvolvingasubcutaneousinfusiondevice.Suchanapproach
shouldminimisepracticeerrorsthatcanresultinseriousadverseevents
andanongoingrisktopatientsafety.Itprovidesbasicinformationfor
beginnerlevelpracticewithsubcutaneousinfusiondevicesorrevisionfor
themoreexperiencedpractitioner.Thepackageisnotdevicespecific,and
inanorganisationalsettingshouldbecomplementedbycomprehensive
informationaboutthesubcutaneousinfusiondevicebeingusedwithinthat
organisationorservice.
Healthprofessionalsareatalltimesaccountableandresponsiblefortheir
ownactionsandshouldbeawareofthelimitsoftheirknowledge,skillsand
competenceandactwithinthoselimits.Competencyhasbeendescribed
asanabilitytothinkinactionandmakeconfident,cleardecisionsbased
onsoundknowledge.Settingupandmanagingasubcutaneousinfusion
deviceisaskillthatmaylapseifnotpractisedregularly,andmaintaining
competencycanbedifficultforpractitionerswhohavevariableexposureto
thedeviceanditsuse.1
Theacquisitionofbasicknowledgeaboutsubcutaneousinfusiondevices,
reasonsfortheiruseandthedrugscommonlyadministeredinthecareof
apalliativepatientshouldbefollowedbydemonstrationsandsupervised
practicetoattainbeginnerlevelcompetencyinaparticulardevice.
Aswithallmedicaldevices,theoperationofasubcutaneousinfusiondevice
shouldonlybeundertakenby,orunderthesupervisionof,appropriately
trainedstaffandinaccordancewithlocalpoliciesandproceduresand
manufacturers’guidelines.
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Learning Aim
Theaimofthislearningpackageistoassistthecliniciantodevelop
knowledgeandskillsofthebasicprinciplesofcareforpeoplewith
subcutaneousinfusiondevicesinpalliativecaresettings.
Thispackageisdesignedtoprovideself-directedlearning;completiondoes
notprovideformalaccreditation.Supervisedpracticewithappropriately
trainedstaffmanagingthedeviceusedbyyourserviceisrecommended.
Learning Objectives
Following successful completion of this package, you should be able to:
• discusstheindicationsandcontraindicationsforsubcutaneous
infusionsinpalliativecare;
• explainmanagementandsafetyprincipleswhenusinginfusion
devices;
• discussprinciplesofappropriateandinappropriatesiteselectionfor
insertionofacannula;
• describestrategiesforpreventingsiterelatedproblems;
• identifydrugscommonlyusedinsubcutaneousinfusions,andtheir
indicationsforuse;
• provideaccurateinformationandeducationtopatientsandfamilies/
carersusingsubcutaneousinfusiondevices;
• safelymonitorthepatientwithasubcutaneousinfusioninsitu.
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Disclaimer
Theinformationcontainedinthismanualhasbeencompiledbythe
CentreforPalliativeCareResearchandEducation(CPCRE)andPalliative
CareAustralia(PCA)foreducationalandinformationpurposesonly.
Itisintendedtoassisthealthcareprofessionalsindevelopingtheir
knowledgeofkeyprinciplesconcerningtheuseofsubcutaneous
infusiondevicesinpalliativecare.
WhileCPCREandPCAhavetakenparticularcareincompilingthis
manual,errorsmayoccur.Therefore,CPCREandPCAgivenowarrantyas
toitsaccuracyorcompleteness.
Themanualisnotintendedtoreplaceorconstitutemedicaladvice
andshouldnotbeconstruedasspecificinstructionsforthedelivery
ofmedicaltreatmentorcareortheuseofanyparticulardevice
forprovidingasubcutaneousinfusion.Itisnotasubstitutefor
independentprofessionalmedicaladviceandshouldnotbereliedupon
tosolveissuesthatmayariseinindividualcases.
CPCREandPCAdonotacceptliabilityforanydirect,incidentalor
consequentiallossordamagearisingfromtheuseoforrelianceupon
theinformationcontainedinthismanual.
Healthcareprofessionalsshouldalsoseektraining,supervisionand
advicefromappropriatelyqualifiedandexperiencedcliniciansinorder
todeveloptherequiredlevelofclinicalcompetencetoproperlytreat
patients,whereappropriate,usingsubcutaneousinfusiondevices.
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How to Use this Self-Directed Learning Package
TheCentreforPalliativeCareResearchandEducation’s‘Guidelinesfor
subcutaneousinfusiondevicemanagementinpalliativecare’(theGuidelines)
areanimportantcomplementarydocumenttothislearningpackage.
Itissuggestedyouworkthrougheachofthesectionsinturn.Readthe
information,readorwatchgivenlinksandcompleteactivities.Thepackage
alsorequiresyoutosourcecertaininformationfromyourownorganisation.
Attheendofeachsection,aseriesofquestionsintheformofashortquiz
willbepresentedtoenableyoutotestyourunderstanding.Theanswers
tothesequestionsarecoveredbythecontent,linksandactivitiesineach
section.Completionoftheselfassessment,includingdiscussionwitha
knowledgablehealthprofessional,isrecommended.
Why are Subcutaneous Infusions Used in Palliative Care?
TheWorldHealthOrganisation(2004)statedthatpalliativecareis“an
approachtocarewhichimprovesqualityoflifeofpatientsandtheirfamilies
facinglife-threateningillness,throughthepreventionandreliefofsuffering
bymeansofearlyidentificationandimpeccableassessmentandtreatment
ofpainandotherproblems,physical,psychosocialandspiritual”.2Palliative
careisprovidedaccordingtotheneedsoftheindividualandmayhappen
days,weeksormonthsbeforedeath.Itshouldbeavailablewhereverthe
personchooses–athomeorinahospital,hospiceorresidentialagedcare
facilityandbesupportedbyateamofhealthprofessionalsincludinga
specialistpalliativecareteamifneeded.
Theadministrationofmedicationusingasubcutaneousinfusiondeviceis
commonpracticeinpalliativecareforthemanagementofpainandother
distressingsymptomswhenotherroutesareinappropriateorineffective.3
Thesedevicesarepowerdriven,deliveringmedicationsatacontrolledrate
toprovidesymptomcontrol.Subcutaneousinfusiondeviceshavebecome
animportantpartofcaretoensurecomfortformanypatients.4
Formanyyears,theGrasebysyringedriverwastheprimarydevicefor
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subcutaneousadministrationofarangeofdrugsinpalliativecare.Inearly
2007themanufactureroftheGrasebyMS16AandMS26syringedrivers
informedtheTherapeuticGoodsAdministration(TGA)oftheirintentionto
withdrawthedevicesfromsaleinAustralia.InOctober2007thenewTGA
regulatorystandardsregardingmedicalinfusiondevicesbecamemandatory.
GrasebysyringedriverspurchasedpriortoOctober2007continuetobe
supportedbythemanufacturerfordevicemaintenance,allowingservices
totransitiontodevicesthatmeetthenewregulatorystandards.Information
containedinthislearningpackageisrelevanttodevicesnowinusein
Australia.5
What are the Advantages and Limitations of Subcutaneous Infusion Devices?
Subcutaneous delivery of medication via an infusion device:
• allowsthecontinuoussupplyofarangeofdrugsbypassingthegutand
associatedproblemswithswallowingandmalabsorption3;
• canprovidemorestableplasmalevelsofdrugsandbettersymptom
controlaspeaksandtroughsofintermittentdrugadministrationare
avoided3;
• generallyinvolvesasmall,portableorrelativelyportablebatteryoperated
pumpthatdeliversmedicationsatanaccuratelycontrolledrate6;
• providesversatilityofferingaconvenient,accessiblealternativefor
continuousadministrationofmedications;
• canbeusedforambulantpatientswithmostdevicesabletobeworn
relativelyunobtrusively,notinterferingwithpatientswantingto
continuewiththeirnormaldailyactivities;
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• canprovidecontinuedmanagementofsymptomsremovingtheneed
forfrequentinterventionslikerepeatedoralmedicationsorinjections
atendoflife.
Indications and Contraindications
Indications for commencement of a subcutaneous infusion include:
• inabilitytoswallowduetodysphagiafromphysicalobstruction/
tumourinthemouth,throatoroesophagus;
• persistentnauseaandvomiting;
• severeweakness;
• unconsciousness;
• bowelobstruction.3
Contraindications for use of this route include:
• lackofpermissionfromthepatientand/orfamily/carerasproxy;
• whereotherviableroutesofadministrationareavailable;
• wherecontraindicationsexistrelatedtothedrugstobeinfused.
Thedecisiontocommenceasubcutaneousinfusionofmedicationshouldbe
madeaftercarefulassessmentandreviewbyhealthprofessionalsinvolved
inthepatient’scare,thepatient,andfamily/carer.
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References
1. CruikshankS,AdamsonE,LoganJ,BrackenridgeK.Usingsyringedriversinpalliative carewithinarural,communitysetting:capturingthewholeexperience.International JournalofPalliativeNursing2010;16(3):126-132.
2. WorldHealthOrganization.http://www.who.int/cancer/palliative/definition/en/ Accessed28July2010.
3. DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
4. MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions. InternationalJournalofPalliativeNursing2001;7(2):75-85.
5. CentreforPalliativeCareResearchandEducation.Guidelinesforsubcutaneous infusiondevicemanagementinpalliativecare(RevisedEdition).Brisbane, Queensland:QueenslandHealth;2010.
6. McNeillyP,PriceJ,McCloskeyS.Theuseofsyringedrivers:apaediatricperspective. InternationalJournalofPalliativeNursing2004;10(8):399-404.
