House Keeping Syringe Driver Training: McKinley T34 Pump Fire - - PDF document

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Syringe Driver Training: McKinley T34 Pump

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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

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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

• f 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

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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

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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….

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Indications For Using The Syringe Driver

Unable to take oral medications Swallowing problems Uncontrolled nausea and/or vomiting Intestinal obstruction Profound weakness in last days of life Malabsorption 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

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Subcutaneous Infusion Sites

 Discuss with patient their preferred

place to site infusion  Visually inspect at each time patient reviewed

Anterior Chest Wall Anterior Aspect Of Upper Arm Anterior Abdominal Wall Anterior Aspect Of Thighs

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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

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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

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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

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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

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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 OxyNorm injection

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PRNs

 Why given?  Dose?  Effective?  Duration?  Pattern?  Acute events?  Over the counter?  Holistic assessment!

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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)

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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

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Transdermal Fentanyl Chart

4 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 diluent

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Haloperidol

Cont:

 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

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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

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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

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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

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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!

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Mixing Drugs

 Ensure correct diluent prescribed and used  Ensure drug compatibility (seek specialist advice if unsure)  Compatibility dependent upon dosages/concentrations

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Case Studies

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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?

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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?

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Equipment

Luer lock syringe (20mls or 30mls) McKinley T34 Syringe driver 9V alkaline Duracell type battery Saf-T-intima subcut cannula Codan extension line Transparent dressing Patient’s drug sheet Drugs Diluent

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Equipment

Cont:

 Syringe Driver box and key Drug additive label Syringe driver checklist Alcohol swabs Sharps disposal bin Gloves Apron

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SAF-T-INTIMA

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Setting Up McKinley T34

Pump Start up sequence Check the pump over Check that the device is clean, visually intact and appropriate for use

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Using The T34

Syringe – Default syringes: Braun Omnifix BD Plastipak, Monoject, Codan/Once Terumo Draw up medication as prescribed : Use Luer Lock

• nly

20ml syringe- fill to 17mls 30ml syringe- fill to 22mls Label syringe Prime 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

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Keypad Lock:

 Prevents powering off of the unit  Protects from tampering Put key pad lock on by pressing the blue “I “ button – hold down for a few seconds until fully locked  Check key pad locked by Pressing any grey key  Complete documentation

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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 Resume NO for New Syringe

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Close down the machine:

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

• ff

Long press on the “OFF” button Disconnect from patient Remove syringe from pump and lower barrel clamp arm Dispose of syringe/line, clean and store pump according to local policy

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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 cause The alarm continues until the START/YES key is pressed (to mute the alarm) or the problem is rectified

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Alerts and Alarms

Screen Info Type Cause Low Battery Alert Battery is almost depleted Program nearly complete Alert Syringe is almost empty

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Alerts and Alarms

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