PROCEDURE FOR THE USE OF THE SYRINGE DRIVER IN …



PROCEDURE FOR THE USE OF THE SYRINGE PUMP IN PALLIATIVE AND END OF LIFE CARE(INCLUDING GUIDELINES FOR ADMINISTRATION OF DRUGS)Version:1.0 (31/01/2013)Name of originator/author:Val RevillDate issued:31/01/2013Review date:28th February 2014Contents1. Scope22. Glossary of terms43. Aim43.1 Client Group43.2 Staff Group44. Introduction55. Indications for using the syringe pump66. Medication66.1 Combinations of more than one drug in a syringe pump67. Drugs87.1 Diamorphine87.2 Oxycodone97.3 Cyclizine107.4 Metoclopramide117.5 Haloperidol127.6 Levomepromazine137.7 Midazolam147.8 Hyoscine Butylbromide157.9 Hyoscine Hydrobromide167.10 Glycopyrronium177.11 Dexamethasone187.12 Octreotide197.13 Drugs not suitable for use in the syringe driver208. The T34 McKinley Syringe Pump218.1 Information for patients218.2 Labelling of the syringe218.3 Calibration of a syringe pump218.4 Decontamination of syringe pump228.5 Decontamination of holster bag229. Standard Operating Procedure2410. Skin site selection and skin care2810.1 Sites suitable for subcutaneous infusion2810.2 Sites not suitable for subcutaneous infusion2810.3 Care of the skin site and checks2911. Trouble shooting3012. Specialist Palliative Care Advice3113. References321. SCOPEThis document is for doctors and registered nurses who have attended organisation approved training sessions on how to use the McKinley T34 Syringe Pump for administration of drugs by subcutaneous infusion (Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2002). These guidelines have been written with the aim of providing information on the safe administration of medications via the subcutaneous route to relieve distressing symptoms in those patients receiving palliative care. Whilst other syringe driver models are available nationally, the McKinley T34 Syringe Pump is the only model currently approved for use in the Northern Lincolnshire locality. Key PointsAll staff using the syringe pump will have been trained in its use and a record of the training is documentedAll staff trained in the use of the syringe pump must be fully conversant with these guidelines and have self-assessed as competent.All actual and near miss adverse events involving the syringe pump are reported viaeach organisations incident reporting mechanism.All syringe pumps must be maintained according to your organisations equipment maintenance policy.The document will guide the Registered Nurse / Doctor / Pharmacist toSafely prescribe or dispense medications for a syringe pumpSafely administer medications via a syringe pump Ensure that the rate setting is correct and that the machine is running to timeEarly detection of uncontrolled symptomsEarly detection of functional problems related to the device - trouble-shooting guideEarly detection of occlusion, or discolouring of solutions being administeredThe document: - Explains the indications for choosing the subcutaneous route of administration of medicines e.g. swallowing problems, uncontrolled nausea, uncontrolled vomiting, intestinal obstruction, too weak to take oral medication, terminal agitation, malabsorption.Demonstrates the procedure for setting up the McKinley T34 syringe pump and the equipment required.Explains how to select skin site and which skin sites should not be used.Explains how to check if the device is running correctly.Explains how to draw up and prepare solutions.Illustrates the medications that can be used in a syringe pump and information about the combinations of drugs that can be used.Clarifies which medications should not be used in a syringe pump.Provides a list of contact numbers for specialist palliative care advisers2.GLOSSARY OF TERMSAccountableResponsible for something or to someoneCompetentPossessing the skills and abilities required for lawful, safe and effective professional practice without direct supervision.DPOWHDiana Princess of Wales HospitalLLHLindsey Lodge HospicemgMilligram mlMillilitremmMillimetreNEL North East LincolnshireNELCCGNorth East Lincolnshire Clinical Commissioning GroupNLNorth LincolnshireNL&GNorthern Lincolnshire and Goole Hospitals NHS Foundation TrustNMCNursing and Midwifery CouncilCPGCare Plus GroupSAHSt Andrew’s HospiceSGHScunthorpe General Hospital3. AIMSafe administration of medications to relieve distressing symptoms in those patients receiving palliative care.To ensure that the rate setting is correct and the machine is running to timeEarly detection of functional problems related to the deviceEarly detection of occlusion or discolouring of solutions being administered3.1 CLIENT GROUPAdults receiving palliative care for whom alternative routes of medication administration are no longer appropriate. e.g. swallowing problems, uncontrolled nausea, uncontrolled vomiting, malabsorption, intestinal obstruction, too weak to take oral medication, terminal agitation and care in the last days of