Management of Subcutaneous Infusions in Palliative Care

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• Learning Modules
  • Introduction:
  • Section 1: The Patient and Family/Carer Experience
  • Section 2: General Equipment
  • Section 3: Selection and Preparation of the Site
  • Section 4: Drugs and Diluents
  • Section 5: Patient and Family/Carer Education
  • Section 6: Patient Assessment and Troubleshooting
• The Guidelines
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Guidelines

The Guidelines for Subcutaneous Infusion Device Management in Palliative Care are intended to provide clinicians and palliative care services with guidelines to inform practice, the development of policy and procedures, and associated training and education programs in relation to portable subcutaneous infusion device management.

 

View the Guidelines

Contents Section One: The patient experience Section Two: Equipment guidelines and principles Section Three: The selection, preparation and maintenance of the site Section Four: Drugs and diluents Section Five: Patient/family education needs Section Six: Patient assessment and troubleshooting guidelines  Appendix A: Levels of evidence  Appendix B: Literature summary  Appendix C: Commonly used drugs in syringe drivers

View the guidelines in PDF format

Summary of the guidelines

Section One: The patient experience

• Health care professionals should consider a subcutaneous infusion device as a means of providing symptom control via subcutaneous infusion of drugs to treat unrelieved pain and other distressing symptoms when other routes are inappropriate or no longer effective2;
• Some patients may view infusion devices as an invasion of their body privacy, and may perceive the device as an indicator of a poor prognosis.3

Section Two: Equipment guidelines and principles

• The most common infusion devices in clinical use in Australia, until their withdrawal from sale in 2007, were the SIMS Graseby® MS16A and the MS263-5;
• Alternatives to the Graseby include the Niki T34®, CADD Legacy®, WalkMed 350LX® and GemStar® infusion devices;
• For further information about alternative infusion devices, see Palliative Care Australia’s ‘Syringe driver report’ at www.palliativecare.org.au
• The organisation’s protocol regarding the preparation and set-up for changing the device should always be used to guide practice;
• Subcutaneous infusion devices have traditionally been used to deliver medications over a 24 hour period to reduce the risk of errors in setting up the Graseby,5-8; microbiological stability and physical and chemical compatibility data most commonly relate to a 24 hour period and it is for this reason that a 24 hour infusion period is still recommended32;
• Use only one type of infusion device in each setting to prevent confusion which may lead to errors6,8,10,18;
• Where more than one device is used in a particular setting, it is recommended the service provider implement strategies to manage potential risks regarding the need for staff to be competent with a number of devices;
• Where a syringe is necessary, a Luer-Lok® syringe should be used to prevent risk of disconnection6,9; 20 ml is the recommended minimum syringe size11 to reduce the risk of incompatibility and adverse site reactions and minimise the effect of priming the line;
• The same brand of syringe should be used each time to minimise errors in setting up the device and calculating the rate6,9 (Graseby only);
• The syringe should be measured every time the device is set up, as different brands of syringes have different diameters and lengths9 (Graseby only);
• An aseptic technique should be used when preparing and setting up the infusion7;
• A minimum volume extension set should be used to minimise deadspace in the line11;
• When changing the extension set and/or cannula, prime the line after drawing up the prescribed medications.2,7-9,11 After priming the line, measure the syringe and document the line change, syringe volume and the time the syringe is calculated to finish;
• Teflon® or Vialon® cannulas are associated with less risk of site inflammation than metal butterfly needles.8,9,11,12,26,27

Section Three: The selection, preparation and maintenance of the site

• General principles for appropriate site selection include:
  • Using an area with a good depth of subcutaneous fat;
  • Using a site that is not near a joint;
  • Selecting a site that is easily accessible such as the chest or the abdomen
• Select and use sites on a rotating basis2;
• Site selection will be influenced by whether the patient is ambulatory, agitated and/or distressed;
• The chest or abdomen are the preferred sites6, specifically the upper, anterior chest wall above the breast, away from the axilla. If the patient is cachectic, the abdomen is a preferred site6;
• When the tubing is placed against the skin, form a loop to prevent dislodgement if the tubing is accidentally pulled9. Use a transparent, semi-occlusive dressing to cover the site, as this permits inspection of the site by the caregiver8,9;
• The longevity of the site can vary considerably from 1–14 days. Many variables influence the longevity of the site, such as the type of medication and type of cannula used;
• Factors that cause site reactions include the tonicity of the medication, the pH of the solution, infection and prolonged presence of a foreign body.12