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Section 1: The Patient and Family/Carer Experience
Healthprofessionalsinvolvedinendoflifecarehaveforalongtime
assumedthatpatientsfinduseofasubcutaneousinfusiondeviceacceptable
becauseofitscompactsizeandthatitsusefacilitatesindependenceandthe
optionofbeingcaredforathome.Howevertherehasbeenlittleresearchinto
patients’attitudestosupportthisassumptionaboutsubcutaneousinfusion
devices.1Althoughitistruethesedeviceshaveallowedmanypatientstobe
athomewiththeirfamily,healthcareprofessionalsneedtobemindfulof
howthepatientandfamily/carerperceivetheexperienceofasubcutaneous
infusiondevice.
Learning Objectives
At the completion of this section, you should be able to:
• describeaspectsoftheexperienceofhavingasubcutaneousinfusion
fromthepatientandfamily/carerpointofview;
• demonstrateanunderstandingofthepotentialimpactonpatientand
family/carerofhavingasubcutaneousinfusion.
Somestudieshavereportedthatsubcutaneousinfusionsarewellaccepted
andcanachievealmost100%complianceamongstpeoplewithalife
limitingillness2,butbeingattachedtoasubcutaneousinfusiondevicecan
posedifficultiesforthepatientandfamily/carer.Inpracticaltermsofnormal
dailyactivities,considerationneedstobegivento:
• choosingclothestowear;
• bathing;
• wearingaseatbeltinrelationtocannulaposition;
• thesizeandweightofthedeviceanditsabilitytobeworndiscreetly;
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• sleepingpositioninrelationtocannulaposition;
• devicesthatmayrequirefrequentbatterychangesorfrequentaccess
toapowerpointforchargingmaycreateareluctancetoleavethehome;
• reportsbysomepatientsthatthedevicesarenoisy3andinconvenient;
• questionsaboutfoodandalcoholintake;
• patientsandfamily/carerswhoperceivethesechangesasanegative
impactontheirlifestyle.
Patientandfamily/carerperceptionsorexperiencesofasubcutaneous
infusiondevicearevariedandindividualtotheperson,theenvironmentand
theunderlyingcauseforuseofthedevice.Beingmindfulthatthedevicewill
beperceiveddifferentlydependentuponthesefactorswillaidthehealth
professionaltoprovideapositiveexperienceforthepatientandfamily/carer.
Rememberingthatthepatientandfamily/carermaynothaveconsidered
advancecareplanninggoals,negativeperceptionsoftheinfusiondevice
maybeinfluencedbythefollowing:
• thedevicemaybeviewedasaninvasionofbodyprivacy;
• thedevicemaybeperceivedasanindicatorofapoorprognosis4;
• thepatientandfamily/carermayhavefearsassociatedwithdrugs
commonlyusedinpalliativecare;
• thedevicemaybecomethefocusoffearofimpendingdeath.
Thoughtfulexplanationgivenwithcaretoprovideinformationandsupport
appropriatetotheindividualpatientandfamily/carermayassistthehealth
professionaltounderstandthesignificancethattheyattachtothechange
incareandanyassociatedemotionaldistress.5Goodanticipatorycarewith
welltimedinformationensuringpatientandfamily/carerunderstandingcan
beassociatedwithapositiveexperienceforpatient,family/carerandhealth
professional.
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Links
Section1‘Guidelinesforsubcutaneousinfusiondevicemanagementin
palliativecare’
Activity
ReadClientandFamily/CarerStatementsattheendofthisbooklet,about
theexperienceofasubcutaneousinfusiondevice.
WatchexcerptfromChapter2–‘WhoNeedsone?’ofBrisbaneSouth
PalliativeCareCollaborative’sGuideforClinicians–HowtoUseaSyringe
DriverforPalliativeCarePatients.
References
1. GrahamF.Thesyringedriverandthesubcutaneousrouteinpalliativecare:the inventor,thehistoryandtheimplications.JournalofPainandSymptomManagement 2005;29(1):32-40.
2. MorganS,EvansN.Asmallobservationalstudyofthelongevityofsyringedriversites inpalliativecare.InternationalJournalofPalliativeNursing2004;10(8):405-412.
3. FletcherC.ReportoncomparativeevaluationofGrasebysyringedriverreplacements. NorthShoreHospiceTrust;2009.Retrieved4October2010fromhttp://www.cme- infusion.com/documents/pub/Report%20on%20Comparative%20Evaluation%20 of%20Graseby%20Syringe%20Driver%20Replacements.pdf
4. Coleridge-SmithE.TheuseofsyringedriversandHickmanlinesinthecommunity. BritishJournalofCommunityNursing1997;2(6):292,294,296.
5. CruikshankS,AdamsonE,LoganJ,BrackenridgeK.Usingsyringedriversinpalliative carewithinarural,communitysetting:capturingthewholeexperience.International JournalofPalliativeNursing2010;16(3):126-132.
22
Quiz: Section 1 - The Patient and Family/Carer Experience
ThisquizwilltesttheobjectivesandcontentinSection1oftheLearning
Packageandthe‘Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) Whenstartingasubcutaneousinfusion,whichofthefollowingshould beconsideredwhenpreparingthepatientandfamily/carerfor
theexperience:
Changesinlevelofalertness
clothing
alcoholintake
driving
alloftheabove
Q2) Commencingasyringedriverisperceivedbysometomean? Goodprognosis
Poorprognosis
Doctorshave‘givenup’onthem
Nothingisworking
Alloftheabove
Q3) Infusionsareonlycommencedwhendeathislikelytohappens withindays
True
False
Q4) Commencingasubcutaneousinfusionviaadevicemeansthatthe personcannotattendtonormalADLs
True
False
Q5) Providinggoodinformationaboutasubcutaneousinfusiondevicecan changetheexperienceforpatientorfamily/carer
True
False
23
Section 2: General Equipment
Learning Objectives
Atthecompletionofthissection,youshouldbeableto:
• describesubcutaneousinfusiondevicescurrentlyinuseinpalliative
careinAustralia;
• explainmanagementprincipleswhencaringforpatientswiththese
devices;
• describeimportantsafetyprincipleswhenusingthisequipment.
Types of Subcutaneous Infusion Devices
Subcutaneousinfusiondevicesaregenerallyelectronic,batterydriven
deviceswithasyringe,cassetteorreservoirtoholdmedicationstobe
deliveredviathesubcutaneousroutetothepatient.Devicescurrentlyinuse
inAustraliaincludetheNikiT34,Graseby,CADDLegacyPCA,GemStarand
WalkMed350LX.
Important Principles when using Subcutaneous Infusion Devices
TheGuidelinesdiscussthefollowingprinciplesregardingequipment
usedforsubcutaneousinfusions.Whensettinguptheequipmentfora
subcutaneousinfusion,itisalwaysimportanttoconsultthemanufacturer’s
guidelinesandverifytheindividualorganisation’sprotocolregardingthe
preparationandset-upforchangingthedevice.
24
General Principles
General management principles for all subcutaneous infusion devices include:
• alwaysusethemanufacturer’sguidelinesandyourorganisation’s
protocolregardingpreparationandset-upforchangingthedeviceto
guideyourpractice;
• anaseptictechniqueshouldbeusedwhenpreparingandsettingup
theinfusion1;
• subcutaneousinfusiondeviceshavetraditionallybeenusedtodeliver
medicationsovera24hourperiodtoreducetheriskoferrorsinsetting
upthedevice1,2-4;
• microbiologicalstabilityandphysicalandchemicalcompatibilitydata
mostcommonlyrelatetoa24hourperiodanditisforthisreasonthat
a24hourinfusionperiodisstillrecommended5;
• documentationofvolumetobeinfused(inthesyringeorreservoir)is
recommendedattimeofset-upandregularchecks;
• considerusingatamper-proof‘lock-box’ifthereisapossibilityofthe
patientorotherstamperingwiththedeviceorusingtheboost
facility;itispossiblethatatamper-proofboxismandatorywithinyour
organisationasariskmanagementstipulation;
• ensurethatthepatientandfamilyhavereceivedafullexplanationof
howthesubcutaneousinfusiondeviceworks,itsindicationsforuse,
anda24-hoursupportnumber;
• devicesshouldbeservicedannuallybythemanufacturerora
biomedicaltechnician.
25
Syringe Related Principles
• whereasyringeisnecessary,aLuer-Lok®syringeshouldbeusedto
preventriskofdisconnection3,6;20mlistherecommendedminimum
syringesize7toreducetheriskofincompatibilityandadversesite
reactions,andminimisetheeffectofprimingtheline;
• thesamebrandofsyringeshouldbeusedeachtimetominimiseerrors
insettingupthedeviceandcalculatingtherate3,6(Grasebyonly);
Cannula Related Principles
BecauseaTeflonorVialoncannulaisassociatedwithlesssiteinflammation,
itshouldbeusedratherthanametalneedle.
Dosage Related Principles
• whenchangingtheextensionsetand/orcannula,primethelineafter
drawinguptheprescribedmedications,andbeforeconnectingtothe
patient.Afterprimingtheline,notethevolumetobeinfusedand
documentthelinechangeandthetimetheinfusioniscalculatedto
finish;
• aminimumvolumeextensionsetshouldbeusedtominimisedead-
spaceintheline7;
• fortheGraseby,itisthelengthofthesolutionwithinthesyringe–not
thevolume–thatwilldeterminetherate,i.e.thesyringedriver
deliveryrateisameasureofdistance,notameasureofvolume
administered.
26
References
1. RatcliffeN.Syringedrivers.CommunityNurse1997;3(6):25-26.
2. O’DohertyC,HallE,SchofieldL,ZeppetellaG.Drugsandsyringedrivers:asurveyof adultspecialistpalliativecarepracticeintheUnitedKingdomandEire.Palliative Medicine2001;15:149-154.
3. DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
4. PalliativeDrugs.com.‘Syringedrivers.’<www.palliativedrugs.com>.Accessed25 January2005.
5. BreckenridgeA.Reportoftheworkingpartyontheadditionofdrugstointravenous infusionfluids[HC(76)9][Breckenridgereport].London:DepartmentofHealthand SocialSecurity;1976.
6. MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions. InternationalJournalofPalliativeNursing2001;7(2):75-85.
7. DickmanA,SchneiderJ,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.2nded.Oxford:OxfordUniversityPress;2005.
27
QUIZ: Section 2 - Equipment Guidelines and Principles
ThisquizwilltesttheobjectivesandcontentinSection2oftheLearning
Packageandthe‘Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) Itisnotnecessarytoverifyyourworkplaceprotocolregarding
preparationandset-upforsubcutaneousinfusiondevice.
True
False
Q2) Therecommendedsubcutaneousinfusionperiodis24hours. True
False
Q3) Thepatientandfamilydonotneedanexplanationofhowthe subcutaneousinfusiondeviceworks,orindicationsforuse.
True
False
Q4) Therecommendedminimumsyringesizeis10ml. True
False
Q5) Alwaysemployanaseptictechniquewhenchangingthecannula. True
False
Q6) Thevolumetobeinfused,i.e.thevolumeinthesyringeorreservoir, shouldbedocumentedatthetimeofset-upandregularchecks.
True
False
28
Section 3: Selection, Preparation and Maintenance of the Site
Learning Objectives
At the completion of this section, you should be able to:
• explainthemostappropriatesitesforsubcutaneousinfusion;
• explainwhichsitesareinappropriateforsubcutaneousinfusion;
• describetechniquesthatmayassistinminimisingsiteirritation;
• describeimportantprinciplesforsiteinspection.
General principles for appropriate site selection
• useanareawithagooddepthofsubcutaneousfat;
• useasitethatisnotnearajoint;
• selectasitethatiseasilyaccessiblesuchasthechestorabdomen;
• selectandusesitesonarotatingbasis1;
• siteselectionwillbeinfluencedbywhetherthepatientisambulatory,
agitatedand/ordistressed;
• thechestorabdomenarepreferredsites2,specificallytheupper,
anteriorchestwallabovethebreast,awayfromtheaxilla.Ifthepatient
iscachectic,theabdomenisapreferredsite2;
• sitelongevitycanvaryfrom1–14days;manyvariablesinfluencesite
longevity,suchastypeofmedicationandtypeofcannulaused;
• factorsthatcausesitereactionsincludetonicityofthemedication,
solutionpH,infection,andprolongedpresenceofaforeignbody.3
29
Inappropriate site selection includes4
• lymphoedematousareas;
• areaswherethereisbrokenskin;
• skinsitesthathaverecentlybeenirradiated;
• sitesofinfection;
• bonyprominences;
• incloseproximitytoajoint;
• sitesoftumour;
• skinfolds;
• inflamedskinareas;
• whereverascitesorpittingoedemaarepresent;
• wherescarringispresent;
• areaswherelymphaticdrainagemaybecompromised1,forexamplein
womenwhohavehadamastectomy.
Site related problems
Remember,anysiteproblemswillcausethepatientdiscomfortandmayalso
interferewithdrugabsorptionandcompromiseeffectivesymptomcontrol.
Therefore,theselectionofanappropriatesiteforsubcutaneousinfusions
viaasyringedriverhasimplicationsforthepatient.
Siteproblemsmaybeassociatedwithinappropriatesiteselection,ordueto
siteirritation.
30
Factors contributing to site irritation/reactions include:
• thetonicity(concentration)ofthemedication;
• thepHofthesolution;
• infection;
• prolongedpresenceofaforeignbody3;
• somemedicationsincluding:
! cyclizine2,5
! levomepromazine
! methadone
! promethazine
! morphinetartrate
! ketamine4
Techniques that may be considered in consultation with the treating physician to minimise site irritation include:
• dilutingthemedicationsbyusingalargersyringesize2;
• usingnormalsaline(0.9%)ifapplicable,insteadofwaterforinjection2;
• adding1mgofdexamethasonetothesyringe6-oneAustraliantrial
foundthattheadditionof1mgofdexamethasonetosyringedrivers
cansignificantlyextendthelongevityofthesubcutaneousinfusionsite7;
• useofaTeflon®orVialon®cannula,e.g.theBDSaf-T-Intima,reduces
siteinflammation.2,8-10
31
Site Inspection
Meticuloussiteinspectionisintegraltoearlyidentificationandprevention
ofsiterelatedcomplications,andshouldbeperformedaspartofroutine
care.6,11,12Anysiteproblemscanpotentiallycausepatientdiscomfort.Theyalso
interferewithdrugabsorptionandcompromiseeffectivesymptomcontrol.
When inspecting the site, check for:
• tendernessorhardnessatthesite;
• presenceofahaematoma;
• leakageattheinsertionsite;
• swelling—asterileabscesscanoccurattheinsertionsite,causinglocal
tissueirritation12;
• erythema(redness);
• thepresenceofbloodinthetubing;
• displacementofthecannula.4
In addition to checking the site regularly (4 hourly is recommended), other important patient checks include:
• askingthepatienthowtheyfeel(orfamilymember/carer,ifthepatient
isunabletocomprehend):aretheirpainandothersymptomscontrolled?
• ensuringthattheinfusiondeviceisworkinge.g.
! ontheNikiT34theLEDlightflashesgreen;
! ontheGemStararrowsprogressacrossthescreen;
! ontheWalkMedLX350,squaresprogressacrossthescreenand
‘infusing’isseenonscreen;
32
! ontheGrasebythelightflashesgreenanda‘whirring’soundcanbe
heardasthedevicedeliverstheinfusion;
• checkingthevolumeremaininginthesyringe,andthatthedeviceis
runningtotime;
• ensuringtherearenoleakages,andthatconnectionstothesyringe
andcannulaarefirm.
Principles for site preparation and cannula insertion include:
• anaseptictechniquemustbeemployed,asmanypatientswhorequire
asubcutaneousinfusionareimmuno-compromised.Ensurehandsare
washedthoroughly12;
• inconsultationwiththepatientandfamily,selectasuitablesite12
usingtheprinciplesforappropriatesiteselection;
• selectandusesitesonarotatingbasis1;
• preparetheskinusinganantisepticwithresidualactivity,e.g.asolution
containing0.5%to2%chlorhexidinegluconatein>70%ethylor
isopropylalcohol13,andwaitforskintodry.NB:‘Thesolutionshould
beappliedvigorouslytoanareaofskinapproximately15cmindiameter,
inacircularmotionbeginninginthecentreoftheproposedsiteand
movingoutward,foratleast30seconds’13;
• thepointofthecannulashouldbeinsertedjustbeneaththe
epidermis.Forthinpeopletheangleofthecannulaoninsertionmay
needtobeless(30degrees)thanforapersonwithmore
subcutaneoustissue(45degrees).Adeeperinfusionmayprolongthe
lifeoftheinfusionsite.
33
To insert:
• grasptheskinfirmlytoelevatethesubcutaneoustissue.Insertthe
cannulaandreleasetheskin;
• removethestyletifusingaBDSaf-T-Intima®andtakecaretohold
thedeviceinsituwhenremovingthestyletsothattheentiredeviceis
notaccidentallyremovedfromthepatient.
Note:Ifametalcannulaisbeingused,placethebevelofthemetaldevicedownwardstodeliverthedrugsmoredeeplyintotheskin,andminimise
irritation.
• theextensiontubingischangedwhenthecannulaischanged;
• whenthetubingisplacedagainsttheskin,formalooptoprevent
dislodgementifthetubingisaccidentallypulled6.Useatransparent,
semi-occlusivedressingtocoverthesite,asthispermitsinspectionof
thesitebythecaregiver6,8;
• whererelevant,placethesyringeinthesyringedriver;
• recordanddocumentthattheinfusionhasbeencommenced,and
volumetobeinfused,asperlocaldrugadministrationpolicies.
Activity
Choosingthesite:WatchexcerptfromChapter2–‘WhoNeedsOne?’of
BrisbaneSouthPalliativeCareCollaborative’sGuideforClinicians–Howto
UseaSyringeDriverforPalliativeCarePatients.
Insertionofcannula:WatchexcerptfromChapter2–‘WhoNeedsOne?’of
BrisbaneSouthPalliativeCareCollaborative’sGuideforClinicians–Howto
UseaSyringeDriverforPalliativeCarePatients.
34
References
1. GomezY.Theuseofsyringedriversinpalliativecare.AustralianNursingJournal 2000;(2):suppl1-3.
2. DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
3. MorganS,EvansN.Asmallobservationalstudyofthelongevityofsyringedriversites inpalliativecare.InternationalJournalofPalliativeNursing2004;10(8):405-412.
4. DickmanA,SchneiderJ,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.2nded.Oxford:OxfordUniversityPress;2005.
5. McNeillyP,PriceJ,McCloskeyS.Theuseofsyringedrivers:apaediatricperspective. InternationalJournalofPalliativeNursing2004;10(8):399-404.
6. MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions. InternationalJournalofPalliativeNursing2001;7(2):75-85.
7. ReymondL,CharlesMA,BowmanJ,TrestonP.Theeffectofdexamethasoneonthe longevityofsyringedriversubcutaneoussitesinpalliativecarepatients.Medical JournalofAustralia2003;178:486-489.
