procedure for the use of the syringe pump in palliative and end of life

PROCEDURE FOR THE USE OF THE SYRINGE PUMP IN

PALLIATIVE AND END OF LIFE CARE

(INCLUDING GUIDELINES FOR ADMINISTRATION OF DRUGS)

Version:

Name of originator/author:

Date issued:

Review date:

1.0 (31/01/2013)

Val Revill

31/01/2013

28 th February 2014

Procedure for the use of the McKinley T34 syringe pump in palliative and end of life care February 2013

Contents

1 . Scope

2. Glossary of terms

3. Aim

3.1 Client Group

3.2 Staff Group

4. Introduction

5. Indications for using the syringe pump

6. Medication

6.1 Combinations of more than one drug in a syringe pump

7. Drugs

7.1 Diamorphine

7.2 Oxycodone

7.3 Cyclizine

7.4 Metoclopramide

7.5 Haloperidol

7.7 Midazolam

7.6 Levomepromazine

7.8 Hyoscine Butylbromide

7.9 Hyoscine Hydrobromide

7.10 Glycopyrronium

7.11 Dexamethasone

7.12 Octreotide

7.13 Drugs not suitable for use in the syringe driver

8. The T34 McKinley Syringe Pump

8.1 Information for patients

8.2 Labelling of the syringe

8.3 Calibration of a syringe pump

8.4 Decontamination of syringe pump

8.5 Decontamination of holster bag

9. Standard Operating Procedure

10. Skin site selection and skin care

10.1 Sites suitable for subcutaneous infusion

10.2 Sites not suitable for subcutaneous infusion

10.3 Care of the skin site and checks

11. Trouble shooting

12. Specialist Palliative Care Advice

13. References

Procedure for the use of the McKinley T34 syringe pump in palliative and end of life care

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1

1. SCOPE

This 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 Points

 All staff using the syringe pump will have been trained in its use and a record of the

training is documented

 All 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 via each 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 to



Safely prescribe or dispense medications for a syringe pump





Safely administer medications via a syringe pump

 Ensure that the rate setting is correct and that the machine is running to time

 Early detection of uncontrolled symptoms

 Early detection of functional problems related to the device - trouble-shooting guide

 Early detection of occlusion, or discolouring of solutions being administered

The 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.


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

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 advisers


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2.

GLOSSARY OF TERMS

Accountable Responsible for something or to someone

Competent

Possessing the skills and abilities required for lawful, safe and effective professional practice without direct supervision.

DPOWH Diana Princess of Wales Hospital

LLH mg

Lindsey Lodge Hospice

Milligram ml mm

Millilitre

Millimetre

NEL North East Lincolnshire

NELCCG North East Lincolnshire Clinical Commissioning Group

NL

NL&G

NMC

CPG

SAH

SGH

North Lincolnshire

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Nursing and Midwifery Council

Care Plus Group

St Andrew’s Hospice

Scunthorpe General Hospital

3. AIM









Safe 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 time

Early detection of functional problems related to the device

Early detection of occlusion or discolouring of solutions being administered

3.1 CLIENT GROUP

Adults 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.

3.2

STAFF GROUP

Registered 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.


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4.

INTRODUCTION

These 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 care



Keep your professional knowledge and skills up to date

 Recognise the limits of your professional competence

 Work with colleagues in the ways that best serve patients interests

Pharmacists will refer to and abide by The Royal Pharmaceutical Society of Great Britain Code of

Ethics.


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5. INDICATIONS FOR USING THE SYRINGE PUMP

NB: 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 obstruction

 Too 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 advice

6. MEDICATION

6.1 Combinations of More than One Drug in a Syringe Pump

Situations 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.


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

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 Drugs

The 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 Drugs

There 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.

Diluent

N.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 .


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7.1

Drug Recommended Dose Comments

DIAMORPHINE

Used because of its high solubility

Available as: -

 5mg ampoules

 10mg ampoules

 30mg ampoules

 100mg ampoules

 500mg ampoules

No 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

Diamorphine

Example One

A 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 hours

120mg divided by 3 = 40 mg subcutaneous

Diamorphine / 24 hours

To 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 )





Caution in renal failure

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 factor

 It 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.

