Palliative & End of Life Care Services N E Lincs · Usual anti-emetic dose 1.5mg –3mg / 24 hours...

Palliative & End of Life Care Services N E Lincs

12/06/20191

Palliative & End of Life Care Services N E Lincs 1Palliative & End of Life Care Services N E Lincs 1

Syringe Driver Training:McKinley T34 Pump

Palliative & End of Life Care Services N E Lincs 2

House Keeping

Fire alarm and toilet facilities

Willingness to participate

Embrace a supportive and safe learning environment

Confidentiality - discussions stay in the room

Non personal

Listen and respect

Mobile phones

Keep to time

Evaluation Form


Aims Of The Training

The registered nurses/practitioners' responsibility and accountability.

Indications for use Support of both patient and family Common drugs used in the syringe driver for palliative and end of

life patients Converting drugs from oral medication to the subcutaneous route Pre-operational inspection of the machine Demonstration of safe and effective preparation and management

of the syringe driver Knowledge of the appropriate policy for Procedure for the use of

the McKinley Syringe Pump in Palliative and End of Life Care


Professional Responsibility And Accountability

The Code (NMC,2015) sets out the core standards of conduct and practice expected of nurses and midwives, it is a positive tool to use that reflects contemporary nursing and midwifery practice and plays a key role in the revalidation process

• Prioritise people• Practice effectively• Preserve safety• Promote professionalism and trust

Be aware of other regulatory bodies


Preserve Safety

18. Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence....

19. Be aware of, and reduce as far as possible, any potential for harm associated with your practice….


Indications For Using The Syringe Driver

Unable to take oral medicationsSwallowing problemsUncontrolled nausea and/or vomiting Intestinal obstructionProfound weakness in last days of lifeMalabsorption

Contra-indications Pain which has not been controlled by oral analgesia Special care to be taken with very restless patients


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Sites That Should Not Be Used For Cannula Placements Are:

Lymphoedematous limbs Sites over a bony prominence Previously irradiated skin area Broken skin Sites near a joint Localised areas of disease Affected limb following lymph node

dissection


Subcutaneous Infusion Sites

Discuss with patient their preferred place to site infusion

Visually inspect at each time patient reviewed

AnteriorChest Wall

Anterior AspectOf Upper Arm

AnteriorAbdominalWall

Anterior AspectOf Thighs


Communication

Explain to the patient and relatives:

What a syringe driver is

How it works

Why the team have chosen to use it

Allow time for questions


Diamorphine

Indications for use: pain control & breathlessness

Caution in renal failure Used because of its high solubility: 1g dissolves

in 1.6mls of water No clinical advantage over Morphine No maximum dose No contra-indications if titrated carefully against

a patient's pain Onset of action 5-10 mins SC, duration of action

4hrs Use water or 0.9% sodium chloride as diluent


Converting Oral Morphine To Subcutaneous Diamorphine

Add together oral analgesia (Not PRN doses) in milligrams/24 hours

Divide total dose by 3

This is the required 24 hour dose of Diamorphine via subcutaneous infusion

Divide the total 24 hour dose of S/C Diamorphine by 6 to give the required dose of S/C breakthrough/prn medication

Holistic assessment of patient


Managing Diamorphine Shortage

As an alternative, prescribe Morphine Sulphate injection (10/15/20/30mg/ml)

Morphine Sulphate is compatible with the commonly used drugs in a syringe pump e.g. Haloperidol, Levomepromazine, Hyoscine Butylbromide, Metoclopramide, Glycopyrronium and Midazolam

Seek specialist advice re conversions etc.


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Oxycodone

Similar properties to Morphine, acts on different pain receptors.

Morphine is always the first drug of choice

Useful for patients who cannot tolerate Morphine. Appears to cause less sedation and vomiting than Morphine but more constipation.

Used for patients with renal impairment

Diluent Water for injection or 0.9% Sodium Chloride

Caution when mixing with subcutaneous Cyclizine


Converting Oxycodone

Oral Oxycodone to SC Oxycodone divide by 2

20mgs Oral Oxycodone = 10mgs s/c Oxycodone

Oral Morphine to Oral Oxycodone divide by 2

20mgs oral morphine = 10mgs oral oxycodone

Note: injection solution is called Oxycodone Hydrochloride solution for injection or OxyNorminjection


PRNs

Why given?

