Management of Subcutaneous Infusions in Palliative Care
Section 6: Patient Assessment and Troubleshooting
Subcutaneous Cannula Site
Priming the Line
Delivery of Medication
Infusion has not run to time
Infusion has stopped
Drug Choice and Dosage
Answers To All Quiz Questions
On completion of this section, you should be able to:
- demonstrate understanding of relevant principles to guide assessment of the patient having a subcutaneous infusion;
- describe strategies to deal with common issues arising with subcutaneous infusions and associated equipment.
Thorough assessment is important when caring for patients with a subcutaneous infusion and should include monitoring of the patient1 and the cannula site2, the device and equipment3, and compatibility of drugs being administered.4,5
Symptom management and control is the key reason for commencing a subcutaneous infusion so it is reasonable that a significant amount of time is spent on assessment of the patient’s symptoms and efficacy of the intervention. Assessment should include:
- asking the patient how they feel and to rate their symptoms; if the patient is unable to respond due to condition or comprehension, ask the carer as an appropriate proxy to rate observable signs of symptoms;
- asking about patterns of symptoms experienced, unrelieved or poor control of symptoms;
- observation for and documentation of side effects of drugs being used.
Use of available, validated tools to assist in assessment of symptoms and condition of patient and family is recommended. Some tools in common use to aid assessment and documentation of findings can be found at the Palliative Care Outcomes Collaboration (PCOC) website http://www.pcoc.org.au/. Services do not need to be enrolled in PCOC to access or use the tools.
Breakthrough medication is defined as extra medication that may be required for symptoms uncontrolled by medications prescribed for continuous delivery.9 Administration of breakthrough doses will aid good pain and symptom control and should be used when:
- a subcutaneous infusion is commenced and symptoms are present, as it may take up to 48 hours for drug levels to reach a steady state;
- a patient continues to report unrelieved or poor control of pain/symptoms; and
- device and site related problems have been excluded.
It is important to successful commencement of an infusion that breakthrough medication is provided and used as needed in the first 48 hours after commencement. If symptoms continue to be unrelieved, a review of medications being infused should be made. Check to ensure the medication is appropriate, that an appropriate dose has been prescribed and the correct dose has been prepared and is being infused.
Subcutaneous infusion devices have been used to deliver medications traditionally over a 24 hour period to reduce the risk of errors in setting up the Graseby syringe driver.7 Although the Graseby is now rarely used, evidence on microbiological stability, and physical and chemical compatibility still most commonly relates to a 24 hour period. Therefore, a 24 hour infusion period is still recommended.7 To minimise risk of a significant site related adverse event, careful inspection of the site and prompt response to any noted change should form part of good care.
Adverse events related to the drugs being infused, though relatively uncommon, should be noted. The infusion should be stopped and followed by observation of the patient and team discussion about ongoing management.
Ideally, site inspections should be performed at least 4 hourly, noting signs of inflammation and local site reaction2 and then be documented on the relevant organisational form. For community services when this is not practical, consider patient and family education regarding observable signs and directions for management of changes.
Other site issues may include:
Inflammation of the cannula insertion site:
- could be a localised skin reaction or an inflammatory response at a previous area of radiotherapy;
- the drugs being infused should be reviewed to confirm they are appropriate for subcutaneous administration and that;
- check drug/drugs are not at a concentration that may cause irritation.
Suggested solutions to manage site inflammation depend on the likely cause and may involve:
- removal and resiting of the subcutaneous cannula;
- increasing the diluent in the device reservoir to reduce the drug concentration;
- addition of dexamethasone to the reservoir to reduce localised site irritation;
- observation and management of consequences that may include infection.9
Pain at the cannula insertion site could be due to:
- inflammation for one of the reasons discussed above;
- shallow cannula insertion which may also be a cause of localised inflammation.
Pain at the insertion site requires removal and resiting of the subcutaneous cannula.
Leakage of infusion fluid at the cannula insertion site indicates:
- an unstable cannula position;
- all connections should be checked to ensure they are secure;
- change components as needed;
- the cannula may need to be removed and resited.
Leakage of fluid will contribute to unrelieved pain/symptoms.
Bleeding at the cannula insertion site:
- may be caused by trauma or a coagulation problem;
- requires removal and resiting of the cannula.
Pressure should be applied to the old site which should be observed for further bleeding.
Limited cannula access points:
- may be due to oedema, infection or cachexia;
- require consideration and discussion with colleagues to confirm appropriateness of subcutaneous medication infusion;
- indicate need to consider appropriate site selection (Section 3 of this package).
If the patient is restless, showing signs of delirium, confusion or impaired cognition:
- potential underlying causes should be investigated and treated;
- the possibility of terminal restlessness should be considered;
- causes of agitation like pain, full bladder or bowel should be checked and managed appropriately;
- siting of the cannula around the scapula should be considered to minimise risk of dislodgement;
- a breakthrough dose of an antipsychotic such as haloperidol, risperidone or olanzapine can also be considered.
Symptom control and efficacy of intervention/infusion should be noted on the appropriate forms of your service. It is suggested documentation should include:
- notations referring to times;
- volumes loaded;
- patient response;
- any adverse incidents or events;
- the capacity for the patient and family to continue management of the infusion device.
The capability of the family/carer to participate in care of the patient with a subcutaneous infusion device should be checked before commencement of the infusion and assessed regularly after that. The status of the carer – employment, physical and emotional health – should be considered as potentially impacting on the outcome of the intervention.