8. PalliativeDrugs.com.‘Syringedrivers.’<www.palliativedrugs.com>.Accessed25 January2005.
9. AbbasS,YeldhamM,BellS.Theuseofmetalorplasticneedlesincontinuous subcutaneousinfusioninahospicesetting.AmericanJournalofHospiceand PalliativeMedicine2005;22(2):134-138.
10.RossJR,SaundersY,CochraneM,ZeppetellaG.Aprospective,within-patient comparisonbetweenmetalbutterflyneedlesandTefloncannulaeinsubcutaneous infusionofdrugstoterminallyillhospicepatients.PalliativeMedicine2002;16:13-16.
11.Coleridge-SmithE.TheuseofsyringedriversandHickmanlinesinthecommunity. BritishJournalofCommunityNursing1997;2(6):292,294,296.
12.RatcliffeN.Syringedrivers.CommunityNurse1997;3(6):25-26.
13.CHRISP(CentreforHealthcareRelatedInfectionSurveillanceandPrevention). Occupationalexposurestobloodandbodyfluids:Recommendedpracticesfor preventinghollow-boreneedlestickinjuries(Recommendation2:Wingedinfusion setsforsubcutaneousandintravenousinfusions).QueenslandGovernment (QueenslandHealth);2007.<http://www.health.qld.gov.au/chrisp/resources/ hollbore_rec_prac.pdf>.Accessed28June2010.
35
QUIZ: Section 3 - Selection, Preparation and Maintenance of the Site
ThisquizwilltesttheobjectivesandcontentinSection3oftheLearning
Packageandthe‘Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) YouarepreparingtoinsertacannulaforMrs.BettySmith,whorequires asubcutaneousinfusionviaasyringedriver.Whatisgenerallythe
preferredsiteforinsertionofthecannula?
UpperArm
Thigh
ChestorAbdomen
Backofthehand
Q2) YouarepreparingtoinsertacannulaforMrs.BettySmith,whorequires asubcutaneousinfusion.Ifshewascachectic,whatmaybethe
preferredsite?
Backofthehand
Abdomen
Thigh
UpperArm
Q3) IfMrs.Smithisdistressedoragitated,andthereisariskof
dislodgement,whichsitemightbeconsidered?
Scapula
Thigh
Abdomen
UpperArm
36
Q4) Eachofthefollowingisanimportantconsiderationinselectingan appropriatesiteEXCEPT:
Choosinganareawithagooddepthofsubcutaneoustissue
Avoidingoedematousareas
Selectingasitethatisclosetoajoint
Selectingasitethatiseasilyaccessible
Q5) Whichofthefollowingmayassistinminimisingsiteirritation? Ensuringthesyringedriverissafelysecuredtopreventdisconnection
Usingametalneedle
Dilutingthemedicationsbyusingalargersyringesize
Changingthecannulatoanothersite
Q6) KeyPrincipleswheninspectingtheinsertionsitewouldincludeallthe followingEXCEPT:
Ensuringthesyringedriverissafelysecuredtopreventdisconnection
Inspectingforrednessatthesite
Inspectingfortendernessorhardnessatthesite
Ensuringthepatientdoesn’tgetoutofbedwhenthesyringedriver
isoperational
37
Section 4: Drugs and Diluents
Learning Objectives
Atthecompletionofthissection,youshouldbeableto:
• describethemostcommonlyuseddrugsinsubcutaneousinfusions,
andtheirindicationsforuse;
• explainwhichdrugsarecontraindicatedinsubcutaneousinfusions;
• statethemostcommonlyuseddiluentinsubcutaneousinfusions.
Drug administration via a subcutaneous infusion device
• aprescriptionfromamedicalofficerorappropriatelycredentialled
nursepractitionerisrequiredbeforeadministeringanymedication;
• subcutaneousinfusiondevicescanbeusedtodeliverdrugstotreat
avarietyofsymptoms,particularlywhenotherdrugroutesareno
longeravailable,orareunacceptabletothepatient;common
symptomsincludepain,nausea,vomiting,breathlessness,agitation,
deliriumand“noisybreathing”1;
• awidevarietyofdrugscanbeusedtogetherindifferentcombinations
withnoclinicalevidenceoflossofefficacy2;
• themoredrugsthataremixedtogether,thegreatertheriskof
precipitationandreducedefficacy3;
• 2–3drugsmaybemixedinasubcutaneousinfusion(occasionallyup
to4drugs4,5);
• ifcompatibilityisanissue,theuseoftwosubcutaneousinfusion
devices3orregularorprnsubcutaneousinjectionsshouldbe
considered;
38
• beforemixinganydrugstogetherinasubcutaneousinfusion,checkfor
stabilityandcompatibilityinformation3,4,6-8e.g.withhospital
pharmacists;othersourcesincludeTheSyringeDriver1and
PalliativeDrugs.com12;
• useoftheboostfacility,whereavailable,isnotadvocated;aboost
doserarelyprovidessufficientanalgesiatorelieveuncontrolledpain,
andmayleadtooverdosingofotherdrugsbeinginfused4;
• itisbettertousebreakthroughmedicationtotreatuncontrolled
symptomsthantheboostfacility9;
• normalsalineisthemostcommonlyuseddiluentinAustralia10;
• theuseofwaterforinjectionhasbeenlinkedtopainduetoits
hypotonicity,althoughnormalsalinemaybemorelikelytocause
precipitation11;
• 5%dextroseisusedonlyoccasionallyasadiluent4,andisnot
commonlyusedinAustralia.12
In the Australian context, symptoms that are encountered at the end of life are generally well controlled by the use of nine commonly used medications.13 These include:
• morphinesulphate/tartrate(anopioid);
• hydromorphone(Dilaudid,anopioid);
• haloperidol(Serenace,anantipsychotic/antiemetic);
• midazolam(Hypnovel,ashortactingbenzodiazepine);
• metoclopramide(Maxolon,anantiemetic);
• hyoscinehydrobromide(hyoscine,anantimuscarinic/antiemetic);
• clonazepam(Rivotril,abenzodiazepine);
• hyoscinebutylbromide(Buscopan,anantimuscarinic);and
• fentanyl(anarcotic).
39
Temperaturemayaffectthestabilityofdrugs.Thiscanbeovercomeby
ensuringtheinfusiondeviceisplacedontopofbedclothesandoutsideof
clothing,ratherthanbeneaththem.4
Medications contraindicated for use via subcutaneous infusion due to severe localised reactions3,11:
• prochlorperazine(Stemetil,anantiemetic);
• diazepam(Valium,ananxiolytic);and
• chlorpromazine(Largactil,anantipsychotic)
Medications linked to abscess formation when used in subcutaneous infusions:
• pethidinehydrochloride(pethidine,ananalgesic);
• prochlorperazine(Stemetil,anantiemetic);and
• chlorpromazine(Largactil,anantipsychotic).1
Diluents
Thechoicebetweenwaterforinjectionand0.9%(normal)salineasadiluent
isamatterofdebate.Theliteratureisdividedwithsomerecommending
waterforinjectionasthediluent3,4,10,12,andrecentliteraturerecommending
normalsaline.1Normalsalinecanbeusedformostdrugs,themain
exceptionbeingcyclizine.4
NormalsalineismostcommonlyusedwithinAustraliafortworeasons1:
• firstly,themajorityofdrugscanbedilutedwithnormalsalinewithonly
40
twoexceptions:cyclizineanddiamorphine(neitherofwhichare
commonlyusedinAustralia);
• secondly,normalsalineisisotonic,asaremostinjectableformulations.
Bydilutingwithnormalsaline,thetonicityofthesolutionisunaltered.
Waterforinjectionishypotonic;usingitasadiluentwillpotentially
produceahypotonicsolution,whichtheliteraturesuggestscan
contributetothedevelopmentofsitereactions.1Forexample,theuse
ofwaterforinjectionhasbeenlinkedtopainduetoitshypotonicity,
althoughnormalsalineismorelikelytocauseprecipitation.11
References
1. DickmanA,SchneiderJ,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.2nded.Oxford:OxfordUniversityPress;2005.
2. LichterI,HuntE.Drugcombinationsinsyringedrivers.TheNewZealandMedical Journal1995;108(1001):224-226.
3. MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions. InternationalJournalofPalliativeNursing2001;7(2):75-85.
4. DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
5. McNeillyP,PriceJ,McCloskeyS.Theuseofsyringedrivers:apaediatricperspective. InternationalJournalofPalliativeNursing2004;10(8):399-404.
6. Coleridge-SmithE.TheuseofsyringedriversandHickmanlinesinthecommunity. BritishJournalofCommunityNursing1997;2(6):292,294,296.
7. NegroS,SalamaA,SanchezY,AzuaratM,BarciaE.Compatibilityandstabilityof tramadolanddexamethasoneinsolutionanditsuseinterminallyillpatients.Journal ofClinicalPharmacyandTherapeutics2007;32:441-444.
8. PetersonG,MillerK,GallowayJ,DunneP.Compatibilityandstabilityoffentanyl admixturesinpolypropylenesyringes.JournalofClinicalPharmacyandTherapeutics 1998;23:67-72.
9. Lloyd-WilliamsM,RashidA.Ananalysisofcallstoanout-of-hourspalliativecare adviceline.PublicHealth2003;117(2):125.
10.FlowersC,McLeodF.Diluentchoiceforsubcutaneousinfusion:asurveyofthe literatureandAustralianpractice.InternationalJournalofPalliativeNursing 2005;11(2):54-60.
41
11.BritishNationalFormulary.Syringedrivers.<www.bnf.org>.Accessed26January2005.