Example Two



For combinations of

Diamorphine with other drugs please see individual drug tables.

A 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 hours

240 mg divided by 3 = 80 mg subcutaneous

Diamorphine / 24 hours

To 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 )

NB: Reassess daily - all breakthrough analgesics used in previous 24 hours to be considered in dosage

calculations.


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7.2

Drug

OXYCODONE

Available as: -

 10mg/ml ampoules

 50mg/ml ampoules

Recommended Dose Comments

No 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

Oxycodone

Example One

A 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 hours

80mg divided by 2 = 40 mg subcutaneous

Oxycodone/ 24 hours

To 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 Two

 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 factor

 It 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% Saline

Compatibility



Do not mix with subcutaneous

Cyclizine

A 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 hours

300 ÷ 2 = 150mg subcutaneous Oxycodone/

24hrs

To 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.


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7.3

Drug

CYCLIZINE

Available as: -

 50mg / ml ampoules

Recommended Dose

50mg – 150mg / 24 hours

Usual starting dose is 150mg

NB: Seek Specialist Palliative Care advice if

maximum dose is not effective

Comments

 Anti-emetic (Anti-histamine) useful for nausea and vomiting due to vagal stimulation from gastrointestinal 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 drugs

Cyclizine + Diamorphine

+Haloperidol

(Concentration dependent) or

+ Midazolam


+ Hyoscine Hydrobromide

(Concentration dependent)

2 drugs

Cyclizine

+Haloperidol or

+ Diamorphine (At concentration less than 10mg / ml of each drug)

 Incompatible with Saline

0.9%

 Use Water for Injection as diluent


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7.4


METOCLOPRAMIDE

Available as: -

 10mg / 2ml ampoules

30mg – 60mg / 24 hours

Usual starting dose 30mg



 Concurrent use of Cyclizine and Metoclopramide antagonises the prokinetic effect of Metoclopramide – do not combine.

 Increased risk of extrapyramidal 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 emptying


3 Drugs

Metoclopramide

+ Diamorphine

+ Haloperidol or

+ Midazolam

2 Drugs

Metoclopramide

+ Diamorphine


+ Midazolam


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7.5


HALOPERIDOL

Available as: -


1.5mg – 10mg / 24 hours

Usual anti-emetic starting dose is 1.5mg – 5mg

/ 24 hours

Use higher doses if sedative or antipsychotic action required e.g. 10mg / 24 hours



 Anti-emetic of choice to prevent opiate induced nausea and vomiting.

 Side-effects include



Sedation



Dizziness



Headache



Skin rashes


3 Drugs

Haloperidol + Diamorphine

+ Cyclizine

(Concentration dependent) or

+ Metoclopramide or

+ Midazolam

(Concentration dependent) or

+ Hyoscine Hydrobromide

2 Drugs

Haloperidol

+ Hyoscine Hydrobromide or

+ Midazolam or

+ Cyclizine or

+ Diamorphine

 Incompatible with Saline

0.9%

 Use Water for Injection as diluent


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7.6


LEVOMEPROMAZINE

Available as: -


6.25mg – 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 hours

For sedative effect: starting dose

12.5mg – 25mg / 24 hours



 Anti-emetic with a broad action.

 Powerful sedative at higher doses – useful for very agitated patients.

 Side-effects



Somnolence (especially at doses higher than 25mg

/day)



Postural hypotension



Extra-pyramidal effects at higher doses

 Use 0.9% Sodium Chloride as diluent

 Can sometimes cause local skin reaction.


3 Drugs

Levomepromazine

+ Diamorphine

+ Hyoscine hydrobromide


+ Hyoscine Butylbromide

2 Drugs

Levomepromazine

+ Diamorphine


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7.7


MIDAZOLAM

Available as: -

 10mg / 5ml ampoules

Or



10mg / 2ml ampoules.


Starting dose 5 – 10mg over 24 hrs

Ensure careful titration when increasing dose.

NB: Seek Specialist Palliative Care advice if maximum dose is not effective

 Benzodiazepine with anxiolytic, anticonvulsant and amnesic properties.

