Subcutaneous Medication Management in the Care of the ...



Canberra Hospital and Health Services

Clinical Procedure

Subcutaneous Medication Management in the Care of the Palliative Patient – Adults Only

|Contents |

Contents 1

Purpose 2

Alerts 2

Scope 2

Section 1 – Requirements for Procedure 2

Section 2 – Guidelines for Practice in the Inpatient setting 3

Section 3 – Day 1: Priming the Line using the Machine 5

Section 4 – Changing a Syringe Only (if not priming) 6

Section 5 – Inserting the Safety Intima cannula 6

Section 6 – Observations while using the Syringe Driver 8

Section 7 – Patient and family/carer education 8

Section 8 – Community Nursing 8

Implementation 9

Related Policies, Procedures, Guidelines and Legislation 9

References 9

Definition of Terms 10

Search Terms 10

|Purpose |

This procedure sets out the process for the administration of subcutaneous medication via a syringe driver in accordance with legislative, statutory and regulatory requirements, at Canberra Hospital Health Service (CHHS) including the community.

This Standard Operating Procedure (SOP) describes for staff the process to

|Scope |

|Alerts |

• Cyclizine should be mixed with water for injection.1

• Cyclizine, methadone, levomepromazine and promethazine should be diluted to a maximum infusible volume to minimise stability problems and to reduce the risk of local skin irritation.1

• Sodium chloride 0.9% (normal saline) is recommended for use as a diluent for ketamine, levomepromazine and ondansatron.1

• diazepam and prochlorperazine should be avoided as they cause local skin irritation if given subcutaneously.1

• For all infusions involving the administration of an S8 medication a “lock box” is to be used with syringe drivers.

• Under the Medication Handling Policy all S8 infusion devices are required to be checked four hourly by the nurse caring for the patient and at the end of each shift at handover from shift nurse to shift nurse. This does not apply in the community setting.

• On completion of the infusion, staff must dispose of the unused portion of the syringe in the presence of a witness and in a way that makes the drug unrecoverable in accordance with the Medication Handling Policy. The discarded amount must be entered into the Discard register for S8 infusions.

• From 730 am to 9 pm call Central Equipment Store for collection of syringe driver on x47171, outside these hours contact the afterhours clinical Nurse Consultant via switch.

|Scope |

This scope applies to all CHHS nursing staff who have received the necessary training to administer medications using the NIKI T34 syringe driver.

|Section 1 – Requirements for Procedure |

• NIKI T34 Syringe Driver and lockable case

• A safety Intima butterfly set

• Luer lock syringe 10, 20, 30 or 50 mL as indicated. Due to the limitation of the syringe driver, it will only function with up to 9mL in a 10mL syringe, 17mL in 20mL syringe 23mL in 30mL syringe and 35mL in a 50mL syringe (please note any syringe larger than 10mL will not fit inside the lock box, therefore, all S8 medications must be placed in a 10mL syringe)

• Drawing up needle

• Transparent dressing or non allergenic tape if indicated

• Disposable 9V battery

• Medication label

• 100cm extension set

• Antiseptic wipe

• Prescribed medications

• Compatible bung

• Disposable gloves

• Hand washing facilities or antimicrobial hand rub.

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|Section 2 – Guidelines for Practice in the Inpatient setting |

• Subcutaneous syringe driver infusions are used to administer medications to maximise symptom management.

• The main indication for the use of a syringe driver is that a patient has persistent symptoms (usually pain and nausea) and does not have the ability to swallow or absorb drugs via the oral route and/or if there is no oral drug substitute to alleviate the symptoms.

• Medications for the syringe driver are prescribed by an authorised prescriber on an inpatient Medication Chart in milligrams (mg) over a 24 hour period.

• Only registered nurses who have been educated and trained in the use of subcutaneous infusion sets and a NIKI T34 syringe driver may administer infusions using this syringe driver. Training includes xxxx

• Under the direct supervision of a Registered Nurse, Student Nurses in accordance with the protocol of their educational institution and who have passed the medication administration component of their education at their educational facility may also administer medications using the NIKI T34 syringe driver

• When trained staff prepare and administer a syringe driver infusion to a patient another staff member must be present to witness the procedure. The witness may be a:

o Medical or Nurse Practitioner

o Registered Nurse

o Credentialed Enrolled Nurse.

• A pro re nata (PRN) order may be prescribed for breakthrough medication and a second dedicated safety Intima butterfly needle is required for this.

Medication Combinations

• It is recommended that no more than three (3) medications be combined in a syringe driver. Check compatibility before mixing two or more drugs together.

• pH and concentrations influence compatibility therefore regular monitoring of the contents of the syringe and the tubing for evidence of physical incompatibility must take place e.g. precipitation, colour change and urgent replacement of both the syringe and line attended if any changes are detected.

