Management of Subcutaneous Infusions in Palliative Care
Section 3: Selection and Preparation of the Site
General principles for appropriate site selection
Inappropriate site selection
Site related problems
Factors contributing to site irritation/reactions
Techniques to minimise site irritation
Other important patient checks
Principles for site preparation and cannula insertion
Answers To All Quiz Questions
On completion of this section, you should be able to:
- explain the most appropriate sites for subcutaneous infusion;
- explain which sites are inappropriate for subcutaneous infusion;
- describe techniques that may assist in minimising site irritation;
- describe important principles for site inspection.
- use an area with a good depth of subcutaneous fat;
- use a site that is not near a joint;
- select a site that is easily accessible such as the chest or abdomen;
- select and use sites on a rotating basis1;
- site selection will be influenced by whether the patient is ambulatory, agitated and/or distressed;
- the chest or abdomen are preferred sites2, specifically the upper anterior chest wall above the breast, away from the axilla. If the patient is cachectic, the abdomen is a preferred site2;
- site longevity can vary from 1–14 days; many variables influence site longevity, such as type of medication and type of cannula used;
- factors that cause site reactions include tonicity of the medication, solution pH, infection, and prolonged presence of a foreign body.3
Inappropriate site selection includes4
- lymphoedematous areas;
- areas where skin is broken;
- skin sites recently irradiated;
- sites of infection;
- bony prominences;
- in close proximity to a joint;
- sites of tumour;
- skin folds;
- inflamed skin areas;
- wherever ascites or pitting oedema are present;
- where scarring is present;
- areas where lymphatic drainage may be compromised1, for example in women who have had a mastectomy.
Remember, any site problems will cause the patient discomfort and may also interfere with drug absorption and compromise effective symptom control. Therefore, selection of an appropriate site for subcutaneous infusions via a syringe driver has implications for the patient. Site problems may be associated with inappropriate site selection, or due to site irritation.
- the tonicity (concentration) of the medication;
- the pH of the solution;
- prolonged presence of a foreign body3;
- some medications including:
Techniques that may be considered in consultation with the treating physician to minimise site irritation include:
- diluting the medications by using a larger syringe size2;
- using normal saline (0.9%) if applicable, instead of water for injection2;
- adding 1 mg of dexamethasone to the syringe6 - one Australian trial found that the addition of 1 mg of dexamethasone to syringe drivers can significantly extend the longevity of the subcutaneous infusion site7;
- use of a Teflon®or Vialon®cannula, e.g. the BD Saf-T-Intima, reduces site inflammation.2,8-10
Meticulous site inspection is integral to early identification and prevention of site related complications, and should be performed as part of routine care.6,11,12 Any site problems can potentially cause patient discomfort. They also interfere with drug absorption and compromise effective symptom control.
When inspecting the site, check for:
- tenderness or hardness at the site;
- presence of a haematoma;
- leakage at the insertion site;
- swelling—a sterile abscess can occur at the insertion site, causing local tissue irritation12;
- erythema (redness);
- the presence of blood in the tubing;
- displacement of the cannula.4
In addition to checking the site regularly (4 hourly is recommended), other important patient checks include:
- ask the patient how they feel (or family member/carer, if the patient is unable to comprehend): are their pain and other symptoms controlled?
- ensure the infusion device is working e.g.
- on the Niki T34 the LED light flashes green;
- on the GemStar arrows progress across the screen;
- on the WalkMedLX350, squares progress across the screen and ‘infusing’ is seen on screen;
- check the volume remaining in the syringe, and that the device is running to time;
- ensure there are no leakages, and that connections to the syringe and cannula are firm.
- aseptic technique must be used, as many patients who require subcutaneous infusion are immuno-compromised; ensure hands are washed thoroughly12;
- in consultation with the patient and family, select a suitable site12 using the principles for appropriate site selection;
- select and use sites on a rotating basis1;
- prepare the skin using an antiseptic with residual activity, e.g. a solution containing 0.5% to 2% chlorhexidine gluconate in >70% ethyl or isopropyl alcohol, and wait for skin to dry. NB: The solution should be applied vigorously to an area of skin approximately 15cm in diameter, in a circular motion beginning in the centre of the proposed site and moving outward, for at least 30 seconds;
- the point of the cannula should be inserted just beneath the epidermis. For thin people the angle of the cannula on insertion may need to be less (30 degrees) than for a person with more subcutaneous tissue (45 degrees). A deeper infusion may prolong the life of the infusion site.
- grasp the skin firmly to elevate the subcutaneous tissue. Insert the cannula and release the skin;
- remove the stylet if using a BD Saf-T-Intima® and take care to hold the device in situ when removing the stylet so that the entire device is not accidentally removed from the patient. Note: If a metal cannula is being used, place the bevel of the metal device downwards to deliver the drugs more deeply into the skin, and minimise irritation.
- the extension tubing is changed when the cannula is changed;
- when the tubing is placed against the skin, form a loop to prevent dislodgement if the tubing is accidentally pulled6. Use a transparent, semi-occlusive dressing to cover the site, as this permits inspection of the site by the caregiver6,8;
- where relevant, place the syringe in the syringe driver;
- record and document that the infusion has been commenced, and volume to be infused, as per local drug administration policies.
- Choosing the site: Watch excerpt from Chapter 2 – ‘Who Needs One?’ of Brisbane South Palliative Care Collaborative’s Guide for Clinicians – How to Use a Syringe Driver for Palliative Care Patients.
- Insertion of cannula: Watch excerpt from Chapter 2 – ‘Who Needs One?’ of Brisbane South Palliative Care Collaborative’s Guide for Clinicians – How to Use a Syringe Driver for Palliative Care Patients.
- This quiz will test the objectives and content in Section 3 of the Learning Package and the ‘Guidelines for subcutaneous infusion device management in palliative care’ document.
- Gomez Y. The use of syringe drivers in palliative care. Australian Nursing Journal 2000;(2):suppl 1-3.
- Dickman A, Schneider J. The syringe driver: continuous subcutaneous infusions in palliative care. 4th Edition. Oxford: Oxford University Press;2016.
- Morgan S, Evans N. A small observational study of the longevity of syringe driver sites in palliative care. International Journal of Palliative Nursing 2004;10(8):405- 412.
- Dickman A, Schneider J, Varga J. The syringe driver: continuous subcutaneous infusions in palliative care. 2nd ed. Oxford: Oxford University Press;2005.
- McNeilly P, Price J, McCloskey S. The use of syringe drivers: a paediatric perspective. International Journal of Palliative Nursing 2004;10(8):399-404.
- Mitten T. Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing 2001;7(2):75-85.
- Reymond L, Charles MA, Bowman J, Treston P. The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients. Medical Journal of Australia 2003;178:486-489.
- PalliativeDrugs.com. Document Library: Syringe drivers. <www.palliativedrugs.com>. Accessed 25 September 2013.
- Abbas S, Yeldham M, Bell S. The use of metal or plastic needles in continuous subcutaneous infusion in a hospice setting. American Journal of Hospice and Palliative Medicine 2005;22(2):134-138.
- Ross JR, Saunders Y, Cochrane M, Zeppetella G. A prospective, within-patient comparison between metal butterfly needles and Teflon cannulae in subcutaneous infusion of drugs to terminally ill hospice patients. Palliative Medicine 2002;16:13-16.
- Coleridge-Smith E. The use of syringe drivers and Hickman lines in the community. British Journal of Community Nursing 1997;2(6):292,294,296.
- Ratcliffe N. Syringe drivers. Community Nurse 1997;3(6):25-26.