life. STAFF GROUPRegistered nurses and doctors who have attended organisation approved training sessions on how to use the McKinley T34 Syringe Pump in NL&G, CPG, NELCCG, Yarborough Clee Care, St Andrew’s Hospice, NL community, Lindsey Lodge Hospice and Care Homes within the Northern Lincolnshire locality.4. IntroductionThese guidelines are intended for the subcutaneous infusion of drugs only via the McKinley T34 Syringe Pump.The syringe pump should be used where there are clear indications to do so. It is important to discuss the syringe pump use with the patient/carer/relatives to ensure their full understanding and compliance. The Nursing & Midwifery Council – The Code 2008““As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions”“The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council’s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner (now independent/supplementary prescriber). It requires thought and the exercise of professional judgment”Keep your skills and knowledge up to date You must have the knowledge and skills for safe and effective practice when working without direct supervision.You must recognise and work within the limits of your competence.You must take part in appropriate learning and practice activities that maintain and develop your competence and performance.The General Medical Council (2006) “The duties of a doctor registered with the GMC states that as a Doctor you must”Respect the rights of patients to be fully involved in their careKeep your professional knowledge and skills up to date Recognise the limits of your professional competenceWork with colleagues in the ways that best serve patients interestsPharmacists will refer to and abide by The Royal Pharmaceutical Society of Great Britain Code of Ethics.5. Indications for using the syringe PUMPNB: Uncontrolled pain is not a reason to commence the syringe pump (Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2005). The indications are as follows:Swallowing problems – e.g. oral or oesophageal cancers, when liquid or transdermal preparations are inappropriate or patient is unable to swallow liquid preparations.Uncontrolled nausea – i.e. oral medication not effective (NB: resume oral medication when controlled).Uncontrolled vomiting – Unable to tolerate oral medication (NB: resume oral medication when controlled).Intestinal obstructionToo weak to take oral medication – semi-conscious, coma.Terminal agitation – Even if not accompanied by pain. Malabsorption – Rare but take into consideration when symptoms are not being managed despite titration of appropriate oral medication (Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2005; Johnson 1998; Northern Lincolnshire and Goole Hospitals NHS Trust (NL&G) 2003).NB: If patient has transdermal Fentanyl (Durogesic?)) patch insitu Do not remove - please seek Specialist Palliative Care advice6. medication6.1 Combinations of More than One Drug in a Syringe PumpSituations often arise in palliative care where two or more drugs are required to be combined in one syringe. Many combinations have been used in clinical practice. Supporting compatibility data / information should be obtained from Section 5.2 of this guideline prior to using combinations of drugs.General principles that should be adhered to when two or more drugs are used in a syringe driver: Mixtures of drugs may be termed physically compatible. This implies that on mixing, the solution remains colourless, clear and free from particles over the specified time. This does not confirm stability because unseen chemical reactions may occur and would only become apparent by laboratory analysis or an adverse event affecting the patient.Rational use of drugs should be observed. It is important to ensure that the drugs are pharmacologically and chemically distinct. The majority of these drugs are not licensed for administration by subcutaneous infusion or in combinations. The recommendations for combinations and doses given in Section 5.2 of this guidance reflect both local and national experience and practice.Two DrugsThe majority of published laboratory stability data is for 2 drug combinations. When the use of two drugs is deemed necessary, well-validated reference sources should be used.Three DrugsThere is little laboratory data available on the mixing of three drugs in a syringe. The majority of laboratory data is concentration dependent, therefore one cannot assume that if a combination is compatible at one concentration it applies to all concentrations. If you are unsure about any combinations, please seek advice from the Specialist Palliative Care team.DiluentN.B. Whilst Water for Injections is the diluent of choice; the following drugs may be mixed with either Water for Injection or 0.9% Saline unless explicitly stated otherwise.7.1DrugRecommended DoseCommentsDiamorphineUsed because of its high solubilityAvailable as: -5mg ampoules10mg ampoules30mg