NOTE:

Incompatible medications are loaded into separate syringes and infused into separate subcutaneous sites.

Commencing Dose

• Calculate the patient’s intake of oral morphine and other Schedule 8 medications as equivalents of morphine over 24 hours and halve this dose.

• The halved dose should be the commencement dose of subcutaneous morphine over 24 hours.

• Authorised prescribers may prefer to use a larger starting dose where appropriate.

• Consideration should be given to the opioid naive patient, the elderly and those with renal or hepatic impairment.

• The EVIQ opioid calculator can be used to assist with dosing.

Breakthrough Medication

• The patient may require subcutaneous breakthrough pain medication more frequently for the initial 24-48 hours.

• Breakthrough doses should have an ongoing order and have unrestricted time limits, although if two or more subcutaneous breakthrough injections are required within 24 hours, the analgesic regime should be reassessed.

• Ensure that a PRN subcutaneous medication for "breakthrough pain" has been ordered.

• Ensure that an anti-emetic is ordered for the patient commencing subcutaneous morphine.

Preparing the Medications in a Syringe Driver

• Attach extension tubing to the subcutaneous infusion set

• Document on syringe driver checklist form medications in syringe, date, time, volume and rate.

• Label syringe: patient information, time, date, dose, volume and sign.

NOTE:

If the line is to be primed, and the volume of the medication in the syringe is less than 5 mL, add water or sodium chloride 0.9% (normal saline) for injection to make up to a minimum of 5mL total. (Water minimises pharmacological interactions and precipitations if medication combinations are used).

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|Section 3 – Day 1: Priming the Line using the Machine |

• Obtain Syringe Driver from Central Equipment Store (call x42771).

• Draw up medication in relevant size syringe. The Luer-lock syringe size can be from 5-30mL. If the line is to be primed and the volume of the medication in the syringe is less than 5mLs add water or saline for injection to make up to a minimum of 5mLs total. (Water minimises pharmacological interactions and precipitations if medication combinations are used).

• Insert battery into NIKI T34 Syringe driver.

• Raise clamp and turn to back of unit (push down again so it is not sticking up)

• Turn on NIKI T34.

• Measure syringe against NIKI T34 and press either FF or Back to align actuator to syringe plunger. Actuator will re-set to previous syringe size, so if same syringe size, no need to alter.

• Load syringe and raise clamp to turn and fit over syringe.

• Use to select correct syringe brand, press YES.

• Check and review data on screen: volume, duration, rate (e.g. 24mL, 24hrs or mL/hr).

• DO NOT start infusion.

• Press FF to purge line and butterfly (it will ask you to press YES to confirm the patient is not attached).

• Hold down the FF key until the line and butterfly are primed (approx 1mL).

• Syringe driver will revert to original screen.

• Again press YES to confirm size and brand of syringe.

• Press YES to Resume.

• Display will now read new volume (load minus prime amount) and new duration (e.g. 23hrs) however, the Rate will remain constant (e.g. mL/hr).

• To confirm press YES.

• Insert infusion line to patient.

• When “Start Infusion?” is displayed, press YES to commence.

• Lock Keypad by holding down the blue key until the black rectangle is completely marked out.

• Place unit in lock box, lock and place in bag next to patient.

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|Section 4 – Changing a Syringe Only (if not priming) |

• Draw up medication in relevant syringe.

• Unlock keypad (by holding down the blue key until the rectangle is unmarked)

• Press STOP.

• Turn off NIKI T34 syringe driver.

• Raise clamp and turn away from screen (push down so it is not sticking up).

• Remove old syringe.

• Turn on NIKI T34.

• Attach new syringe to infusion line. Measure syringe against NIKI T34 and press either FF or Back to align actuator to syringe plunger. Actuator will re-set to previous syringe size, so if same syringe size, no need to alter.

• Pull clamp up and over new syringe.

• Use to Select syringe brand, press YES.

• Check data on screen, Volume, Duration, Rate (e.g. 24mL, 24hrs, 1mL/hr, battery life).

• To confirm press YES.

• When “Start Infusion?” is displayed, to commence press YES.

• Lock Keypad by holding down the blue key until the black rectangle is completely marked out.

• Place unit in lockable case, lock and place in bag next to patient.

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|Section 5 – Inserting the Safety Intima cannula |

• Put on gloves and clean insertion site with an alcohol swab and allow to dry.

• Insert cannula through the skin at a 30-45 degree angle into the subcutaneous tissue.

Note:

Hold wings together during insertion for stability, with the bubbled surface of the wings facing the patient’s skin, the cannula should be attached to a primed subcutaneous infusion set.

