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
Palliative & End of Life Care Services N E Lincs 3
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
Palliative & End of Life Care Services N E Lincs 4
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
Palliative & End of Life Care Services N E Lincs 5
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….
Palliative & End of Life Care Services N E Lincs 6
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
Palliative & End of Life Care Services N E Lincs
12/06/20192
Palliative & End of Life Care Services N E Lincs 7
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
Palliative & End of Life Care Services N E Lincs 8
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
Palliative & End of Life Care Services N E Lincs 9
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
Palliative & End of Life Care Services N E Lincs 10
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
Palliative & End of Life Care Services N E Lincs 11
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
Palliative & End of Life Care Services N E Lincs 12
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.
Palliative & End of Life Care Services N E Lincs
12/06/20193
Palliative & End of Life Care Services N E Lincs 13
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
Palliative & End of Life Care Services N E Lincs 14
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
Palliative & End of Life Care Services N E Lincs 15
PRNs
Why given?
Dose?
Effective?
Duration?
Pattern?
Acute events?
Over the counter?
Holistic assessment!
Palliative & End of Life Care Services N E Lincs 16
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)
Palliative & End of Life Care Services N E Lincs 17
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
Palliative & End of Life Care Services N E Lincs 18
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
Palliative & End of Life Care Services N E Lincs
12/06/20194
Palliative & End of Life Care Services N E Lincs 19
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
Palliative & End of Life Care Services N E Lincs 21
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
Palliative & End of Life Care Services N E Lincs 22
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
Palliative & End of Life Care Services N E Lincs 23
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
Palliative & End of Life Care Services N E Lincs 24
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
Palliative & End of Life Care Services N E Lincs
12/06/20195
Palliative & End of Life Care Services N E Lincs 25
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!
Palliative & End of Life Care Services N E Lincs 26
Mixing Drugs
Ensure correct diluent prescribed and used
Ensure drug compatibility (seek specialist advice if unsure)
Compatibility dependent upon dosages/concentrations
Palliative & End of Life Care Services N E Lincs 27
Case Studies
Palliative & End of Life Care Services N E Lincs 28
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?
Palliative & End of Life Care Services N E Lincs 29
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?
Palliative & End of Life Care Services N E Lincs 30
Palliative & End of Life Care Services N E Lincs
12/06/20196
Palliative & End of Life Care Services N E Lincs 31
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
Palliative & End of Life Care Services N E Lincs 32
Equipment Cont:
Syringe Driver box and key
Drug additive label
Syringe driver checklist
Alcohol swabs
Sharps disposal bin
Gloves
Apron
Palliative & End of Life Care Services N E Lincs 33
SAF-T-INTIMA
Palliative & End of Life Care Services N E Lincs 34
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
Palliative & End of Life Care Services N E Lincs
12/06/20197
Palliative & End of Life Care Services N E Lincs 37
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
Palliative & End of Life Care Services N E Lincs 38
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
Palliative & End of Life Care Services N E Lincs 39
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
Palliative & End of Life Care Services N E Lincs 40
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
Palliative & End of Life Care Services N E Lincs 41
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
Palliative & End of Life Care Services N E Lincs 42
Alerts and Alarms
Screen Info Type Cause
Low BatteryAlert Battery is almost depleted
Program nearly complete Alert Syringe is almost empty
Palliative & End of Life Care Services N E Lincs
12/06/20198
Palliative & End of Life Care Services N E Lincs 43
Alerts and Alarms
Palliative & End of Life Care Services N E Lincs 44