Useful for agitation and in terminal stages.

 May cause sedation


3 Drugs

Midazolam + Diamorphine

+ Haloperidol or

+ Hyoscine Hydrobromide or

+ Metoclopramide or

+Hyoscine Butylbromide or

+ Cyclizine

2 Drugs

Midazolam

+ Diamorphine or

+ Haloperidol or

+ Hyoscine Hydrobromide or

+ Metoclopramide


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7.8

Drug

HYOSCINE

BUTYLBROMIDE

Do not confuse with

Hyoscine Hydrobromide

Available as: -



20mg / ml ampoules

Recommended Dose

For colic:

60mg – 120mg / 24 hours

(higher doses sometimes used)

Usual starting dose 60mg

For respiratory secretions:


Comments

 Useful for spasm of smooth muscle (gastro-intestinal and ureteric colic)

 Used to dry up noisy respiratory secretions

 Less likely to cause CNS effects (including sedation) than Hyoscine Hydrobromide


3 Drugs

Hyoscine Butylbromide +

Diamorphine

+ Levomepromazine or

+ Midazolam

2 Drugs

Hyoscine Butylbromide +

Diamorphine or

+ Haloperidol

+ Midazolam


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7.9

Drug

HYOSCINE

HYDROBROMIDE

Do not confuse with

Hyoscine Butylbromide

Available as: -



400 microgram / 1ml ampoules




Recommended Dose Comments

For bronchial secretions:

800 micrograms –

2400 micrograms / 24 hours



Usual starting dose

1200 micrograms, reduce if patient frail and

/ or elderly 



For Colic: 600 micrograms– 1200 micrograms / 24 hours

NB: Hyoscine Butylbromide may be preferred for colic.





 Anti-cholinergic drug

Use 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 action

Side effects – more likely if dose

exceeds 1200 micrograms



Dry mouth



Dizziness



Constipation

 Confusion


3 drugs

Hyoscine hydrobromide +

Diamorphine


+ Midazolam or


+ Cyclizine

2 drugs

Hyoscine hydrobromide +

Diamorphine


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7.10


GLYCOPYRRONIUM

Available as: -



200 microgram / 1ml

 ampoules


For bronchial secretions:

600 micrograms –

1200 micrograms / 24 hours

Usual starting dose

600 micrograms - reduce if patient frail and/or elderly

For Colic and intestinal obstruction: 600 micrograms– 1200 micrograms / 24 hours





 Antimuscarinic drug

Use 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 action

 Side 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;



Constipation



Confusion (particularly in the

elderly),



Very rarely, angle-closure

glaucoma

3 drugs

Glycopyrronium + Diamorphine


+ Midazolam or


+ Cyclizine

2 drugs

Glycopyrronium + Diamorphine


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7.11


DEXAMETHASONE

(Dexamethasone Sodium

Phosphate)

Available as: -

 Dexamethasone

4mg / ml ampoules

8mg / ml vials

4mg – 16mg Dexamethasone





Do not mix with other drugs – use a separate syringe driver

Remember: 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.



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7.12


OCTREOTIDE

Available as: -

 50 microgram / 1ml ampoules



200 micrograms – 600 micrograms / 24 hours

Starting dose 200 micrograms

NB: Refer to Specialist Palliative Care for advice if maximum dose is not effective.

 Stimulates water and electrolyte absorption and inhibits water secretion in bowel

 Useful for nausea and copious vomiting associated with intestinal obstruction

 Can be used for leaking fistulae, e.g. rectal / vaginal


NB: seek advice before mixing with other drugs

Combination 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 pump

CHLORPROMAZINE



Can cause skin irritation

PROCHLORPERAZINE



Can cause skin irritation subject to light sensitivity

DIAZEPAM



Can cause skin irritation

N.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.


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8.0 The T34 McKinley Syringe Pump

8.1

. Information for Patients

A 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 pump

All 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 pump

Syringe 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.


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8.4 Decontamination of the McKinley T34 Syringe pump

Aim

To 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.

Process

The 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

Aim

To prevent the holster from becoming a vehicle for cross infection, and prevent the transfer of body fluids from one individual or another.