12.PalliativeDrugs.com.‘Syringedrivers.’<www.palliativedrugs.com>.Accessed25 January2005.
13.JointTherapeuticsCommission.Asurveyofdoctorsontheirpreferredmedicationsfor varioussymptomsinpalliativecare.Brisbane:Unpublisheddata;2005.
42
QUIZ: Section 4.1 - Drugs and Diluents
ThisquizwilltesttheobjectivesandcontentinSection4oftheLearning
Packageandthe’Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) Whichtwoofthefollowingdrugsarecontraindicatedforsubcutaneous infusions?
MorphineTartrate
Fentanyl
Chlorpromazine
Pethidine
Q2) Normalsalineisthemostcommonlyuseddiluentforsubcutaneous infusionsinAustralia.
True
False
Q3) ThegenericnameforDilaudidis: Serenace
Hypnovel
Durogesic
Hydromorphone
Q4) Thebrandnameforhaloperidolis: Maxolon
Durogesic
Buscopan
Serenace
43
Q5) Thebrandnameformidazolamis: Hypnovel
Metaclopramide
Serenace
Dilaudid
Q6) ThegenericnameforBuscopanis: Durogesic
HyoscineButylbromide
Hypnovel
HyoscineHydrobromide
Q7)ThegenericnameforMaxolonis: Morphine
Buscogesic
Metoclopramide
Hydromorphone
Q8) Whataretwoindicationsfortheuseofmorphinesulphate/tartratein subcutaneousinfusions?
Morphineiswellabsorbed
Itisoftenusedtodryterminalsecretions
Higherdosesmaycontrolagitationandconfusion
Itisanopioidforpaincontrol
Q9) Whataretwoindicationsfortheuseofhydromorphonein subcutaneousinfusions?
Itisanopioidforpaincontrol
Itmaybeusedwhenmorphineisnoteffective
Itisusedasanantiemetic
Itiseffectiveforcontrollinganxietyorterminalrestlessness
44
Q10)Whataretwoindicationsfortheuseofhaloperidolinsubcutaneous infusions?
Itisnotdirectlyanantiemetic,butdoesreducegastrointestinal
secretions
Itisanantipsychoticagentanddopamineantagonist
Itisanopioidforpaincontrol
Itmaybeusedinlowdosestocontrolnauseaandvomiting
Q11)Whataretwoindicationsfortheuseofmidazolaminsubcutaneous infusions?
Itisanantiemetic
Itisanarcotic
Itisashort-actingbenzodiazepine,usedtocontrolanxietyor
terminalagitation
Itisashort-actingbenzodiazepine,usedtocontrolseizures
Q12)Whataretwoindicationsfor/characteristicsoftheuseof metoclopramideinsubcutaneousinfusions?
Itisusefulinthetreatmentofnauseaandvomiting
Itmaybeusedwhenmorphineisnoteffective
Higherdosesmaycontrolagitationandconfusion
Itiscontraindicatedincompleteorsuspectedintestinal
obstruction
Q13)WhataretwoindicationsfortheuseofBuscopaninsubcutaneous infusions?
Itisanopioidforpaincontrol
ForthetreatmentofGITspasm
Higherdosesmaycontrolagitationandconfusion
Itreducesgastrointestinalsecretions
45
Q14)Whatwouldbeanindicationforusingfentanylinasubcutaneous infusion?
Itisoftenusedtodryterminalsecretions
Itisoftenusedtocontrolseizuresandanxiety
Itisanarcoticforseverepain
Itisusedasanantiemetic
QUIZ: Section 4.2 - Drugs and Diluents (Calculations)In the following 6 questions, calculate the volume for each of the break-through drugs ordered, using the strengths indicated.
Q15)(morphine10mgin1ml)morphine2.5mg=?ml
Q16)(morphine10mgin1ml)morphine25mg=?ml
Q17)(morphine120mgin1.5ml)morphine80mg=?ml
Q18)(midazolam5mgin1ml)midazolam2.5mg=?ml
Q19)(midazolam5mgin1ml)midazolam7.5mg=?ml
Q20)(haloperidol5mgin1ml)haloperidol1.5mg=?ml
In the next 4 questions you should calculate the volume required of each medication for the following subcutaneous infusion order over 24 hours: midazolam 10mg; morphine 15mg; metoclopramide 20mg. Note: the strength of available drug is shown in each question.
Q21)10mgofmidazolam(15mg/3ml)=?ml
Q22)15mgofmorphinesulphate(30mg/1ml)=?ml
Q23)20mgofmetoclopramide(10mg/2ml)=?ml
46
Q24)Whatisthetotalvolumeofthemedication?=?ml
For the next 4 questions, the subcutaneous infusion order has now changed: re-calculate using the following medication order.
Q25)25mgofmidazolam(15mg/3ml)=?ml
Q26)45mgofmorphinesulphate(30mg/1ml)=?ml
Q27)25mgofMaxolon(10mg/2ml)=?ml
Q28)Whatisthetotalvolumeofthemedication?=?ml
47
Section 5: Patient and Family/Carer Education
Carefulexplanationandeducationaboutwhatthedevicewilldo,its
advantagesandpossibledisadvantages,aswellasa24-hoursupport
number,isrequiredforpatientswithsubcutaneousinfusiondevicesand
theirfamilies.1Whenhealthprofessionalsprovideeducationtopatients
andfamily/carersitpromotessafetyandacceptanceoftheinfusiondevice
asameansofprovidingimprovedsymptomcontrol.2Good,welltimed
informationcanpreparethefamily/carerfortheroletheyaretakingon,
minimisingpotentialadverseconsequences.3
Learning Objectives
At the completion of this section, you should be able to:
• outlinethekeyelementsofpatient/familyeducationtopromotesafe
useofsubcutaneousinfusiondevicesbythepatient/family;
• describestrategiestosupportpatient/familydecisionmaking
regardingsymptommanagement.
Strategies for Providing Effective Education and Support
Thepatientandfamily/carershouldbegivenverbalandpracticalguidance
aboutlivingwithasubcutaneousinfusiondevice.Healthprofessionals
shouldbemindfulthatinformationandeducationgivenwhenthepatient
isunwellandthefamily/carerisanxiousmayneedtoberepeatedand
reinforced.
Explanation, demonstration and practice should be:
• simpleandfocusonneededmotorskillse.g.changingthebattery;
48
• repeatedasneeded;
• reassuringtothepatientandfamily/carerabouttheirabilitytomanage
thedevice.
Written information should:
• beclearandunderstandable;
• includeinformationaboutmanagementofcommonissueswiththe
deviceinuse;
• includewhattodoifthedevicealarms;
• includehowtocontactaknowledgeablehealthpractitionerout
ofhours.
Topics for Education
Information about the device
Subcutaneousinfusiondevicesareveryreliable.Itisimportantthatthe
patientandfamily/carerareinformedaboutindicatorsofnormaldevice
functioningsuchasa‘whirring’noise,asmallflashinglightorascreenwith
arrowsrunningacrossit.
Thepatientand/orfamily/carershouldbeencouragedtocheckthedevice
regularlytoensureitisfunctioningnormally,buttheyshouldalsobe
encouragednottoworryaboutcheckingitovernight.
Thepatientandfamily/carershouldbereassuredthatiftheybelieve
somethingiswrongwiththeinfusiondeviceorifthealarmsounds,itis
likelytobeaproblemthatiseasilyrectified.Forthesedevicesitisimportant
thepatientandfamily/carerareconfidentintheirabilitytomanagesimple
issuesthatmayariseinthenormalfunctioningofthedevice.
49
Daily Living
Thepatientandfamily/carershouldbeencouragedandguidedinwaysto
incorporatethesubcutaneousinfusiondeviceintotheireverydaylife.These
devicesaredesignedtomakethepatient’slifemorecomfortableandtobe
abletocontinuewithdailyroutines.
• thepatientmayshowerorbatheasnormal;
• instructionandclearwritteninformationregardingdisconnectionfrom
theinfusiondeviceforshowering,andreconnectionafterwards,
shouldbegivenbythehealthprofessional.Theperiodofdisconnection
shouldbeasbriefaspossible;
• patientsandfamily/carersshouldbegiveninformationaboutgeneral
careofthedevicetoallayfearsofdroppingordamagingthedevice4;
• thepatientshouldbeprovidedwithabagorencouragedtopurchasea
beltbagtoconcealandcarrytheinfusiondevice;
• alockedboxorperspexcovershouldbeprovidedaspatientsand
family/carershavereportedfeelingsofinsecurityandconcernabout
therobustnessofthedevice.
Medications
Patientsandfamily/carersshouldbeinformedtheremaybeachangein
thepatient’slevelofalertnessasaconsequenceofadministeringsome
medicationssubcutaneously.Theyshouldbereassuredthattheresponseis
generallytransitory,dependentonthegeneralconditionofthepatient,and
thedrugscanbetitratedappropriatelyifitremainsaproblemafterafewdays.
Thepatientandcarershouldbegivenclearinstructionsaboutmanagement
ofbreakthroughpainorothersymptomsandbereassuredabouttheuse
ofmedicationsonthoseoccasions.5Breakthroughmedicationisdefined
50
asextramedicationthatmayberequiredforsymptomsnotcontrolledby
medicationsprescribedforcontinuousdelivery.
Drug Storage and safety
Thepatientandfamily/carershouldbeadvisedaboutappropriatesafetyand
storagemeasuresformedicationsincludinginformationaboutthesupply
tobeheldinthehome,safestorageinalockedcupboardifappropriate,as
wellastemperatureandmoisturecontrol.
