Management of Subcutaneous Infusions in Palliative Care · Management of Subcutaneous Infusions in...

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.

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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.


4. PalliativeDrugs.com.‘Syringedrivers.’<www.palliativedrugs.com>.Accessed25 January2005.

5. BreckenridgeA.Reportoftheworkingpartyontheadditionofdrugstointravenous infusionfluids[HC(76)9][Breckenridgereport].London:DepartmentofHealthand SocialSecurity;1976.


7. DickmanA,SchneiderJ,VargaJ.Thesyringedriver:continuoussubcutaneous infusionsinpalliativecare.2nded.Oxford:OxfordUniversityPress;2005.

27

QUIZ: Section 2 - Equipment Guidelines and Principles




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


• 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.






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




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


2. LichterI,HuntE.Drugcombinationsinsyringedrivers.TheNewZealandMedical Journal1995;108(1001):224-226.





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


Packageandthe’Guidelinesforsubcutaneousinfusiondevicemanagement


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?


Itmaybeusedwhenmorphineisnoteffective

Itisusedasanantiemetic

Itiseffectiveforcontrollinganxietyorterminalrestlessness

44

Q10)Whataretwoindicationsfortheuseofhaloperidolinsubcutaneous infusions?

Itisnotdirectlyanantiemetic,butdoesreducegastrointestinal

secretions

Itisanantipsychoticagentanddopamineantagonist


Itmaybeusedinlowdosestocontrolnauseaandvomiting

Q11)Whataretwoindicationsfortheuseofmidazolaminsubcutaneous infusions?

Itisanantiemetic

Itisanarcotic

Itisashort-actingbenzodiazepine,usedtocontrolanxietyor

terminalagitation

Itisashort-actingbenzodiazepine,usedtocontrolseizures

Q12)Whataretwoindicationsfor/characteristicsoftheuseof metoclopramideinsubcutaneousinfusions?

Itisusefulinthetreatmentofnauseaandvomiting

Itmaybeusedwhenmorphineisnoteffective


Itiscontraindicatedincompleteorsuspectedintestinal

obstruction

Q13)WhataretwoindicationsfortheuseofBuscopaninsubcutaneous infusions?


ForthetreatmentofGITspasm


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


• 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.


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.


7. DriscollA.Managingpostdischargecareathome:ananalysisofpatients’andtheir carer’sperceptionsofinformationreceivedduringtheirstayinhospital.Journalof AdvancedNursing2000;31(5):1165-1173.

52

Quiz: Section 5 – Patient and Family/Carer Education




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


• 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.

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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.


5. PalliativeCareMatters.<www.pallcareinfo>.Accessed10August2010



65

8. PalliativeCareOutcomesCollaborative<http://chsd.uow.edu.au/pcoc/>.Accessed13 August2010.


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




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.

69

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.

70

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


Section 6 - Patient Assessment and Troubleshooting



Q3) bandc–tendernessandrednessandswelling/hardness


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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)

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