Process

The 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.


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9.0 Standard Operational Procedure for setting up a Syringe Pump

It 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.

ACTION RATIONALE

Discuss 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.

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 syringes

Patient and carer are informed and are aware of safety issues.

Informed consent received.

Risk of cross infection/contamination reduced.

To 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 Set

Prime the line.

Label the syringe with contents, date, time, batch number and the nurse’s signature.

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.

To expel air

To ensure infusion is clearly labeled.

To ensure the pump is functioning correctly.


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Use another pump and send one requiring servicing to Medical Physics.

ACTION

Allow 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 confirm



Discard the battery if there is less than 40% remaining. The average battery life, starting at 100%, is 3-4 days but depends on usage.

To ensure safety and reliability of pumps.

RATIONALE

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)

To ensure safe fixation of the syringe.


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– 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.

Select 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.

To ensure correct delivery of medication

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.

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.

Secure the needle and line with a vapour permeable adhesive film dressing. Specific IV dressing is preferable if available.

To follow infection control guidelines.

To enable a subcutaneous route for drug administration.

To ensure needle remains in position and the site can be observed.

Complete 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.


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10. SKIN SITE SELECTION AND SKIN CARE

10.1 Skin For Subcutaneous Infusion

The 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 )


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





10.3 Care Of the Skin Site and Checks

Hospital, Hospice and Nursing Home

 Check 4 hourly.



Check position of needle

 Condition of site



Volume infused (mls)

 Check symptom control



Record above details on syringe driver observation chart

Community



Patient/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 needle



Condition of site



Volume infused (mls)

 Check symptom control

 Record findings

For 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. Teflon



Mix drugs with 0.9% Sodium Chloride if compatible



Reconsider alternative drugs and/or routes of administration.

If skin site reaction continues - seek specialist advice as further measures can be taken


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11. TROUBLE SHOOTING CONSIDERATIONS

PROBLEM POSSIBLE CAUSE

Infusion ended early





Incorrect rate setting

Scale length measured incorrectly

 Tampering

Infusion ended late  Incorrect rate setting

 Scale length measured incorrectly

 Malfunctioning pump

Infusion stopped  Blockage in the line

 Battery exhausted

 Line kinked

 Syringe/tubing disconnected

ACTION

 Report as an incident according to trust/organisational policy





Report as an incident according to trust/organisational policy

If infusion has been stopped for greater than one hour, report as an incident according to trust policy

Infusion won’t start  Battery inserted incorrectly

 Battery exhausted

 Start button not depressed sufficiently

Medication crystallises

Alarm – battery is depleted

 Incompatibility of drugs or diluent in syringe

 Battery needs replacing







Correct as appropriate

STOP - seek urgent medical and pharmaceutical advice. Ensure that the patient is comfortable

Replace battery

Infusion motor running

Light still flashing

Periodic click





Syringe plunger mechanism has worn out

Use another syringe driver

 Unit to be returned to Medical

Electronics Department

Syringe pumps should be serviced annually according to organisational policy.


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12. SPECIALIST ADVICE

12.1 CONTACT NUMBERS FOR SPECIALIST PALLIATIVE CARE ADVICE

SITE CONTACT CONTACT NUMBER

St Andrews Hospice

Senior Nurse on duty (01472) 350908

Lindsey Lodge Hospice

Senior Nurse on duty (01724) 270835

Scunthorpe & Goole Hospitals

Macmillan Nurses – Palliative Care (01724) 387709

Diana Princess of Wales Hospital Macmillan Nurses – Palliative Care or

Macmillan End of Life Clinical Care

Co-ordinator

(01472) 874111 Ext 3596 or

(01472) 874111 Ext 3595 or via hospital switchboard

(01472) 250623

North East Lincolnshire

Care Plus Group

Macmillan Nurses – Palliative Care

East Riding Community Health

NHS Trust

Macmillan Nurse – Palliative Care

(Goole only)

(01405) 721314

North Lincolnshire Community

Macmillan Team

Macmillan Nurses – Palliative Care (01724) 871556


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CME Medical

13 REFERENCES

AUTHOR PUBLICATION

DATE

2011

Cooper, J. &

Mitten, T.