Dose?

Effective?

Duration?

Pattern?

Acute events?

Over the counter?

Holistic assessment!


Transdermal Fentanyl

Strong opioid licensed for severe chronic (persistent, long-term) pain

It is not licensed for uncontrolled or acute pain. Available in 12mcg, 25mcg, 50mcg, 75mcg and

100mcg in 72hrs Pain unrelieved by Morphine will not be

relieved by Fentanyl Steady-state plasma concentration generally

achieved by 36-48hrs, but sometimes only achieved after 9-12 days

Small percentage of patients require patch change every 2 days (Always seek specialist advice in this situation)


Transdermal Fentanyl

Indications for use Difficulty swallowing tablets/tablet

phobia/compliance Intolerable effects with Morphine e.g.

nausea/vomiting/hallucinations/constipation Renal impairment High risk of tablet misuse

The Fentanyl patch should continue to be changed as prescribed and will control the background/chronic pain


Transdermal Fentanyl Chart4 hourly oral Morphine (mg) Transdermal Fentanyl Patch

Strength (mcg/hr)24 Hourly Oral Morphine (mg)

<20 25 <135

25 – 35 50 135 – 224

40 – 50 75 225 – 314

55 – 65 100 315 – 404

70 – 80 125 405 – 494

85 – 95 150 495 – 584

100 – 110 175 585 – 674

115 – 125 200 675 – 764

130 – 140 225 765 – 854

145 – 155 250 855 – 944

160 – 170 275 945 - 1034

175 – 185 300 1035 - 1124


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Haloperidol

Potent D2 antagonist anti-emetic

Used for opiate/chemical induced nausea and vomiting

Usual anti-emetic dose 1.5mg – 3mg / 24 hours

Usual PRN dose 0.5mg – 1.5mg S/C

Onset of action S/C 10-15mins, plasma half life 12-38hrs, duration of action ≥24hrs

Usually no more than 5mg daily

Incompatible with Saline 0.9%

Use Water for Injection as diluentPalliative & End of Life Care Services N E Lincs 20

HaloperidolCont:

Used for delirium which is characterised by cognitive impairment (hallucinations, aggression, plucking, increased or decreased psychomotor activity)

Hypoactive delirium Hyperactive delirium

Use in higher doses for sedative or antipsychotic action e.g 10mg / 24 hours


Metoclopramide

D2 antagonist anti-emetic Pro-kinetic (speeds up gastric motility) Early satiety 30mg – 60mg S/C over 24 hours

DO NOT USE IF COMPLETE INTESTINAL OBSTRUCTION IS SUSPECTED

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


Levomepromazine

Broad spectrum anti-emetic Anti-emetic dose 6.25mg – 12.5mg/24 hours Powerful sedative at higher doses – useful for

very agitated patients Sedative effect 12.5mg – 25mg/24 hours Onset of action 30mins, plasma half life 15-

30hrs, duration of action 12-24hrs Use 0.9% Sodium Chloride as diluent, WFI can be

used in combination with other drugs Can sometimes cause local skin reaction


Midazolam

Restlessness, terminal agitation and seizures

Can be very sedating

Consider reversible causes

Onset of action 5-10mins, plasma half life 1-4hrs

2.5mg-5mg S/C PRN

5mg – 10mg/24 hours

Usual maximum dose 30mg/24 hours – if symptoms persist seek specialist advice


Glycopyrronium

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

Onset of action 30-40mins, plasma half life 1-1.5hrs, duration of action 7hrs

200 mcg S/C 800 mcg – 1200 mcg / 24 hours


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Hyoscine Butlybromide(Buscopan)

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

Reduces bronchial secretions Also used to treat large volume vomiting caused

by bowel obstruction For colic 60mg – 120mg/24 hours For respiratory secretions 20mg-60mg/24hrs Onset of action 10mins, plasma half life 5-10hrs,

duration of action 2hrs Don’t confuse with Hyoscine Hydrobromide!


