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 Revill
Date issued: / 31/01/2013
Review date: / 28th February 2014
Contents
1. Scope 2
2. Glossary of terms 4
3. Aim 4
3.1 Client Group 4
3.2 Staff Group 4
4. Introduction 5
5. Indications for using the syringe pump 6
6. Medication 6
6.1 Combinations of more than one drug in a syringe pump 6
7. Drugs 8
7.1 Diamorphine 8
7.2 Oxycodone 9
7.3 Cyclizine 10
7.4 Metoclopramide 11
7.5 Haloperidol 12
7.6 Levomepromazine 13
7.7 Midazolam 14
7.8 Hyoscine Butylbromide 15
7.9 Hyoscine Hydrobromide 16
7.10 Glycopyrronium 17
7.11 Dexamethasone 18
7.12 Octreotide 19
7.13 Drugs not suitable for use in the syringe driver 20
8. The T34 McKinley Syringe Pump 21
8.1 Information for patients 21
8.2 Labelling of the syringe 21
8.3 Calibration of a syringe pump 21
8.4 Decontamination of syringe pump 22
8.5 Decontamination of holster bag 22
9. Standard Operating Procedure 24
10. Skin site selection and skin care 28
10.1 Sites suitable for subcutaneous infusion 28
10.2 Sites not suitable for subcutaneous infusion 28
10.3 Care of the skin site and checks 29
11. Trouble shooting 30
12. Specialist Palliative Care Advice 31
13. References 32
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.
· 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
2.
GLOSSARY OF TERMSAccountable / 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 / Lindsey Lodge Hospice
mg / Milligram
ml / Millilitre
mm / Millimetre
NEL / North East Lincolnshire
NELCCG / North East Lincolnshire Clinical Commissioning Group
NL / North Lincolnshire
NL&G / Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
NMC / Nursing and Midwifery Council
CPG / Care Plus Group
SAH / St Andrew’s Hospice
SGH / 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.
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.
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.
- 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.
7.1
Drug / Recommended Dose / CommentsDiamorphine
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 )
Example Two
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 ) / · 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.
· 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.
7.2
Drug / Recommended Dose / CommentsOXYCODONE
Available as: -
· 10mg/ml ampoules
· 50mg/ml ampoules / 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
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. / · 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
7.3