Section Four: Drugs and diluents

• Anecdotal evidence suggests some clinicians are not adding diluent to medications to be infused subcutaneously. The evidence indicates site longevity is likely to be reduced by such practices11,12;
• Subcutaneous infusion devices can be used to deliver drugs to treat a variety of symptoms. Common symptoms include pain, nausea, vomiting, breathlessness, agitation, delirium and ‘noisy breathing’;
• A wide variety of drugs can be used together in different combinations with no clinical evidence of loss of efficacy11,13;
• The more drugs that are mixed together, the greater the risk of precipitation and reduced efficacy9;
• 2–3 drugs may be mixed for a subcutaneous infusion (occasionally up to 4 drugs6,10,11);
• If compatibility is an issue, the use of two infusion devices3 or regular or prn subcutaneous injection should be considered;
• Before mixing any drugs together in a subcutaneous infusion, check for stability information3,6,9,11,28,29 and check with hospital pharmacists;
• Use of the boost facility, where available, is not appropriate; breakthrough medication should be used to treat uncontrolled symptoms. A boost dose rarely provides sufficient analgesia to relieve uncontrolled pain, and may lead to overdosing of other drugs being infused6,14 such as metoclopramide, an overdose of which could trigger extrapyramidal symptoms such as an oculogyric crisis;
• Normal saline is the most commonly used diluent in Australia15;
• The use of water for injection has been linked to pain due to its hypotonicity (having a lower osmotic pressure than body fluids), although normal saline may be more likely to cause precipitation16;
• 5% dextrose is used only occasionally as a diluent6, and is not commonly used in Australia.8

Section Five: Patient/family education needs

• Patient and family education promotes safety and acceptance of the subcutaneous infusion device as a means to providing improved symptom control12;
• Patient and family education includes:
  • Explanation and education about what the device will do, and its advantages and possible disadvantages;
  • Safety aspects;
  • Ways to incorporate a subcutaneous infusion into everyday life;
  • Troubleshooting guidelines.9

Section Six: Patient assessment and troubleshooting guidelines

• When troubleshooting the equipment used in subcutaneous infusions, it is important to understand the usual functioning of the device9;
• Ensure that drug calculations are checked according to best practice, legislative requirements and organisational policy and protocols when the infusion device is set-up17;
• Use only one type of infusion device in each setting to prevent confusion which may lead to errors6,8,10,18;
• Where more than one device is used in a particular setting, it is recommended the service provider implement strategies to manage potential risks regarding the need for staff to be competent with a number of devices;
• Ensure that the organisational protocol is followed regarding priming of the line2,6-9;
• Ensure that drugs being delivered are compatible3,19;
• Ensure that a spare battery, where relevant, is always available5,6,8;
• Thorough patient assessment is important when caring for patients with a subcutaneous infusion7,12;

Principles to include in patient assessment, recording and documentation include:

• Asking the patient how they feel (or family member/carer, if the patient is unable to comprehend): for example, are their pain and other symptoms controlled? (this should not replace clinical assessment/responsibility);
• Documentation of symptom control and efficacy of interventions;
• Careful inspection of site, at least 4 hourly, for signs of inflammation and site reaction, and documentation of findings17;
• Careful inspection of syringe volume remaining6, at least 4 hourly, and documentation of findings;
• Careful inspection of tubing for patency8,9 at least 4 hourly and documentation of findings;
• Site inspection should be performed as part of routine care and includes principles such as checking for: tenderness at the site, presence of a haematoma and leaking at the insertion site.3,7,9