Danne et al

David, J

Dickman et al.

2000

2000

1992

2005

2006

TITLE

T34 Ambulatory Syringe pump. Device Use and Training

Resource

Continuous Subcutaneous Infusions

Chapter 3, P 56 In (Ed.) Cooper, J. Stepping Into Palliative

Care. A Handbook For Community Professionals. Radcliffe

Medical Press.

An Audit Of Subcutaneous Syringe Drivers In A Non-

Specialist Hospital

International Journal Of Palliative Nursing. 6, No. 5

A Survey Of The Use Of The Syringe Drivers In Marie Curie

Centres

European Journal Of Cancer Care. 4 P 23 - 28

The Syringe Driver – Continuous Subcutaneous Infusion In

Palliative Care

Oxford University Press

Duties of a Registered Doctor General

Medical

Council

Johnson, J. 1998

Macmillan et al 1994

The Syringe Driver

In (Ed.) Faull, C., Carter, Y., And Woof, R., Handbook Of

Palliative Care. Blackwell Science

A Prospective Comparison Study Between A Butterfly And

A Teflon Cannulae For Subcutaneous Narcotic

Administration

Journal Of Pain And Symptom Management. 9, P 82 - 84

Mitten, T. 2001

2008

Subcutaneous Drug Infusions: A Review Of Problems And

Solutions

International Journal Of Palliative Nursing. 17 No 2

Code of Professional Conduct Nursing &

Midwifery

Council

Nursing &

Midwifery

Council

Northern

Lincolnshire

And Goole

Hospitals NHS

Trust

2008

2006

Guidelines For The Administration Of Medicines

NMC

The Medicines Code

A Guide To The Use Of Medicines In Northern Lincolnshire

& Goole Hospitals NHS Trust


February 2013

29

Ross, J. R. 2002

A Prospective, Within Patient Comparisons Between

Butterfly Needs And Teflon Cannulae In Subcutaneous

Infusions Of Drugs To Terminally Ill Hospital Patients

Journal Of Pain And Symptom Management. 16, P 15 - 16

Trissel, L 2003

Handbook On Injectable Drugs

12 th Edition. American Society Of Health System

Pharmacists

Twycross, R. et al

2002

Symptom Management In Advanced Cancer

Twycross et al 2011

3rd Ed. Chapter 2, P 42. Radcliffe Medical Press

The Palliative Care Formulary 4 th Edition, Radcliffe

Medical Press

ORIGINAL AUTHORS

Bealey, Muriel

Chester, Janet

Dyer, Chris

Foster, Liz

Henry, Christine

Head of Adult Services, St Andrew’s Hospice, Grimsby

Macmillan Palliative Care Nurse Specialist, N. Lincs PCT

Senior Nurse, Lindsey Lodge Hospice, Scunthorpe

Macmillan Palliative Care Nurse Specialist, NE Lincs PCT

Macmillan Palliative Care Nurse Specialist, Scunthorpe Hospital

Maloney, Lindsay Macmillan Palliative Care Nurse Specialist, NE Lincs PCT

Morris, Ann Macmillan Lead GP, N. Lincs PCT & Medical Director, Lindsey Lodge

Hospice

Prucyck, Julie

Purser, Paul

Revill, Val

Rose, Ann

Macmillan Palliative Care Nurse Specialist, Scunthorpe Hospital

Macmillan Lead GP, NE. Lincs PCT & Medical Director, St Andrew’s Hospice

Macmillan Lead Nurse for Palliative Care, NE Lincs PCT

Clinical district Nurse Lead, N. Lincs PCT

Smith, Elaine Palliative Care Support Nurse, Scunthorpe Hospital

Staniforth, Rachel Pharmaceutical Advisor, NE Lincs PCT

Turner, Martyn

Walker, Helen

Chief Pharmacist, NL&G

Medicine Information Pharmacist, NL&G

Watson, Sally

Wilkinson, Su

Macmillan Palliative Care Nurse Specialist, NE Lincs PCT

Clinical Documentation Project Manager, NL&G


February 2013

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