MOUNT VERNON CANCER NETWORK Collaborative working Party McKinley T34 Syringe Pump Training Pack

1. MOUNT VERNON CANCER NETWORK Collaborative working Party McKinley T34 Syringe Pump Training Pack (for nurses new to their trust or to syringe pumps) November 2012

2. Aims • To provide nurses new to their trust or to syringe pumps to develop knowledge and skills to safely commence, monitor and discontinue syringe pumps • For nurses to understand the rationale for commonly used drugs, doses, compatabilities

3. Objectives At the end of this session, the learner should be able to: 1. Give 3 examples of when the use of a syringe pump should be considered. 2. Identify the 5 infusion sites that can be used for the syringe pump. 3. List the equipment necessary in order to start a CSCI. 4. Demonstrate how to use a syringe pump. 5. List 8 reasons for the pump not working and how to resolve 6. Identify the local proceed for maintenance, cleaning and storage 7. List 6 common different drugs, their rationale and dosages, used within a syringe pump

4. What are the indications for the use of the syringe pump? Where a patient is unable to take oral medication due to: • Dysphagia • Nausea and vomiting • Malabsorption • Rectal route may be inappropriate • Semiconscious or unconscious • Intractable vomiting

5. Why subcutaneous? • Continuous subcutaneous infusion (CSI) is a method of symptom control that can provide relief of multiple symptoms via one route. • It offers the following benefits: • • The variation in plasma concentration levels between injections is avoided. • • There is no need for four hourly injections they are unpleasant (particularly for a cachetic and dehydrated patient) and are time consuming for nurses and doctors alike. • Mixtures of drugs may be administered. • • Patient mobility and independence is maintained.

6. Infusion sites Anterior Chest Wall Scapula Region Anterior Aspect of Upper Arms Anterior Abdominal Wall Anterior Aspect of Thighs • Check preferred method of wearing pump before selecting infusion site. • Avoid upper arm site in bed-bound patients who require regular turning. • Check site regularly.

7. T34 Features and Functions • Lock On • Clinical Support October 2011

8. 1. Feature Recognition: Front

9. 1. Feature Recognition: Top and Back Driving screw Plunger sensor Collar sensor Barrel clamp arm sensor Actuator Pump info/symbols BodyComm Communications connection Battery Fitting

11. T34-Battery fitting and Testing • 9 volt alkaline or lithium battery only. • Variation in size between different brands (do not force into compartment) • Battery Test • Switch the pump on • Press INFO key • Select battery life using ↓↑ keys, press YES • Verify sufficient battery power for programme. • Replace battery as per local policy

12. Enter Set Up Code 0 Change ↑↓, Press YES

13. 4. Info Menu Info Menu => Battery Level Select ↑↓, Press YES

15. 2 to 50ml syringes • Syringe Max. Volume (approx) • 20ml syringe = 18 volume • 30ml syringe = 24ml volume • 50m syringe = 35ml volume

16. Anti-siphon & free-flow valve/priming volume/colour coding Clear Blue stripe cannula

17. 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

19. Check the pump Insert battery Power on Observe Pre-Loading Check battery level Load syringe Confirm syringe Programming Start infusion The number of screens that display will depend on local policy and: • The mode of operation • Enabled features • Prime/load or load/prime sequences • Option to select for “Press YES Resume, • NO for New Program/ Syringe” screen prompt • following purge

20. 9. Pump Start up sequence • Check the pump • Check that the device is clean, visually intact and appropriate for the • intended use • b) Insert battery

21. c) Power on d) Observe Pre-Loading T34 NCAT xxxx ID: Syringe Pump

22. e) Check battery level Load Syringe Info Menu => Battery Level Select ↑↓, Press YES Battery Level 90% Empty Full Load Syringe

23. f) Load syringe: • Align syringe • Adjust actuator if required • Lift the barrel clamp arm • Insert syringe • Lower the barrel clamp arm BD Plastipak Load Syringe BD Plastipak Check Syringe Loaded Correctly

24. g) Confirm syringe BD Plastipak 20ml BD Plastipak Select ↑↓, Press YES

25. Trapped Object from Actuator Remember to keep objects/fingers away from the actuator when it is moving automatically or when manually adjusting.

26. Lock ON (Prime / Load) Volume 12.0ml Duration 24:00 Rate 0.50ml/h Confirm, Press YES • h) Programming • i) Start infusion Start Infusion? Time Remaining 23:59 Rate 0.5 ml/hr 20ml BD Plastipak (<<< Pump Delivering)

27. 10. Recommended Safety Checks During Infusion Battery Level 90% Empty Full Infusion Summary VTBI 11.7 VI 0.3

28. 11. Lockbox and Keypad lock • Lockbox and keypad use are mandatory • NOTE: If using an alternate brand of administration (other than a CME set) and with certain 30ml syringe brands, these may prevent the lockbox from fully closing and locking. Lock Mode On Off

29. Lock Mode On Off

30. WARNING ! • When changing infusion • switch the pump OFF. • This screen will appear if • the battery goes flat and is • replaced without the syringe being • removed or if the syringe contents • are changed and the pump is not • switched off [but just stopped]. • ‘NO for new program’ always • defaults to 24hrs. ‘Yes to resume’ • protects the prescription i.e. it • continues at the same rate [volume • and time may change].

