Management of Subcutaneous Infusions in Palliative Care · Management of Subcutaneous Infusions in Palliative Care ... Management of Subcutaneous Infusions in ... This manual provides

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

1

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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4

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.

6

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.

7

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.

8

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.

9

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.

19

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;

20

• 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.

21

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.


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.

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.


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


71

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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