ampoules100mg ampoules500mg ampoulesNo maximum dose. Titrate upwards until pain is controlled and there are no intractable side effects.Please carefully monitor for toxicity.When converting from oral Morphine divide total 24 hour dose by 3 to obtain total 24 hour dose of DiamorphineExample OneA patient taking modified release oral Morphine Sulphate (e.g. MST / Zomorph) 60mg BD will require 40mg of subcutaneous Diamorphine for equivalent pain control i.e.60 + 60 = 120mg oral Morphine / 24 hours120mg divided by 3 = 40 mg subcutaneous Diamorphine / 24 hoursTo calculate the appropriate therapeutic dose of medication for breakthrough pain, calculate the total amount of Diamorphine given in the driver over 24 hours and divide by 6, e.g. Patient taking 40mg of Diamorphine subcutaneously over 24 hours. 40 divided by 6 = 5mg Diamorphine subcutaneously PRN (to nearest rounded figure )Example TwoA patient taking 120mg of modified release Oral Morphine (e.g. MST / Zomorph) bd will require 80 mgs of subcutaneous Diamorphine over 24 hours i.e.120 mg x 2 = 240mg oral Morphine / 24 hours240 mg divided by 3 = 80 mg subcutaneous Diamorphine / 24 hoursTo calculate the appropriate therapeutic dose of medication for breakthrough pain, calculate the total amount of Diamorphine given in the driver over 24 hours and divide by 6, e.g. Patient taking 80mg of Diamorphine subcutaneously over 24 hours 80 divided by 6 = 15mg Diamorphine subcutaneously PRN (to nearest rounded figure ) Caution in renal failureIf pain was not controlled previously, increase total daily dose by one third to one half. N.B.do not increase if malabsorption of oral medication is considered a contributing factorIt is advisable to have a one sixth of the total 24-hour dose prescribed as subcutaneous injection for breakthrough pain if there is concern about adequate pain relief.When starting a patient on a syringe driver it is advisable to give an initial bolus dose subcutaneously to raise blood plasma levels quickly as the subcutaneous infusion has a slow onset of action.For combinations of Diamorphine with other drugs please see individual drug tables.NB: Reassess daily - all breakthrough analgesics used in previous 24 hours to be considered in dosage calculations.7.2DrugRecommended DoseCommentsOXYCODONEAvailable as: -10mg/ml ampoules50mg/ml ampoulesNo maximum dose. Titrate upwards until pain is controlled ensuring there are no intractable side effects.When converting from oral Oxycodone (Oxycontin) divide total 24 hour dose by 2 to obtain total 24 hour dose of subcutaneous OxycodoneExample OneA patient taking oral Oxycodone (Oxycontin) 40 mg bd will require 40mg of subcutaneous Oxycodone for equivalent pain control i.e.40 + 40 = 80mg oral Oxycodone / 24 hours80mg divided by 2 = 40 mg subcutaneous Oxycodone/ 24 hoursTo calculate the appropriate therapeutic dose of medication for breakthrough pain, calculate the total amount of Oxycodone given in the syringe driver over 24 hours and divide by 6, e.g. Patient taking 40mg of Oxycodone subcutaneously over 24 hours. 40 ÷ 6 = 5mg Oxycodone subcutaneously PRN (to nearest rounded figure)Example TwoA patient taking 150mg of Oxycodone (Oxycontin) bd will require 120 mgs of subcutaneous Oxycodone over 24 hours i.e.150 + 150 = 300mg oral Oxycodone / 24 hours300 ÷ 2 = 150mg subcutaneous Oxycodone/ 24hrsTo calculate the appropriate therapeutic dose of medication for breakthrough pain, calculate the total amount of Oxycodone given in the syringe driver over 24 hours and divide by 6, e.g. Patient taking 150mg of Oxycodone subcutaneously over 24 hours 150 divided by 6 = 25mg Oxycodone subcutaneously PRN NB: All breakthrough medication used in previous 24 hours to be included in dosage calculations.If pain was not controlled previously, increase total daily dose by one third to one half. N.B.do not increase if malabsorption of oral medication is considered a contributing factorIt is advisable to have a one sixth of the total 24-hour dose prescribed as subcutaneous injection for breakthrough pain if there is concern about adequate pain relief.When starting a patient on a syringe driver it is advisable to give an initial bolus dose subcutaneously to raise blood plasma levels quickly as the subcutaneous infusion has a slow onset of action.Diluent Water for injection or 0.9% SalineCompatibilityDo not mix with subcutaneous Cyclizine7.3DrugRecommended DoseCommentsCyclizineAvailable as: -50mg / ml ampoules50mg – 150mg / 24 hoursUsual starting dose is 150mgNB: Seek Specialist Palliative Care advice if maximum dose is not effectiveAnti-emetic (Anti-histamine) useful for nausea and vomiting due to vagal stimulation from gastro-intestinal tract (i.e. constipation, colic) and genitourinary tract or raised intra cranial pressure.Acceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 drugsCyclizine + Diamorphine+Haloperidol (Concentration dependent) or+ Midazolam (Concentration dependent) or+ Hyoscine Hydrobromide (Concentration dependent)2 drugsCyclizine+Haloperidol or+ Diamorphine (At concentration less than 10mg / ml of each drug)Incompatible with Saline 0.9%Use Water for Injection as diluent7.4DrugRecommended DoseCommentsmetoclopramideAvailable as: -10mg / 2ml ampoules30mg – 60mg / 24 hoursUsual starting dose 30mgNB: Seek Specialist Palliative Care advice if maximum dose is not effectiveConcurrent use of Cyclizine and Metoclopramide antagonises the prokinetic effect of Metoclopramide –do not combine. Increased risk of extra-pyramidal side effects in patients less than 20 years old (especially women) if combined with Haloperidol or Levomepromazine.Do not use if complete intestinal obstruction is suspected.Promotes gastric emptyingAcceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 DrugsMetoclopramide + Diamorphine+ Haloperidol or+ Midazolam 2 DrugsMetoclopramide + Diamorphine (Concentration dependent) or+ Midazolam7.5DrugRecommended DoseCommentsHaloperidolAvailable as: -5mg / ml ampoules1.5mg – 10mg / 24 hoursUsual anti-emetic starting dose is 1.5mg – 5mg / 24 hoursUse higher doses if sedative or antipsychotic action required e.g. 10mg / 24 hoursNB: Seek Specialist Palliative Care advice if maximum dose is not effectiveAnti-emetic of choice to prevent opiate induced nausea and vomiting.Side-effects includeSedationDizzinessHeadacheSkin rashesAcceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 Drugs Haloperidol + Diamorphine+ Cyclizine (Concentration dependent) or + Metoclopramide or+ Midazolam (Concentration dependent) or+ Hyoscine Hydrobromide2 DrugsHaloperidol+ Hyoscine Hydrobromide or+ Midazolam or+ Cyclizine or+ DiamorphineIncompatible with Saline 0.9%Use Water for Injection as diluent7.6DrugRecommended DoseCommentsLevomepromazineAvailable as: -25mg / ml ampoules6.25mg – 50mg / 24 hours(higher doses can be used if indicated – please contact specialist palliative care team for advice)For anti-emetic action: starting dose 6.25mg – 12.5mg / 24 hoursFor sedative effect: starting dose 12.5mg – 25mg / 24 hoursNB: Seek Specialist Palliative Care advice if maximum dose is not effectiveAnti-emetic with a broad action.Powerful sedative at higher doses – useful for very agitated patients.Side-effectsSomnolence (especially at doses higher than 25mg /day)Postural hypotension Extra-pyramidal effects at higher dosesUse 0.9% Sodium Chloride as diluent Can sometimes cause local skin reaction.Acceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 DrugsLevomepromazine + Diamorphine+ Hyoscine hydrobromide (Concentration dependent) or+ Hyoscine Butylbromide2 DrugsLevomepromazine + Diamorphine7.7DrugRecommended DoseCommentsmidazolamAvailable as: -10mg / 5ml ampoulesOr10mg / 2ml ampoules.5mg – 60mg / 24 hoursStarting dose 5 – 10mg over 24 hrsEnsure careful titration when increasing dose.NB: Seek Specialist Palliative Care advice if maximum dose is not effectiveBenzodiazepine with anxiolytic, anticonvulsant and amnesic properties. Useful for agitation and in terminal stages.May cause sedationAcceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 Drugs Midazolam + Diamorphine+ Haloperidol or + Hyoscine Hydrobromide or+ Metoclopramide or +Hyoscine Butylbromide or+ Cyclizine 2 DrugsMidazolam + Diamorphine or+ Haloperidol or + Hyoscine Hydrobromide or+ Metoclopramide 7.8DrugRecommended DoseCommentsHyoscine ButylbromideDo not confuse with Hyoscine Hydrobromide Available as: -20mg / ml ampoulesFor colic:60mg – 120mg / 24 hours(higher doses sometimes used)Usual starting dose 60mgFor respiratory secretions:20mg – 60mg / 24 hoursUseful for spasm of smooth muscle (gastro-intestinal and ureteric colic)Used to dry up noisy respiratory secretionsLess likely to cause CNS effects (including sedation) than Hyoscine Hydrobromide Acceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 DrugsHyoscine Butylbromide + Diamorphine+ Levomepromazine or+ Midazolam 2 DrugsHyoscine Butylbromide + Diamorphine or+ Haloperidol+ Midazolam7.9DrugRecommended DoseCommentshyoscine hydrobromideDo not confuse with Hyoscine ButylbromideAvailable as: -400 microgram / 1ml ampoules600 microgram / 1ml ampoulesFor bronchial secretions: 800 micrograms – 2400 micrograms / 24 hoursUsual starting dose 1200 micrograms, reduce if patient frail and / or elderlyFor Colic: 600 micrograms– 1200 micrograms / 24 hoursNB: Hyoscine Butylbromide may be preferred for colic.Anti-cholinergic drugUse to dry up noisy respiratory secretions (it may not relieve the noise of existing secretions but is likely to prevent further exacerbation)May also relieve colic associated with intestinal obstruction.Some anti-emetic actionSide effects – more likely if dose exceeds 1200 microgramsDry mouthDizzinessConstipationConfusionAcceptable combinations in syringe based on laboratory data and clinical practice at recommended doses and concentrations:3 drugsHyoscine hydrobromide + Diamorphine+ Levomepromazine or+ Midazolam or+ Haloperidol or+ Cyclizine2 drugsHyoscine hydrobromide + Diamorphine7.10DrugRecommended DoseCommentsGLYCOPYRRONIUMAvailable as: -200 microgram / 1ml ampoules600 microgram / 3ml ampoulesFor bronchial secretions: 600 micrograms – 1200 micrograms / 24 hoursUsual starting dose 600 micrograms - reduce if patient frail and/or elderlyFor Colic and intestinal obstruction: 600 micrograms– 1200 micrograms / 24 hoursAntimuscarinic drugUse to dry up noisy respiratory secretions (it may not relieve the noise of existing secretions but is likely to prevent further exacerbation)Less sedating than Hyoscine Hydrobromide.Does not cross the blood brain barrier – therefore is less likely to cause confusion than Hyoscine Hydrobromide May also relieve colic Some anti-emetic actionSide effects Dry mouth Constipation, Transient bradycardia (followed by tachycardia)Urinary urgency and retention,Visual disturbances,Flushing and dryness of the skin.Nausea, vomiting, and giddiness; ConstipationConfusion (particularly in the elderly), Very rarely, angle-closure glaucoma3 drugsGlycopyrronium + Diamorphine+ Levomepromazine or+ Midazolam or+ Haloperidol or+ Cyclizine2 drugsGlycopyrronium + Diamorphine7.11DrugRecommended DoseCommentsdexamethasone(Dexamethasone Sodium Phosphate)Available as: -Dexamethasone 4mg / ml ampoules 8mg / ml vials4mg – 16mg DexamethasoneDo not mix with other drugs – use a separate syringe driverRemember: Dexamethasone has a long half life and can be given as a once or twice daily injection rather than setting up a syringe driver. If administered by this method, do not give after 14.00 as can cause insomnia.Use 0.9% Sodium Chloride as diluent 7.12DrugRecommended DoseCommentsoctreotideAvailable as: -50 microgram / 1ml ampoules100 microgram / 1ml ampoules500 microgram / 1ml ampoules200 micrograms – 600 micrograms / 24 hoursStarting dose 200 microgramsNB: Refer to Specialist Palliative Care for advice if maximum dose is not effective.Stimulates water and electrolyte absorption and inhibits water secretion in bowelUseful for nausea and copious vomiting associated with intestinal obstructionCan be used for leaking fistulae, e.g. rectal / vaginalUse 0.9% Sodium Chloride as diluentNB: seek advice before mixing with other drugsCombination data is the best available at the time of publication. Practitioners should ensure that when combinations are in use the syringe and the patient should be monitored closely especially if any of the doses or concentrations are modified.Concentration dependent combinations are more susceptible to instability when doses or concentrations of drugs are changed and should be closely monitored. 7.13 Drugs not suitable for use in the syringe pumpChlorpromazineCan cause skin irritationProchlorperazineCan cause skin irritation subject to light sensitivityDiazepam Can cause skin irritationN.B Once the syringe has been primed and the syringe pump infusion commenced, DO NOT add additional drugs to the driver. If a further symptom presents that requires management using a drug via a syringe pump, a completely new syringe should be primed using a full 24 hour dose of all drugs and the driver recommenced.8.0 The T34 McKinley Syringe Pump8.1. Information for PatientsA full explanation of the device and the procedure to be undertaken is to be discussed with the patient and their informed consent to the procedure must be obtained and documented.Syringe pumps should be sited and maintained by nurses that have been assessed as competent who feel confident in their own ability and possess current knowledge and skills in relation to use of a McKinley T34 syringe pump.All patients who are using a syringe pump and their carers need to be informed of the reasons why the syringe pump is being used. Please refer to the McKinley T34 Syringe Pump Patient Reference Guide Where appropriate the nurse should give information about type of medication used, and its common side effects.Lockable boxes should be used to ensure safe administration for patient.8.2 Labeling of the syringe in the syringe pumpAll Luerlock syringes are to be labeled with patient identifiers name, NHS number, contents, name of drug, strength and dosage to be administered, volume/amount, any diluents or mixes, date, time, of preparation and date and time of expiry and nurses signature, when used for the administration of medication via a syringe pump. Rationale:To ensure infusion is clearly labeled.NMC Standards for Medicines Management (August 2008)8.3 Calibration of a syringe pumpSyringe Pumps will be calibrated and serviced on an annual basis, unless there is concern about the functioning of the syringe pump when it should be sent immediately to the Medical Physics Department at Northern Lincolnshire & Goole Hospitals. If at the time of malfunction the syringe pump was in use then an incident form should also be completed in line