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Management of Subcutaneous Infusions in Palliative Care

Section 2: General Equipment

Learning Objectives
Types of Subcutaneous Infusion Devices
Important Principles when using Subcutaneous Infusion Devices
General Principles
Syringe Related Principles
Cannula Related Principles
Dosage Related Principles
Quiz
Answers To All Quiz Questions
References

Learning Objectives

At the completion of this section, you should be able to:

  • describe subcutaneous infusion devices currently in use in palliative care in Australia;
  • explain management principles when caring for patients with these devices;
  • describe important safety principles when using this equipment.

Types of Subcutaneous Infusion Devices

Subcutaneous infusion devices are generally electronic, battery driven devices with a syringe, cassette or reservoir to hold medications to be delivered via the subcutaneous route to the patient. Devices commonly used in Australia include the Niki T34, CADD Legacy PCA, and GemStar. Less commonly used are the Alaris and the WalkMed 350LX.

Important Principles when using Subcutaneous Infusion Devices

The Guidelines discuss the following principles regarding equipment used for subcutaneous infusions. When setting up the equipment for a subcutaneous infusion, it is always important to consult the manufacturer’s guidelines and verify the individual organisation’s protocol regarding the preparation and set-up for changing the device.

General Principles

General management principles for all subcutaneous infusion devices include:

  • always use the manufacturer’s guidelines and your organisation’s protocol regarding preparation and set-up for changing the device to guide your practice;
  • an aseptic technique should be used when preparing and setting up the infusion1;
  • 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 device1,2-4;
  • microbiological stability and physical and chemical compatibility data most commonly relate to a 24 hour period and it is for this reason a 24 hour infusion period is still recommended5;
  • documentation of volume to be infused (in the syringe or reservoir) is recommended at time of set-up and regular checks;
  • consider using a tamper-proof ‘lock-box’ if there is a possibility of the patient or others tampering with the device or using the boost facility;
  • it is possible a tamper-proof box is mandatory within your organisation as a risk management stipulation;
  • ensure  the patient and family have received a full explanation of how the infusion device works, its indications for use, and a 24-hour support number;
  • devices should be serviced annually by the manufacturer or a biomedical technician.

Syringe Related Principles

  • where a syringe is necessary, a Luer-Lok® syringe should be used to prevent risk of disconnection3,6; 20 ml is the recommended minimum syringe size3 to reduce 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 rate3,6;

Cannula Related Principles

Because a Teflon or Vialon cannula is associated with less site inflammation, it should be used rather than a metal needle.

Dosage Related Principles

  • when changing the extension set and/or cannula, prime the line after drawing up the prescribed medications, and before connecting to the patient. After priming the line, note the volume to be infused and document the line change and the time the infusion is calculated to finish;
  • a minimum volume extension set should be used to minimise deadspace in the line3;
  • for the Graseby, it is the length of the solution within the syringe – not the volume – that will determine the rate, i.e. the Graseby syringe driver delivery rate is a measure of distance, not of volume administered.

Quiz

  • This quiz will test objectives and content in Section 2 of the Learning Package and ‘Guidelines for subcutaneous infusion device management in palliative care’ document.

References

  1. Ratcliffe N. Syringe drivers. Community Nurse 1997;3(6):25-26.
  2. O’Doherty C, Hall E, Schofield L, Zeppetella G. Drugs and syringe drivers: a survey of adult specialist palliative care practice in the United Kingdom and Eire. Palliative Medicine 2001;15:149-154.
  3. Dickman A, Schneider J. The syringe driver: continuous subcutaneous infusions in palliative care. 4th Edition. Oxford: Oxford University Press;2016.
  4. PalliativeDrugs.com. ‘Document library: Syringe drivers.’ <www.palliativedrugs.com>. Accessed 25 September 2019.
  5. Breckenridge A. Report of the working party on the addition of drugs to intravenous infusion fluids [HC(76)9] [Breckenridge report]. London: Department of Health and Social Security;1976.
  6. Mitten T. Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing 2001;7(2):75-85.

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Last updated: 8 January 2020