Mixing Drugs

Ensure correct diluent prescribed and used

Ensure drug compatibility (seek specialist advice if unsure)

Compatibility dependent upon dosages/concentrations


Case Studies


Case Study 1:

• Female, 68• Metastatic pancreatic cancer• Currently taking Zomorph 30mg BD and Oramorph 10mg as

required• Had 3 doses Oramorph yesterday and one the previous day

None today • Has vomited once today. Vomited 3 times yesterday and

twice the previous day• Is complaining of pain• Feels nauseous

• What would your assessment and plan be?


Case Study 2:

• Male, 72• Lung cancer with bone metastases to spine and left hip• Lying flat in bed with one pillow• Unable to communicate own needs• Been on syringe driver for 3 days with Oxycodone

30mg/24hrs• Has required 3x 5mg oxycodone s/c in last 24 hours for

breakthrough pain with good effect- settled on your arrival• Has retained bronchial secretions today. Family extremely

distressed by the noise

• What would your assessment and plan be?



12/06/20196


Equipment

Luer lock syringe (20mls or 30mls)McKinley T34 Syringe driver 9V alkaline Duracell type batterySaf-T-intima subcut cannulaCodan extension line Transparent dressingPatient’s drug sheetDrugsDiluent


Equipment Cont:

Syringe Driver box and key

Drug additive label

Syringe driver checklist

Alcohol swabs

Sharps disposal bin

Gloves

Apron


SAF-T-INTIMA


Setting Up McKinley T34

Pump Start up sequence

Check the pump over

Check that the device is clean, visually intact and appropriate for use

Palliative & End of Life Care Services N E Lincs 35 Palliative & End of Life Care Services N E Lincs 36

Using The T34

Syringe – Default syringes:Braun OmnifixBD Plastipak, Monoject, Codan/Once Terumo

Draw up medication as prescribed : Use Luer Lock only

20ml syringe- fill to 17mls30ml syringe- fill to 22mls Label syringePrime line


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Keep lever arm down Switch on Check battery power Observe Pre loading: observe movement of actuator Use ff and back keys to line up syringe Load syringe

Follow the display screen: 20ml braun omnifix - confirm by pressing YES

Volume duration rate - confirm by pressing YES

Lock in lock box Attach to the patient Start infusion - confirm by pressing YES

Check running by ……<<pump delivering, rate and time


Keypad Lock:

Prevents powering off of the unit Protects from tamperingPut key pad lock on by pressing the

blue “I “ button – hold down for a few seconds until fully locked

Check key pad locked byPressing any grey key

Complete documentation


Programming, Protection and “Resume/New Syringe”

• If the user presses “YES to Resume” – the current programme is resumed (fixed rate). If the syringe volume has changed, the duration of delivery will change accordingly to account for the syringe volume

• If the user presses “NO for New Syringe” the current programme is immediately deleted. A new programme (ml/hour rate) will be calculated based on the current syringe volume

Press YES to ResumeNO for New Syringe


Close down the machine:

Press blue Info key until bleeps to unlock key padPress red STOP button – wait until the light goes

offLong press on the “OFF” buttonDisconnect from patientRemove syringe from pump and lower barrel

clamp armDispose of syringe/line, clean and store pump

according to local policy


Alerts and Alarms•ALERT ACTIVATION - When an alert activates:

• The infusion continues• Three beeps are heard approximately every three/four minutes• A screen message alternates with the infusion running screen

The alert activates approximately 15-30 minutes prior to an alarm state

ALARM ACTIVATION - When an alarm activates:• The infusion stops• The LED indicator light turns from green to red • The alarm sound continuously• An error message appears on the LCD display screen indicating the

alarm causeThe alarm continues until the START/YES key is pressed (to

mute the alarm) or the problem is rectified


Alerts and Alarms

Screen Info Type Cause

Low BatteryAlert Battery is almost depleted

Program nearly complete Alert Syringe is almost empty


12/06/20198


Alerts and Alarms


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Palliative & End of Life Care Services N E Lincs · Usual anti-emetic dose 1.5mg –3mg / 24 hours...

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