with the requirements of each organization.The McKinley T34 syringe pump will display the message “Calibration Due send for service” to inform users that a service is due when the machine is switched on. It should then be returned to Medical Physics for servicing.8.4 Decontamination of the McKinley T34 Syringe pumpAimTo prevent the syringe pump from becoming a vehicle for cross infection and prevent the transfer of body fluids from one individual to another. To create a detailed log of syringe pump usage to enable an audit trail.ProcessThe syringe pump must be decontaminated between individual uses; prior to service, inspection or repair; as part of good housekeeping if contaminated or if it appears visibly dirty during use (including the main pump screw and guiding rods).Standard precautions should be used whenever there is a potential risk of exposure to blood, body fluids, secretions and excretions.All consumables should be disposed of in accordance with the Waste Management Policy and Strategy. Prior to cleaning the syringe pump, a 1% hypochlorite solution should be used on blood, i.e. Virkon, HAZ-tabs or Sanichlor. This should then be wiped off to protect the equipment.The syringe pump should be cleaned by wiping the outside with a soft cloth dampened with a diluted mild detergent. The removable outer clear plastic cover should be washed in warm soapy water, rinsed and allowed to dry.Cleaning with organic solvents, e.g. surgical spirit or abrasive cleaners may damage some of the plastic parts and should therefore not be used.Warning: Never dip or immerse the syringe pump in any liquid or try to sterilize it with steam or gas. It is not completely sealed.A record of each syringe pump should be kept, with a detailed log of when the syringe pump is removed from storage, and by whom; the name of the patient using the equipment, or a reason validating its absence, i.e., service; the date the syringe pump is decontaminated and by what method; and the date the equipment is returned to the store, and by whom.8.5 Decontamination of the Holster bag AimTo prevent the holster from becoming a vehicle for cross infection, and prevent the transfer of body fluids from one individual or another. ProcessThe holster bags should be decontaminated between individual uses; as part of good housekeeping. Disposable bags should be used for single patient only and disposed of after use. Permanent Holsters should be laundered locally as per hospital equipment at 60 degrees Celsius. Within the Community if no access to NHS laundering services, then holster bags must be disposed of after use.9.0 Standard Operational Procedure for setting up a Syringe PumpIt is the responsibility of individual practitioners to ensure that they undertake the specified training to use this piece of equipment and are deemed competent through assessment, knowledge and ongoing training. They must feel confident in their own ability with up to date knowledge and skills because they are accountable for their own practice in line with the NMC Code of Conduct (2011) Professional Standards for Nurses and Midwives.ACTIONRATIONALEDiscuss the use, storage of drugs and siting of the syringe pump with patient and carer. Discuss the cleaning requirements of the syringe pump and holster bag.Patient and carer are informed and are aware of safety rmed consent received.Risk of cross infection/contamination reduced.Check and draw up the prescribed drugs – with the correct diluent.When using a 20mls syringe draw up to a maximum of 17mls in total.When using a 30mls syringe draw up to a maximum of 22mls in total.NOTE: use only 20ml or 30ml LUERLOCK syringesTo prevent instability of drug mixtures To ensure correct dosage/volume of diluent and prevention of syringe disconnection.Attach the charged syringe to the winged infusion set or Sof SetPrime the line.To expel airLabel the syringe with contents, date, time, batch number and the nurse’s signature.To ensure infusion is clearly labeled.Turn on the power. Ensure barrel clamp is down. Self test screen appears on the pump LCD screen. If servicing is required the message “Calibration due send for service” will be displayed at this time. Use another pump and send one requiring servicing to Medical Physics.To ensure the pump is functioning correctly.To ensure safety and reliability of pumps.ACTIONRATIONALEAllow pre-loading to complete (actuator moves to the position of the last syringe that was in place, at the start of the previous infusion). Use << FF or Back >> buttons to position actuator for syringe loading if necessary.Checking the battery – Always check the battery power before starting the infusion.Press the INFO key repeatedly until the battery level appears on the screen and then press “Yes” to confirmDiscard the battery if there is less than 40% remaining. The average battery life, starting at 100%, is 3-4 days but depends on usage.Verify that there