31. Monitoring of syringe pumps • Review cannula entry site regularly according to local policy • Check contents of syringe and line for any abnormality • Record details in the relevant documentation.

32. Inspection and Maintenance • Inspect Box contents • Damage • Missing items • Cleaning – as per local guidelines • In case of malfunction make a written note of: - • pump serial number (see back of unit) • circumstances (as detailed as possible) • screen messages/error codes (press info key to obtain) and note • withdraw pump from use and return to authorised service engineers for inspection

33. 13. Alerts and Alarms

34. 14. Alerts and Alarms

35. Event No: 2635 22:10:2010 16:30 Stop Infusion Press INFO- details VI 1.03ml VTBI 14.35ml Rate 0.64ml/h 30ml BD Plastipak Travel 2.73mm/ml IN (0mmHg) =18mA 28N (540mmHg) = 83mA Motor Current 0 mA Occlusion 720mmHg Battery 7.8V Info Menu Event Log Select ↓↑, Press YES

36. 16. Close down • Stop infusion • Disconnect/clamp line from patient • Power off • Remove syringe from pump and lower barrel clamp arm • Dispose of syringe/line, clean and store pump according to local policy

38. Quiz time • Device competency sign off

39. Tea time

40. Drugs What drugs are used in syringe pumps?

41. Diamorphine • Indications: - Pain - Dyspnoea -Remains Drug of choice -Conversion from Oral Morphine is 1/3 of 24 hour oral morphine dose i.e. 60mg Oral Morphine = 20mg s/c Diamorphine -P.R.N Dose = 1/6 of total 24 hour infusion dose

42. Oxycodone • Indications: - Pain - Dyspnoea - Good alternative if Diamorphine unavailable - Patient may be already taking orally? - Conversion: Oral oxycodone to s/c Oxycodone = ½ of 24hr oral dose e.g. 30mg Oxycodone bd dose (total 60mg) = 30mg Oxycodone s/c over 24hrs Diamorphine to Oxycodone s/c is equal - P.R.N. Dose: 1/6 of total 24hr dose e.g. 60mg Oxycodone total 24hr dose = 10mg for breakthrough

43. Fentanyl Patch • Indications: - Pain - Dypsnoea - Use s/c doses as required 4 hourly over 24hr period – equivalent dose of diamorphine may be given via syringe driver in addition to Fentanyl patch. - 4 hourly dose of diamorphine s/c = Fentanyl Patch ÷ 5 e.g. Fentanyl 100mg ÷ 5 = 20mg Diamorphine s/c 4 hourly break through pain dose.

44. Morphine • Indication: - Pain - Dyspnoea - Used when Diamorphine unavailable - Conversion: Oral morphine to s/c morphine ½ of oral dose: e.g. 24hour Oral Morphine dose 60mg = 24 hour s/c morphine dose 30mg over 24 hours - Revert all medications back to oral morphine to work out doses

45. Cyclizine • Indications: - Nausea and vomiting associated motion sickness. - Intestinal obstruction - Raised intra-cranial pressure - Start Dose: usual 100mg – 150mg over 24 hours - P.R.N Dose: 50mg s/c 8 hourly - Side Effects: skin reaction, dry mouth, drowsiness

46. Haloperidol • Indications: - Nausea and vomiting – drug induced - Psychotic symptoms - Metabolic causes of nausea - Start Dose: 3mg – 5mg over 24 hours in syringe driver - P.R.N. Dose: 1.5mg – 3mg s/c 8 hourly

47. Levomepromazine (Nozinan) • Indications: - Nausea and Vomiting (covers most receptors) - Terminal Agitation - Start Dose: for Nausea/Vomiting: 6.25mg – 25mg for Terminal Agitation: 25mg – 150mg - P.R.N. Dose: 6.25mg – 12.5mg 4-6 hourly

48. Midazolam • Indications: - Terminal Agitation - Multi – focal myoclonus - Start Dose: 10mg – 60mg via Syringe Driver over 24 hours - P.R.N. Dose: 2.5mg – 5mg s/c 4 hourly

49. Hyoscine Hydrobromide • Indications: - Increased noisy secretions - Colic - Start Dose: 1.2mg – 2.4mg via Syringe Driver over 24 hours - P.R.N. Dose: 0.4mg – 0.6mg 4-6 hourly - Can cause sedation and will dry all secretions

50. Octreotide • Indications: - Intestinal obstruction associated with vomiting - Intractable Diarrhoea -fistulae - Start Dose: 300mg -600mg over 24 hours via Syringe Driver - P.R.N. Dose: 50 – 100mg 8 hourly