Carer Support
Educationandinformationconcerningtheprovisionofcareathomehas
beenrecognisedasemotionallybeneficialforfamily/carers6,reducingthe
riskofcareranxietyandstress.Thefamily/carermaydescribeadditional
concernsasthepatient’sconditionchangesandtheyarecalleduponto
makeproxydecisionsaboutsymptomsandbreakthroughmedications.
Thefamily/carershouldbeprovidedwithappropriateinformationabout
adjustmentstocareasthepatient’sconditionchangesandbereassured
abouttheircapabilitytomakeproxydecisionsandcontinueprovidingcare.
Equallytheyshouldbereassuredthatiftheycannolongercareforthe
patientwithasubcutaneousinfusiondevice,theywillbeassistedinseeking
outacarealternative.
Simpleinformationstrategiessuchaswrittenguidance,supervisedpractice
andprofessionalcontactwhenneededcandecreasethefamily/carer’s
anxiety,reducethechancesofforgettinginformation,andmaycontributeto
alowerincidenceofproblems.7Goodinformationwillassistthefamily/carer
tobeconfidentindecisionmaking,maintainthepatient’scomfortandhave
apositiveexperienceofcare.
51
Links
Section5of‘Guidelinesforsubcutaneousinfusiondevicemanagementin
palliativecare(RevisedEdition)’
Consumermedicineandsymptomguide,availablefrom:
http://www.healthnetworks.health.wa.gov.au/cancer/docs/Consumer_Book.pdf
(GovernmentofWesternAustralia,DepartmentofHealth.Palliativecare
medicineandsymptomguide.WACancerandPalliativeCareNetwork;2010.)
Activity
Reviewyourorganisation’swritteninstructions/guidelines/informationfor
patientsandfamily/carers.
References
1. PalliativeDrugs.com.SyringeDrivers.<www.palliativedrugs.com>.Accessed25January 2005.
2. MorganS,EvansN.Asmallobservationalstudyofthelongevityofsyringedriversites inpalliativecare.InternationalJournalofPalliativeNursing2004;10(8):405-412.
3. Yatesetal.2004inCruikshankS,AdamsonE,LoganJ,BrackenridgeK.Usingsyringe driversinpalliativecarewithinarural,communitysetting:capturingthewhole experience.InternationalJournalofPalliativeNursing2010;16(3):126-132.
4. FletcherC.ReportoncomparativeevaluationofGrasebysyringedriverreplacements. Auckland,NZ:NorthShoreHospiceTrust;2009.
5. Lloyd-WilliamsM,RashidA.Ananalysisofcallstoanout-of-hourspalliativecare adviceline.PublicHealth2003;117(2):125.
6. CentreforPalliativeCareResearchandEducation.Guidelinesforsubcutaneous infusiondevicemanagementinpalliativecare(RevisedEdition).Brisbane, Queensland:QueenslandHealth;2010.
7. DriscollA.Managingpostdischargecareathome:ananalysisofpatients’andtheir carer’sperceptionsofinformationreceivedduringtheirstayinhospital.Journalof AdvancedNursing2000;31(5):1165-1173.
52
Quiz: Section 5 – Patient and Family/Carer Education
ThisquizwilltesttheobjectivesandcontentinSection5oftheLearning
Packageandthe‘Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) Maintainingpersonalhygienewithasubcutaneousinfusiondevicecan beanissueforpatientsandfamily/carers.Whatadvicewouldyougive?
a.Don’tworry,patientscanhaveashowerbecausethedeviceis
waterproof
b.Theinfusioncanbedisconnectedforabriefamountoftimefor
showering
c. Patientswillneedtohavespongebathsaftertheinfusionis
commenced
Q2) Patientsandfamily/carersmaybecomeconcernedthatpainandother symptomsstillwon’tbecontrolledasthesamedrugshavebeentried
byotherroutes.Whatreassurancewouldyougive?
a.Ifthereisbreakthroughpainorothersymptomsthenextra
medicationcanbegiven
b.Allpainandsymptomswillbemanaged,therewillbenomore
problems
c. Ifthesubcutaneousinfusiondoesn’twork,nothingwill
Q3) Patientsmayhaveafeelingofsedationoroverwhelmingtiredness whenreceivingmedicationsviaasubcutaneousinfusion.Whatwould
youtellthem?
a.Thisisnormalandtheywilladjustinfewdaysafter
commencing/changingdoseintheinfusion
b.Sedationisasideeffectofthedrugs,nothingcanbedoneaboutit
c.Oncesymptomsarecontrolled,thedosecanbeadjustedifit
remainsaproblemforthem
d.Alloftheabove
53
Q4) Patientsandfamily/carersneedtotakeinalotofinformationwhena subcutaneousinfusiondeviceisbeingused.Whatkindofeducation
strategiescouldyouusetoensurethattheyareabletosafelymanage
thedevicewithconfidence?
a.Provideunderstandable,writtenguidelinesforthemtofollow
b.Explain,demonstrateandallowtimetopracticeanymotorskills
eg.changingthebattery
c. Provideinformationaboutoutofhourspointofcontactwitha
trainedhealthprofessional
d.Alloftheabove
54
Section 6: Patient Assessment and Troubleshooting
Thoroughassessmentisimportantwhencaringforpatientswitha
subcutaneousinfusionandshouldincludemonitoringofthepatient1
andthesubcutaneouscannulasite2,thedeviceandequipment3,and
compatibilityofdrugsbeingadministered.4,5
Whentroubleshootingequipmentusedinsubcutaneousinfusionsof
medicationviaapowerdrivendevice,itisimportanttounderstandthe
normalfunctioningofthedevice.6Theuseofonlyonetypeofdeviceineach
settinghasbeensuggestedtopreventconfusionwhichmayleadtoerrors.7
Learning Objectives
At the completion of this section, you should be able to:
• demonstrateanunderstandingofrelevantprinciplestoguide
assessmentofthepatienthavingasubcutaneousinfusion;
• describestrategiestodealwithcommonissuesthatarisewith
subcutaneousinfusionsandassociatedequipment.
Patient Assessment
Symptom assessment
Symptommanagementandcontrolisthekeyreasonforcommencinga
subcutaneousinfusionsoitisreaonablethatasignificantamountoftime
shouldbespentuponassessmentofthepatient’ssymptomsandefficacyof
theintervention.Assessmentshouldinclude:
• askingthepatienthowtheyfeelandtoratetheirsymptoms,orifthe
patientisnotabletorespondduetoconditionorcomprehension,ask
55
thecarerasanappropriateproxytorateobservablesignsof
symptoms;
• askingaboutpatternsofsymptomsexperienced,unrelievedorpoor
controlofsymptoms;
• observationforanddocumentationofsideeffectsofdrugsbeingused.
Useofavailable,validatedtoolstoassistintheassessmentofsymptoms
andconditionofpatientandfamily/carerisrecommended.Sometoolsin
commonusetoaidassessmentanddocumentationoffindingscanbefound
atthePalliativeCareOutcomesCollaborative(PCOC)website
http://chsd.uow.edu.au/pcoc/.8ServicesdonotneedtobeenrolledinPCOC
toaccessorusethetools.
Unrelieved symptoms
Breakthroughmedicationisdefinedasextramedicationthatmaybe
requiredforsymptomsnotcontrolledbymedicationsprescribedfor
continuousdelivery.9Administrationofbreakthroughdoseswillaidgood
painandsymptomcontrolandshouldbeusedwhen:
• asubcutaneousinfusioniscommencedasitmaytakeupto48hours
fordruglevelstoreachasteadystate;
• apatientcontinuestoreportunrelievedorpoorcontrolofpain/
symptoms;and
• deviceandsiterelatedproblemshavebeenexcluded.
Itisimportanttothesuccessfulcommencementofaninfusionthat
breakthroughmedicationisprovidedandusedasneededinthefirst48
hoursaftercommencement.Ifsymptomscontinuetobeunrelieveda
reviewofmedicationsbeinginfusedshouldbemade.Checktoensurethe
56
medicationisappropriate,thatanappropriatedosehasbeenprescribed
andthatthecorrectdosagehasbeenpreparedandisbeinginfused.
Adverse effects
Subcutaneousinfusiondeviceshavebeenusedtodelivermedications
traditionallyovera24hourperiodtoreducetheriskoferrorsinsettingup
theGraseby.7AlthoughtheGrasebyisnowbeingphasedout,evidenceon
microbiologicalstability,andphysicalandchemicalcompatibilitystillmost
commonlyrelatestoa24hourperiod.Itisforthisreasonthata24hour
infusionperiodisstillrecommended.9Tominimisetheriskofasignificant
siterelatedadverseevent,carefulinspectionofthesiteandprompt
responsetoanynotedchangeshouldformpartofgoodcare.
Adverseeventsrelatedtothedrugsbeinginfused,thoughrelatively
uncommon,shouldbenoted.Theinfusionshouldbestoppedand
followedbyobservationofthepatientandteamdiscussionaboutongoing
management.
Subcutaneous cannula site
Ideally,siteinspectionsshouldbeperformedatleast4hourly,notingsigns
ofinflammationandlocalsitereaction2andthenbedocumentedonthe
relevantorganisationalform.Forcommunityserviceswhenthisisnot
practical,considerpatientandfamily/carereducationregardingobservable
signsanddirectionsformanagementofchanges.
Inspectionofthesubcutaneouscannulasiteshouldbepartofroutinecare
andincludechecksfortendernessandpresenceofahaematomaatthe
cannulainsertionsite.1,4,6
57
Othersiteissuesmayinclude:
Inflammationofthecannulainsertionsite:
• couldbealocalisedskinreactionoraninflammatoryresponseata
previousareaofradiotherapy;
• thedrugsbeinginfusedshouldbereviewedtoconfirmtheyare
appropriateforsubcutaneousadministrationandthat;
• thedrug/drugsarenotataconcentrationthatmaycauseirritation.