is sufficient battery power for the programme.Load syringe – lift and turn barrel clamp arm. Place syringe into plunger and collar sensor simultaneously (syringe scale facing towards front). Turn and lower the barrel clamp arm to secure the syringe.The syringe size and brand option will then be displayed, if these match the screen message press “Yes” key to confirm. If the syringe size and/or brand do not match scroll down arrows until the correct selection appears, then press “Yes” key to confirm.If the correct syringe brand cannot be found on the menu, this may be due to incorrect positioning of the syringe. Remove the syringe and refit ensuring the syringe is fitted securely into all 3 detection points.The pump calculates and displays the deliverable volume, duration of the infusion (24hours) and rate of infusion (mls per hour) – Press “YES” to confirm or ON/OFF to return to the syringe options.Pump Screen prompts “START INFUSION”- do not press “yes” at this time.Check the line is connected to the pump.Serious incidents have been reported involving uncontrolled flow of medication when the syringe has not been correctly or securely fitted to syringe pumps.To ensure safe fixation of the syringe.To ensure correct delivery of medicationSelect a suitable site for insertion.In an area of as much subcutaneous fat as possible e.g. Anterior chest wall, top of thigh, upper arms, anterior abdominal wall.Ensure comfort of patient wherever possible.Cleanse the skin at selected site with an alcohol skin wipe and allow to dry (clip hair if necessary). If long term use is anticipated, clean the skin with liquid soap and water and allow drying.To follow infection control guidelines.Insert the needle SUBCUTANEOUSLY as per guidelines for giving sets.45 degree angle for winged infusion set.90 degree angle for sof set and remove introducer needle.To enable a subcutaneous route for drug administration.Secure the needle and line with a vapour permeable adhesive film dressing. Specific IV dressing is preferable if available.To ensure needle remains in position and the site can be plete documentation in patient notes, drug authorization and administration record and the stock record sheet(s).To adhere to NMC Guidelines for Record Keeping (2008). To provide an audit trail.10. Skin site selection and skin care10.1 Skin For Subcutaneous InfusionThe best sites to use for continuous infusion of drugs are: -(Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2002; Johnson 1998; Macmillan et al 1994)10.2 Sites Which Should Not Be Used For Cannula Placements Are:Lymphoedematous limbs. The rate of absorption from the site would be adversely affected and infection could also occur.Sites over a bony prominence: the amount of subcutaneous tissue would be diminished impairing the rate of drug absorption.Previously irradiated skin area. Radiotherapy can cause sclerosis of small blood vessels, thus reducing skin perfusion.Sites near a joint, excessive movement may cause cannula displacement and patient discomfort.Broken skin.Localised areas of disease e.g. chest wall with breast cancer.Affected limb following lymph node dissection. Patients may decide (in partnership with the nurse responsible for their care) for themselves, after consultation, a suitable site that will interfere as little as possible with their lifestyle (Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2002; Johnson 1998 )10.3 Care Of the Skin Site and ChecksHospital, Hospice and Nursing Home Check 4 hourly. Check position of needleCondition of siteVolume infused (mls)Check symptom controlRecord above details on syringe driver observation chart CommunityPatient/carer may be taught how to assess if appropriate. The District Nurse or Community Nurse will check the site at each visit.Check position of needleCondition of siteVolume infused (mls)Check symptom controlRecord findingsFor all The cannula should be re-sited when there is evidence of Inflammation Poor absorption (a hard subcutaneous swelling). The time taken for this to occur can vary from hours to weeks dependent on the patient and the drugs being infused. Avoid immediate area for re-siting; relocate to another skin site (Cooper and Mitten 2000; Danne et al 2000; Dickman et al 2002). If The Skin Sites Break Down Rapidly, Suggestions Include: -Further dilute the drug infused by using a larger volume of diluent in a larger syringe.Change the site regularly (e.g. daily/48 hours or on visual inspection) before it breaks down.Consider changing to an alternative brand of cannula. E.g. TeflonMix drugs with 0.9% Sodium Chloride if compatibleReconsider alternative drugs and/or routes of administration. If skin site reaction continues - seek specialist advice as further measures can be taken11. Trouble Shooting ConsiderationsProblemPOSSIBLE CAUSEACTIONInfusion ended earlyIncorrect rate settingScale length measured incorrectlyTamperingReport as an