• Remove guide wire while stabilising the wings with the other hand

• Cover with clear occlusive dressing and anchor tubing

• Write the date and time of insertion of the cannula on the tape provided with the occlusive dressing.

Possible sites for Subcutaneous Needle (see diagram below)

• Upper outer thigh

• Upper outer arm

• Upper chest

• Back upper shoulders

• Abdomen

[pic]

Areas to avoid

• Porta Cath or central line site

• Pace maker site

• Tumours

• Mastectomy site or arm on mastectomy side

• Areas of local irritation, stoma site or areas with oedema.

Clinical Indications for Site Change include

• Redness at insertion site

• Pain at site

• Swelling

• Line obstruction

• Itchiness at site

• Hardened or engorged tissue

• By using a site rotation pattern, the chance of any problems at injection sites will be minimised

• Check the injection site four hourly and at change of shift in the hospital setting, daily in the community. Change the injection site if indicated or at least every 10 days. Document change of needle site on Syringe Driver Checklist form.

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|Section 6 – Observations while using the Syringe Driver |

• Check and document observations every four (4) hours and at change of shift on the Syringe Driver Checklist form. In the community, observations occur daily.

• Check that the correct infusion rate is being run.

• Check that the volume in syringe is reducing appropriately.

• Check that the injection site is not inflamed or leaking.

• Check the effectiveness of the infusion through observation and asking the patient.

• Report any side effects or any issues relating to the syringe driver to the hospital treating team/ Palliative and Supportive Care.

• Monitor the appropriateness of the syringe driver on a regular basis and discuss the need for change or cessation with the MO/ Palliative and Supportive Care team.

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|Section 7 – Patient and family/carer education |

Provide education to the patient and family/carer about:

• Why the device is required?

• What the device will do and its advantages and possible disadvantages.

• Breakthrough dose administration.

• Safety aspects using a belt bag to conceal and carry the device discreetly without risk of pulling the butterfly catheter out.

• How not to get the syringe driver wet and how to manage the device when having a shower.

• The keypad and that it has a locking mechanism which prevents unintentional power off.

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|Section 8 – Community Nursing |

• Priming the line: draw up extra medication so that the syringe driver is able to run the prescribed time e.g. 24 or 48hrs:

o Draw up a proportional dose to prime the line (this could be the lowest denominator e.g. half, third, or quarter). Where there are 2 drugs or more, the proportion of these drugs must remain the same,  Or

o Draw up 2 identical 24/48 hour syringes, purge with one, and then discard. Use 2nd syringe to load syringe driver for the full 24/48 hours.

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|Implementation |

Updated information will be communicated to all Clinical Development Nurses and Clinical Nurse consultants.

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|Related Policies, Procedures, Guidelines and Legislation |

Policies

• Medication Handling Policy

• Healthcare Associated Infections Policy

Guidelines

• eTG November 2016 edition, Therapeutic Guidelines Ltd, Published July 2016

• Australian Pharmaceutical Advisory Council Guiding Principles for Medication Management in the Community 2006

Legislation

• ACT Medicines, Poisons and Therapeutic Goods Act 2008

• ACT Medicines, Poisons and Therapeutic Goods Regulation 2008

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|References |

1. Marshford M L, Aranda S, Ashby M, Bowman J, Brooksbank M, Cairns W, Currow D, Hynson J, Kissane D, Maddocks I, Mitchell G, O’Connor M, Poole S, Ravenscroft P, Robinson J, Smith M 2010.Therapeutic guidelines: palliative care Version 3, Therapeutic guidelines limited, Victoria, Australia

2. BPAC 2012 Using a syringe driver in Palliative Care. Best Practice Journal: 48

3. Caesarea Medical Electronics Ltd, NIKI T 34 Syringe Pump Instruction Manual May 2010

4. Reymond L, Charles M A, Bowman J, Treston P 2003 The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients. Medical journal of Australia, 178 (10): 486-9

5. State & Territory Nurses Boards of Australia.

6. Yates, P (2006) “Guidelines for Syringe Driver Management in Palliative Care”

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|Definition of Terms |

Breakthrough medication an extra dose of the patient’s prescribed opioid given in response to pain

Direct supervision is provided when the registered nurse is present, observes, works with and directs the person who is being supervised

Lock Box-a secured box to place the syringe driver into to prevent unauthorised access

Precipitation- a substance that has separated from or settled out of a solution

Purged (primed)- a syringe driver infusion line is loaded with the contents of the syringe driver combination

Scope of practice- covers the activities and responsibilities that a health professional is educated, trained, authorised and competent to perform.

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|Search Terms |

Syringe driver, subcutaneous medication infusion, subcutaneous infusion,

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

|Date Amended |Section Amended |Approved By |

|Eg: 17 August 2014 |Section 1 |ED/CHHSPC Chair |

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