Management of Subcutaneous Infusions in Palliative Care

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  • 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
• References
• Resources
• Printable Documents
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Learning Modules:

Introduction

Why are Subcutaneous Infusions Used in Palliative Care?
What are the Advantages and Limitations of Subcutaneous Infusion Devices?
Indications and Contraindications
References

Why are Subcutaneous Infusions Used in Palliative Care?

The World Health Organisation (2004) stated that palliative care is “an approach to care which improves quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.² Palliative care is provided according to the needs of the individual and may happen days, weeks or months before death. It should be available wherever the person chooses – at home or in a hospital, hospice or residential aged care facility and be supported by a team of health professionals including a specialist palliative care team if needed.

The administration of medication using a subcutaneous infusion device is common practice in palliative care for the management of pain and other distressing symptoms when other routes are inappropriate or ineffective.³ These devices are power driven, delivering medications at a controlled rate to provide symptom control. Subcutaneous infusion devices have become an important part of care to ensure comfort for many patients.⁴ For many years, the Graseby syringe driver was the primary device for subcutaneous administration of a range of drugs in palliative care. In early 2007 the manufacturer of the Graseby MS16A and MS26 syringe drivers informed the Therapeutic Goods Administration (TGA) of their intention to withdraw the devices from sale in Australia. In October 2007 the new TGA regulatory standards regarding medical infusion devices became mandatory. Graseby syringe drivers purchased prior to October 2007 continue to be supported by the manufacturer for device maintenance, allowing services to transition to devices that meet the new regulatory standards. Information contained in this learning package is relevant to devices now in use in Australia.⁵

What are the Advantages and Limitations of Subcutaneous Infusion Devices?

Subcutaneous delivery of medication via an infusion device:

• allows the continuous supply of a range of drugs bypassing the gut and associated problems with swallowing and malabsorption³;
• can provide more stable plasma levels of drugs and better symptom control as peaks and troughs of intermittent drug administration are avoided³;
• generally involves a small, portable or relatively portable battery operated pump that delivers medications at an accurately controlled rate⁶;
• provides versatility offering a convenient, accessible alternative for continuous administration of medications;
• can be used for ambulant patients with most devices able to be worn relatively unobtrusively, not interfering with patients wanting to continue with their normal daily activities;
• can provide continued management of symptoms removing the need for frequent interventions like repeated oral medications or injections at end of life.

Indications and Contraindications

Indications for commencement of a subcutaneous infusion include:

• inability to swallow due to dysphagia from physical obstruction/ tumour in the mouth, throat or oesophagus;
• persistent nausea and vomiting;
• severe weakness;
• unconsciousness;
• bowel obstruction.³

Contraindications for use of this route include:

• lack of permission from the patient and/or family/carer as proxy;
• where other viable routes of administration are available;
• where contraindications exist related to the drugs to be infused.

The decision to commence a subcutaneous infusion of medication should be made after careful assessment and review by health professionals involved in the patient’s care, the patient, and family/carer.

References

1. Cruikshank S, Adamson E, Logan J, Brackenridge K. Using syringe drivers in palliative care within a rural, community setting: capturing the whole experience. International Journal of Palliative Nursing 2010;16(3):126-132.
2. World Health Organization. http://www.who.int/cancer/palliative/definition/en/ Accessed 28 July 2010.
3. Dickman A, Littlewood C, Varga J. The syringe driver: continuous subcutaneous infusions in palliative care. Oxford: Oxford University Press;2002.
4. Mitten T. Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing 2001;7(2):75-85.
5. Centre for Palliative Care Research and Education. Guidelines for subcutaneous infusion device management in palliative care (Revised Edition). Brisbane, Queensland: Queensland Health;2010.
6. McNeilly P, Price J, McCloskey S. The use of syringe drivers: a paediatric perspective. International Journal of Palliative Nursing 2004;10(8):399-404.

 

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