When troubleshooting equipment used in subcutaneous infusions of medication via a power driven device, it is important to understand the normal functioning of the device.6 The use of only one type of device in each setting has been suggested to prevent confusion which may lead to errors.7
It is important that you understand the normal functioning of the device being used in your service area.6 The small flashing light on the front of the NikiT34 and the Graseby, the intermittent ‘whirring’ sound of the Graseby and the arrows running constantly across the screen of the GemStar all indicate the device is functioning normally.
Ensure that organisational protocol regarding priming of the extension tubing/device line is followed when setting up a subcutaneous infusion (see section 2 of this package - Dosage Related Principles).
Each device has different settings for triggering its alarms. An alarm will sound if:
- the infusion reservoir (syringe or cassette) is empty;
- the battery or power source is exhausted requiring battery change or placement in a charging cradle;
- tubing is kinked, the cassette is unseated or the syringe is jammed;
- air is detected in the GemStar line or cassette (correction will require clearing the air from the line and re-priming).
The device should be monitored for a short time after correction to confirm normal functioning.
Battery life is variable. To reduce the potential for a slowed or stopped infusion, batteries should be checked regularly to ensure they are not exhausted. If the device used by your service uses a charging cradle, ensure it is plugged in to mains power, that the device sits easily and properly into the charger, and the indicator light confirming it is on mains power ‘flicks’ on.
Inspection of the volume remaining7 ideally should be at least 4 hourly with findings documented on the relevant organisational form. When this is not practical, consider patient and family/carer education regarding observation of infusion volume and management of findings.
As with any medication, the delivery of the right drug at the right time is essential.
Regular assessment is required to identify any concerns
Care should be taken at set up or refilling that correct measures (syringe and cassette volume) and rate of infusion are used. If the infusion does not end ‘on time’ or within accepted parameters, either early or late finish, basic checks should be made ensuring that:
- the rate has been set correctly and not been altered;
- the syringe length and volume to be infused has been measured correctly;
- the syringe or cassette reservoir is loaded properly into the device;
- there are no impediments to the tubing/line e.g. kinks, or clamps left on;
- the device has not sustained any water damage;
- the device has not been purposefully stopped;
- the device battery has power and is not flat which could cause the infusion to be slowed or stopped6;
- the ‘boost button’ has not been activated;
- estimated and prescribed breakthrough doses have not been exceeded.
For issues with the GemStar repeatedly finishing early due to more than expected breakthrough doses, the prescription can be altered to provide higher volume for infusion while maintaining the same drug concentration.
The most likely reason for the infusion to stop is there is no remaining fluid to be infused and reloading according to the medical prescription is required. If fluid for infusion remains then check that:
- the device battery is not flat causing the infusion to stop6;
- neither the line nor cannula are blocked;
- the drugs in the infusion mixture have not precipitated (crystallised) blocking the tubing;
- there is no mechanical malfunction causing failure of the infusion.
Careful inspection of tubing for patency6 should ideally be done at least 4 hourly noting twists, kinks, signs of precipitation and secure connections. Findings should be documented on the appropriate form for your service.
If it is suspected there has been purposeful tampering with the device settings or undirected use of the ‘boost’ facility, a tamper proof ‘lock box’7 or locking of the device’s key pad should be considered to maintain infusion/drug security.
When a subcutaneous infusion via a device is being set up or reloaded, all drug calculations should be checked according to local legislative requirements, organisational policy and protocol.
There are a number of drugs suitable and commonly prescribed for subcutaneous infusion in palliative care settings (Section 4).
Prescriptions should be checked to ensure that:
- drugs to be infused are appropriate for subcutaneous administration;
- the drug is not at a concentration that may cause localised irritation at the cannula insertion site;
- the drug will provide comfort for the patient.
When a drug is to be infused, or if more than one drug is to be infused in combination, it is important to check the compatibility of the drug/drugs and the diluent to be used5,7 to prevent problems with:
- precipitation/crystallisation in tubing or the syringe which would require the syringe or cassette and tubing to be discarded and infusion set up commenced again;
- skin irritation from known drug irritants which would require change of cannula insertion site, but could be avoided by using a larger volume of diluent.7
- Identify the tools currently used in your service/organisation for assessment of people receiving palliative care.
- Do the tools cover key areas of assessment as outlined in this module?
- Are the tools used by your service/organisation validated and/or supported by recent best evidence for palliative care?
- Review your service/organisation’s documentation for the management of subcutaneous infusions via a device – are they consistent with best practice?
- This quiz will test the objectives and content in Section 6 of the Learning Package and the ‘Guidelines for subcutaneous infusion device management in palliative care’ document.
- Ratcliffe N. Syringe drivers. Community Nurse 1997;3(6):25-26.
- Reymond E, Charles M. An intervention to decrease medication errors in palliative patients requiring subcutaneous infusions: Brisbane South Palliative Care Service and Adverse Drug Event Prevention Program; unpublished report presented to Clinical Services Evaluation Unit; Princess Alexandra Hospital. Brisbane, Queensland;2005
- PalliativeDrugs.com. Document Library: Syringe drivers and infusion pumps. <www.palliativedrugs.com>. Accessed 2 January 2018.
- 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.
- Palliative Care Matters. <www.pallcare.info>. Accessed 10 August 2017
- Mitten T. Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing 2001;7(2):75-85.
- Dickman A, Schneider J. The syringe driver: continuous subcutaneous infusions in palliative care. 4th Edition. Oxford: Oxford University Press;2016.