Suggested solutions to manage site inflammation depend on the likely cause and may involve:
• removalandresitingofthesubcutaneouscannula;
• increasingthediluentinthedevicereservoirtoreducethedrug
concentration;
• additionofdexamethasonetothereservoirtoreducelocalisedsite
irritation;
• observationandmanagementofconsequencesthatmayinclude
infection.9
Painatthecannulainsertionsitecouldbedueto:
• inflammationforoneofthereasonsdiscussedabove;
• shallowcannulainsertionwhichmayalsobeacauseoflocalised
inflammation.
Painattheinsertionsiterequiresremovalandresitingofthesubcutaneous
cannula.
58
Leakageofinfusionfluidatthecannulainsertionsiteindicates:
• anunstablecannulaposition;
• allconnectionsshouldbecheckedtoensuretheyaresecure;
• changecomponentsasneeded;
• thecannulamayneedtoberemovedandresited.
Leakageoffluidwillcontributetounrelievedpain/symptoms.
Bleedingatthecannulainsertionsite:
• maybecausedbytraumaoracoagulationproblem;
• requiresremovalandresitingofthecannula.
Pressureshouldbeappliedtotheoldsitewhichshouldbeobservedfor
furtherbleeding.
Limited cannula accesspoints:
• maybeduetooedema,infectionorcachexia;
• requireconsiderationanddiscussionwithcolleaguestoconfirm
appropriatenessofsubcutaneousmedicationinfusion;
• indicateneedtoconsiderappropriatesiteselection(Section3ofthis
package).
If the patient is restless,showingsignsofdelirium,confusionorimpairedcognition:
• potentialunderlyingcausesshouldbeinvestigatedandtreated;
• thepossibilityofterminalrestlessnessshouldbeconsidered;
59
• causesofagitationlikepain,fullbladderorbowelshouldbechecked
andmanagedappropriately;
• sitingofthecannulaaroundthescapulashouldbeconsideredto
minimiseriskofdislodgement;
• abreakthroughdoseofanantipsychoticsuchashaloperidol,
risperidoneorolanzapinecanalsobeconsidered.10
Documentation
Symptomcontrolandefficacyofintervention/infusionshouldbenotedon
theappropriateformsofyourservice.Itissuggesteddocumentationshould
include:
• notationsreferringtotimes;
• volumesloaded;
• patientresponse;
• anyadverseincidentsorevents;
• thecapacityforthepatientandfamilytocontinuemanagementofthe
infusiondevice.
Family/Carer
Thecapabilityofthefamily/carertoparticipateincareofthepatientwitha
subcutaneousinfusiondeviceshouldbecheckedbeforecommencement
oftheinfusionandassessedregularlyafterthat.Thestatusofthecarer
–employment,physicalandemotionalhealth–shouldbeconsideredas
potentiallyimpactingontheoutcomeoftheintervention.
60
Device
Itisimportantthatyouunderstandthenormalfunctioningofthedevice
beingusedinyourservicearea.6Thesmallflashinglightonthefrontofthe
NikiT34andtheGraseby,theintermittent‘whirring’soundoftheGraseby
andthearrowsrunningconstantlyacrossthescreenoftheGemStarall
indicatethedeviceisfunctioningnormally.
Priming the line
Ensurethatorganisationalprotocolregardingprimingoftheextension
tubing/devicelineisfollowedwhensettingupasubcutaneousinfusion(see
section1ofthispackage).
Alarms
Eachdevicehasdifferentsettingsfortriggeringitsalarms.Analarmwillsoundif:
• theinfusionreservoir(syringeorcassette)isempty;
• thebatteryorpowersourceisexhaustedrequiringbatterychangeor
placementinachargingcradle;
• tubingiskinked,thecassetteisunseatedorthesyringeisjammed;
• airisdetectedintheGemStarlineorcassette(correctionwillrequire
clearingtheairfromthelineandre-priming).
Thedeviceshouldbemonitoredforashorttimeaftercorrectiontoconfirm
normalfunctioning.
61
Battery/Power
Batterylifeisvariable.Toreducethepotentialforaslowedorstopped
infusion,batteriesshouldbecheckedregularlytoensuretheyarenot
exhausted.Ifthedeviceusedbyyourserviceusesachargingcradle,ensure
itispluggedintomainspower,thatthedevicesitseasilyandproperlyinto
thecharger,andtheindicatorlightconfirmingitisonmainspower‘flicks’on.
Delivery of Medication
Inspectionofthevolumeremaining7ideallyshouldbeatleast4hourlywith
findingsdocumentedontherelevantorganisationalform.Whenthisisnot
practical,considerpatientandfamily/carereducationregardingobservation
ofinfusionvolumeandmanagementoffindings.
Aswithanymedication,thedeliveryoftherightdrugattherighttimeis
essential.
Regular assessment is required to identify any of the following concerns:
Infusion has not run to time
Careshouldbetakenatsetuporrefillingthatcorrectmeasures(syringe
andcassettevolume)andrateofinfusionareused.Iftheinfusiondoesnot
end‘ontime’orwithinacceptedparameters,eitherearlyorlatefinish,basic
checksshouldbemadeensuringthat:
• theratehasbeensetcorrectlyandnotbeenaltered;
• thesyringelengthandvolumetobeinfusedhasbeenmeasured
correctly;
• thesyringeorcassettereservoirisloadedproperlyintothedevice;
• therearenoimpedimentstothetubing/linee.g.kinks,orclampslefton;
62
• thedevicehasnotsustainedanywaterdamage;
• thedevicehasnotbeenpurposefullystopped;
• thedevicebatteryhaspowerandisnotflatwhichcouldcausethe
infusiontobeslowedorstopped6;
• the‘boostbutton’hasnotbeenactivated;
• estimatedandprescribedbreakthroughdoseshavenotbeen
exceededortheGemStar.
ForissueswiththeGemStarrepeatedlyfinishingearlyduetomorethan
expectedbreakthroughdoses,theprescriptioncanbealteredtoprovide
highervolumeforinfusionwhilemaintainingthesamedrugconcentration.
Infusion has stopped
Themostlikelyreasonfortheinfusiontostopisthatthereisnoremaining
fluidtobeinfusedandreloadingaccordingtothemedicalprescriptionis
required.Iffluidforinfusionremainsthencheckthat:
• thedevicebatteryisnotflatcausingtheinfusiontostop6;
• neitherthelinenorcannulaareblocked;
• thedrugsintheinfusionmixturehavenotprecipitated(crystallised)
blockingthetubing;
• thereisnomechanicalmalfunctioncausingfailureoftheinfusion.
Tubing
Carefulinspectionoftubingforpatency6shouldideallybedoneatleast4
hourlynotingtwists,kinks,signsofprecipitationandsecureconnections.
Findingsshouldbedocumentedontheappropriateformforyourservice.
63
Tampering
Ifitissuspectedthattherehasbeenpurposefultamperingwiththedevice
settingsorundirecteduseofthe‘boost’facility,atamperproof‘lockbox’7or
lockingofthedevice’skeypadshouldbeconsideredtomaintaininfusion/
drugsecurity.
Drugs
Calculations
Whenasubcutaneousinfusionviaadeviceisbeingsetuporreloaded,
alldrugcalculationsshouldbecheckedaccordingtolocallegislative
requirements,organisationalpolicyandprotocol.
Drug Choice and Dosage
Thereareanumberofdrugssuitableandcommonlyprescribedfor
subcutaneousinfusioninpalliativecaresettings(Section4).Prescriptions
shouldbecheckedtoensurethat:
• drugstobeinfusedareappropriateforsubcutaneousadministration;
• thedrugisnotataconcentrationthatmaycauselocalisedirritationat
thecannulainsertionsite;
• thedrugwillprovidecomfortforthepatient.
Compatibility
Whenadrugistobeinfused,orifmorethanonedrugistobeinfusedin
combination,itisimportanttocheckthecompatibilityofthedrug/drugsand
thediluenttobeused5,7topreventproblemswith:
64
• precipitation/crystallisationintubingorthesyringewhichwould
requirethesyringeorcassetteandtubingtobediscardedandinfusion
setupcommencedagain;
• skinirritationfromknowndrugirritantswhichwouldrequirechangeof
cannulainsertionsite,butcouldbeavoidedbyusingalargervolume
ofdiluent.7
Links
Section6of‘GuidelinesforSyringeDriverManagementinPalliativeCare’
Activity
Identifythetoolscurrentlyusedinyourservice/organisationforassessment
ofpeoplereceivingpalliativecare.
References
1. RatcliffeN.Syringedrivers.CommunityNurse1997;3(6):25-26.
2. ReymondE,CharlesM.Aninterventiontodecreasemedicationerrorsinpalliative patientsrequiringsubcutaneousinfusions:BrisbaneSouthPalliativeCareService andAdverseDrugEventPreventionProgram;unpublishedreportpresentedtoClinical ServicesEvaluationUnit;PrincessAlexandraHospital.Brisbane,Queensland;2005
3. PalliativeDrugs.com.SyringeDrivers.<www.palliativedrugs.com>.Accessed25January 2005.
4. Coleridge-SmithE.TheuseofsyringedriversandHickmanlinesinthecommunity. BritishJournalofCommunityNursing1997;2(6):292,294,296.
5. PalliativeCareMatters.<www.pallcareinfo>.Accessed10August2010
6. MittenT.Subcutaneousdruginfusions:areviewofproblemsandsolutions. InternationalJournalofPalliativeNursing2001;7(2):75-85.