incident according to trust/organisational policy Infusion ended lateIncorrect rate settingScale length measured incorrectlyMalfunctioning pumpReport as an incident according to trust/organisational policyInfusion stoppedBlockage in the lineBattery exhaustedLine kinkedSyringe/tubing disconnectedIf infusion has been stopped for greater than one hour, report as an incident according to trust policyInfusion won’t startBattery inserted incorrectlyBattery exhausted Start button not depressed sufficientlyCorrect as appropriateMedication crystallisesIncompatibility of drugs or diluent in syringeSTOP - seek urgent medical and pharmaceutical advice. Ensure that the patient is comfortableAlarm – battery is depletedBattery needs replacingReplace batteryInfusion motor runningLight still flashingPeriodic clickSyringe plunger mechanism has worn outUse another syringe driverUnit to be returned to Medical Electronics DepartmentSyringe pumps should be serviced annually according to organisational policy.12. SPECIALIST advice12.1 Contact Numbers for specialist palliative care adviceSiteContactContact numberSt Andrews HospiceSenior Nurse on duty(01472) 350908Lindsey Lodge HospiceSenior Nurse on duty(01724) 270835Scunthorpe & Goole HospitalsMacmillan Nurses – Palliative Care (01724) 387709Diana Princess of Wales HospitalMacmillan Nurses – Palliative Care orMacmillan End of Life Clinical Care Co-ordinator(01472) 874111 Ext 3596or (01472) 874111 Ext 3595 orvia hospital switchboardNorth East Lincolnshire Care Plus GroupMacmillan Nurses – Palliative Care (01472) 250623East Riding Community Health NHS Trust Macmillan Nurse – Palliative Care (Goole only)(01405) 721314North Lincolnshire Community Macmillan TeamMacmillan Nurses – Palliative Care(01724) 87155613 REFERENCESAUTHORPUBLICATION DATETITLECME Medical2011T34 Ambulatory Syringe pump. Device Use and Training ResourceCooper, J. & Mitten, T.2000Continuous Subcutaneous InfusionsChapter 3, P 56 In (Ed.) Cooper, J. Stepping Into Palliative Care. A Handbook For Community Professionals. Radcliffe Medical Press.Danne et al2000An Audit Of Subcutaneous Syringe Drivers In A Non-Specialist HospitalInternational Journal Of Palliative Nursing. 6, No. 5David, J1992A Survey Of The Use Of The Syringe Drivers In Marie Curie CentresEuropean Journal Of Cancer Care. 4 P 23 - 28Dickman et al.2005The Syringe Driver – Continuous Subcutaneous Infusion In Palliative CareOxford University PressGeneral Medical Council2006Duties of a Registered DoctorJohnson, J.1998The Syringe DriverIn (Ed.) Faull, C., Carter, Y., And Woof, R., Handbook Of Palliative Care. Blackwell ScienceMacmillan et al1994A Prospective Comparison Study Between A Butterfly And A Teflon Cannulae For Subcutaneous Narcotic AdministrationJournal Of Pain And Symptom Management. 9, P 82 - 84Mitten, T.2001Subcutaneous Drug Infusions: A Review Of Problems And SolutionsInternational Journal Of Palliative Nursing. 17 No 2Nursing & Midwifery Council2008Code of Professional ConductNursing & Midwifery Council2008Guidelines For The Administration Of MedicinesNMCNorthern Lincolnshire And Goole Hospitals NHS Trust2006The Medicines CodeA Guide To The Use Of Medicines In Northern Lincolnshire & Goole Hospitals nhs TrustRoss, J. R.2002A Prospective, Within Patient Comparisons Between Butterfly Needs And Teflon Cannulae In Subcutaneous Infusions Of Drugs To Terminally Ill Hospital PatientsJournal Of Pain And Symptom Management. 16, P 15 - 16Trissel, L2003Handbook On Injectable Drugs12th Edition. American Society Of Health System PharmacistsTwycross, R. et al2002Symptom Management In Advanced Cancer3rd Ed. Chapter 2, P 42. Radcliffe Medical PressTwycross et al2011The Palliative Care Formulary 4th Edition, Radcliffe Medical PressORIGINAL AUTHORSBealey, MurielHead of Adult Services, St Andrew’s Hospice, GrimsbyChester, JanetMacmillan Palliative Care Nurse Specialist, N. Lincs PCTDyer, ChrisSenior Nurse, Lindsey Lodge Hospice, ScunthorpeFoster, LizMacmillan Palliative Care Nurse Specialist, NE Lincs PCTHenry, ChristineMacmillan Palliative Care Nurse Specialist, Scunthorpe HospitalMaloney, LindsayMacmillan Palliative Care Nurse Specialist, NE Lincs PCTMorris, AnnMacmillan Lead GP, N. Lincs PCT & Medical Director, Lindsey Lodge HospicePrucyck, JulieMacmillan Palliative Care Nurse Specialist, Scunthorpe HospitalPurser, PaulMacmillan Lead GP, NE. Lincs PCT & Medical Director, St Andrew’s HospiceRevill, ValMacmillan Lead Nurse for Palliative Care, NE Lincs PCTRose, AnnClinical district Nurse Lead, N. Lincs PCTSmith, ElainePalliative Care Support Nurse, Scunthorpe HospitalStaniforth, RachelPharmaceutical Advisor, NE Lincs PCTTurner, MartynChief Pharmacist, NL&GWalker, HelenMedicine Information Pharmacist, NL&GWatson, SallyMacmillan Palliative Care Nurse Specialist, NE Lincs PCTWilkinson, SuClinical Documentation Project Manager, NL&G ................
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