Subcutaneous Medicine in Palliative Care Flashcards
what are Indications for Subcutaneous Route
- When oral route is not possible due to
• persistent nausea and vomiting
• dysphagia
• gastro-intestinal obstruction
• severe weakness/unconsciousness - Poor absorption by oral route (uncommon)
- When patients would otherwise require regular injections
do Syringe pumps deliver a better analgesic effect than the oral route
not unless there is a problem with absorption or administration
what are sites available
- Anterior aspect of the upper arms or anterior abdominal wall
- Anterior aspect of the thigh
- The scapula if the patient is distressed and/or agitated
- Anterior chest wall
what are Factors affecting stability of the drug
- Diluent
- Other drugs
- Temperature
- Time
- Concentration of final product
- pH
- Light
what are outcomes of drug instability
Degradation of one chemical molecule to another (Degradation is often invisible and not always instantaneous)
Potential loss of effect and production of toxic by-products
Precipitation may block lines, irritate tissue and cause treatment failure
what must be considered when giving drugs through sub cut syringe pumps
Combinations outwith those listed in the SC Guidelines (blue booklet) should be used only on the recommendation of a palliative care specialist.
Use 2 pumps if necessary (or consider alternative routes)
Solutions should be freshly prepared and used within 24 hours
Visual inspection before and during infusion essential, especially when high dose diamorphine combined with other drugs
Change in dose prescribed - do not adjust rate, but destroy the remainder of the solution in syringe, and start again
Calculations - independent check
Documentation
Luer lok syringes (BD Plastipak only)
Subcutaneous infusion sets- Saf-T-Intima and McKinley extension line
Clean technique
what can cause Irritation of tissues around the infusion site
¥ Patient to patient variation
¥ Chemical nature of the drug/pH of the formula
¥ Concentration of the drug and tonicity of the solution
¥ Infection
¥ Needle/cannula
what are the groups of drugs that can be given though sub cut pump
Painkillers (analgesics) Anti-sickness Medicines Sedation/Anxiety Excessive respiratory secretions Difficulty in breathing (dyspnoea)
explain giving analgesic subcut
e.g. morphine/diamorphine which are strong opioids
Similar in structure to our own endorphins
No maximum ceiling dose as long as the patient tolerates the medicine
Dose is individualised to patient
Alternatives available if patient unable to tolerate morphine/diamorphine e.g. oxycodone, alfentanil, hydromorphone
explain giving anti-emetics subcut
Lots of different choices available e.g. metoclopramide, cyclizine, haloperidol, levomepromazine
Attempt to pick medicine according to likely cause of nausea/vomiting e.g. metoclopramide for gastric stasis (60mg over 24 hours by SC infusion and 10mg SC as required)
explain giving sedation/anxiety medication subcut
Usually midazolam (benzodiazepine) at a dose of e.g. 10mg over 24 hours by SC infusion and 2mg SC as required Cause drowsiness and relax the patient thereby reducing anxiety, also relax muscles
explain giving medications for Excessive respiratory secretions subcut
Can happen at the end of life when patients become confined to bed
Use anti-muscarinic medicines e.g. hyoscine butylbromide 60mg over 24 hours and 20mg SC as required to try to dry up the secretions
Non-pharmacological interventions just as important e.g. patient position and family re-assurance
explain giving medications for difficulty breathing subcut
Patients can feel that they are suffocating-anxiety can play a role
Opioids such as morphine/diamorphine can reduce the respiratory rate
Midazolam may also be helpful if anxiety is present