7. DickmanA,LittlewoodC,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.Oxford:OxfordUniversityPress;2002.
65
8. PalliativeCareOutcomesCollaborative<http://chsd.uow.edu.au/pcoc/>.Accessed13 August2010.
9. CentreforPalliativeCareResearchandEducation.Guidelinesforsubcutaneous infusiondevicemanagementinpalliativecare(RevisedEdition).Brisbane, Queensland:QueenslandHealth;2010.
10.PalliativeCareExpertGroup.Therapeuticguidelines:palliativecare.Version3. Melbourne:TherapeuticGuidelinesLtd;2010,p.292.
11.DriscollA.Managingpostdischargecareathome:ananalysisofpatients’andtheir carer’sperceptionsofinformationreceivedduringtheirstayinhospital.Journalof AdvancedNursing2000;31(5):1165-1173.
66
Quiz: Section 6 - Patient Assessment and Troubleshooting
ThisquizwilltesttheobjectivesandcontentinSection6oftheLearning
Packageandthe‘Guidelinesforsubcutaneousinfusiondevicemanagement
inpalliativecare’document.
Q1) YourpatientMrsSmithhasasubcutaneousinfusiondeviceinsitu.Her symptomshavebeenwellcontrolledhowever,sheisnowcomplaining
ofanexacerbationofhersymptoms.Possiblereasonsmayinclude:
a.Devicemalfunction
b.Medicationrequiresreview
c.MrsSmith’sconditionischangingordeteriorating
d.Alloftheabove
Q2) MrsSmith’sinfusionisnotrunning‘ontime’.Whatkeyareasshould beassessed?
a.Correctvolume(moreorlessthanrequired)addedtoreservoirat
preparation
b.Failuretoaccountforinfusionvolumerequiredtoprimethe
tubing
c. Infusiondevicesetatcorrectrate
d.Alloftheabove
Q3) Whichtwoofthefollowinginfusionsitecharacteristicswouldindicate problems?
a.Pinkskin
b.Tenderness/redness
c. Swelling/hardness
d.Absenceoftenderness
Q4) Regularassessmentofapatientwithasubcutaneousinfusionshould include:
a.Effectivenessofsymptommanagement
b.Siteinspection/assessment
c. Checkingpatencyoftubingandsyringevolumeremaining
d.Alloftheabove
67
Self AssessmentThefollowingtoolprovidesanopportunityforhealthcareprofessionalsinvolvedinthemanagementofsubcutaneousinfusionstoundertakeaself-directedassessmentoftheircompetencyandthendiscusstheirconclusions,ifnecessary,withanotherclinician.
This is a guide for individual knowledge and does not replace direct clinical teaching and supervision.
Consider your answer to each of the following questions. I can . . .
I understand and am able to practise safely I need to learn more
identifyindicationsandcontraindicationsforuseofasubcutaneous(s/c)infusiondevice(seeIntroduction)
identifyessentialequipmentrequiredforas/cinfusionofmedication(seeSection2)
describe/demonstratecorrectsiteselectionandrationaleforselection(seeSection3)
demonstratecorrectpreparationandmanagementofas/cinfusion(seeSection2andSection3)
demonstrateunderstandingofindicationsfordrugscommonlyusedins/cinfusionsinpalliativecare(seeSection4)
demonstrateunderstandingofrelevantdrugcompatibilities(seeSection4)
demonstratecorrectsetupofas/cinfusiondeviceusedinyourorganisationincludingrelevantsafetyandequipmentchecks(seeSection2andSection3)
describehowtotroubleshoot/solveproblemsthatmayoccurduringsubcutaneousinfusionofmedication(seeSection6)
describethenurse’sroleinensuringindividualneedsaremetincludingeducationofpatientandcarer(seeSection5)
demonstrateunderstandingofassessmentprinciples,symptoms,interventions,andpotentialadverseeffects(seeSection6)
demonstrateknowledgeofrequireddocumentation(seeSection6)
explainwheretofindlegislation,policiesandproceduresrelatingtosubcutaneousinfusionofmedication(seeSection6-Drugs)
68
Conclusion
Theuseofsubcutaneousinfusiondeviceshasbecomestandardand
commonpracticeinpalliativecare.Theiruseenhancespatientcomfort
byadministrationofmedicationsataconstantratetoassistinsuccessful
controlofvarioussymptoms.
Appropriateuseofasubcutaneousinfusiondeviceallowspatientsand
familiesthechoiceofcareathomebyfamilyandfriendswiththesupport
oftheirGeneralPractitioner,visitingnurses,andthelocalspecialist
palliativecareteamasrequired.Itallowseffectivesymptommanagement
withreductionofinterventionssuchasrepeatedinjections.However
healthcareprofessionalsshouldconsiderthatpatientandfamily/carer
knowledgeandunderstandingofasubcutaneousinfusiondevicemaybe
limited,contributingtopossiblenegativeperceptionsofsuchdevices.
Comprehensiveeducationaboutsubcutaneousinfusiondevicesby
healthprofessionalsinvolvedinthecareofthesepatientsandfamilies
mayimprovetheirknowledgeandunderstanding,andreducenegative
perceptions.
Aswithallmedicaldevicestherearesomelimitationsandtheiruseisnot
withoutrisksincludingtechnicalproblems,medicationincompatibilities,
andskinreactionsatthesiteofcannulainsertion.Subcutaneousinfusion
devicesshouldbemanagedbyknowledgable,appropriatelytrainedstaff
tominimisetheriskspresentedbythelimitationsofindividualdevicesand
theiruse.
Completionofallsectionsofthislearningpackageprovidesbaseline
informationforbestpracticeuseofsubcutaneousinfusiondevicesin
palliativecare,allowingforcompetencydevelopmentandmaintenance.
Completionoftheselfassessmentincludingdiscussionwithaknowledgable
healthprofessionalisrecommended.
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Quiz Answers
Section 1 - The Patient and Family/Carer Experience
Q1) Alloftheabove
Q2) Poorprognosis
Q3) False
Q4) False
Q5) True
Section 2 - Equipment Guidelines and Principles
Q1) False
Q2) True
Q3) False
Q4) False
Q5) True
Q6) True
Section 3 - Selection, Preparation and Maintenance of the Site
Q1) Chestorabdomen
Q2) Abdomen
Q3) Scapula
Q4) Selectingasitethatisclosetoajoint
Q5) Dilutingthemedicationsbyusingalargersyringe
Q6) Ensuringthepatientdoesn’tgetoutofbedwhentheinfusiondeviceisoperational
Section 4.1 - Drugs and Diluents
Q1) 3and4-chlorpromazineandpethidine
Q2) True
Q3) hydromorphone
Q4) Serenace
Q5) Hypnovel
Q6) hyoscinebutylbromide
Q7) metoclopramide
Q8) 1and4–morphineiswell-absorbedanditisanopioidforpaincontrol.
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Q9) 1and2–itisanopioidforpaincontrolanditmaybeusedwhenmorphineisnot
effective
Q10) 2and4–itisanantipsychoticagentanddopamineantagonistanditmaybe
usedinlowdosestocontrolnauseaandvomiting.
Q11) 3and4–itisashort-actingbenzodiazepine,usedtocontrolanxietyorterminal
agitationanditisashort-actingbenzodiazepine,usedtocontrolseizures.
Q12) 1and4–itisusefulinthetreatmentofnauseaandvomitinganditis
contraindicatedincompleteorsuspectedintestinalobstruction
Q13) 2and4–forthetreatmentofGITspasmanditreducesgastrointestinalsecretions
Q14) 3–itisanarcoticforseverepain
Section 4.2 - Drugs and Diluents
Q15) 0.25ml
Q16) 2.5ml
Q17) 1ml
Q18) 0.5ml
Q19) 1.5ml
Q20) 0.3ml
Q21) 2ml
Q22) 0.5ml
Q23) 4ml
Q24) 6.5ml
Section 5 - Patient and Family/Carer Education
Q1) b–theinfusioncanbedisconnectedforabriefamountoftimeforshowering
Q2) a–ifthereisbreakthroughpainorothersymptomsthenextramedicationcanbe
givenforthis
Q3) d–Alloftheabove
Q4) d–Alloftheabove
Section 6 - Patient Assessment and Troubleshooting
Q1) d–Alloftheabove
Q2) d–Alloftheabove
Q3) bandc–tendernessandrednessandswelling/hardness
Q4) d–Alloftheabove
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Patient and Family/Carer Statements
‘Ifeltfine,[abouthavingthes/cinfusion]Ifeltquitegoodaboutitbecause
Ithoughtratherthangettinganinjection–becauseIwasgettingoneevery
night–Ithoughtwellthat’sfinebecauseit’sover24hours,it’sboundto
helpratherthantakingtabletsandstillbeingsick.’(Patient)
‘Oncehegotthe[s/cinfusion]hestoppedbeingsick,soitwasgrand.Life
waseasierforhimandforme.’(Carer)
‘Soifhehadn’thadthe[s/cinfusion],hemaybewouldn’thavebeenableto
stayathome.’(Carer)
‘Ireallydidn’twantit.Ithoughttheonlytimetheyhookyouuptothings
likethiswaswhenyourtimewasup.Mydoctortalkedtomeforalongtime
aboutwhyIneedit–butIstilldon’tliketheideaofneedingapumpjustto
getthroughtheday.’(Patient)
‘Itmeansthatwedon’tleavethehousemuchnow.Thenurseskeeptelling
methatwecangooutbutwhatifsomethinghappens...thebatterywent
flattheotherday–whatifwehadbeensomewhereandcouldn’tgetit
changed.It’stoomuchofaworrysowestayhome.’(Carer)