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Subcutaneous Medication Administration in Palliative Care

Subcutaneous Medication Administration in Palliative Care. Amy Mohler, MD Hospice and Palliative Care of Western Colorado. Historically. 1914 First published report of subcutaneous fluids (hypodermoclysis) given to pediatric patients 1970s

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Subcutaneous Medication Administration in Palliative Care

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  1. Subcutaneous Medication Administration in Palliative Care Amy Mohler, MD Hospice and Palliative Care of Western Colorado

  2. Historically • 1914 • First published report of subcutaneous fluids (hypodermoclysis) given to pediatric patients • 1970s • Palliative care physicians in the United Kingdom began using continuous subcutaneous infusions (CSI) for pain management

  3. Indications for CSI • Pain Management • Nausea and vomiting • Terminal restlessness • Diuresis • Secretions • Seizures • Hydration

  4. Evidence • Randomized trial comparing 3 methods of postoperative analgesia in gynecology patients: patient-controlled intravenous, scheduled intravenous, and scheduled subcutaneous. AmJofOB&Gyn: Nov. 2007:472.e1-472.37

  5. Evidence • 130 pts undergoing “major transabdominal gynecologic operation” • Randomized to • PCA • IV • SQ • Primary Endpoint • Patient self assessment of pain at 12, 24 and 48hrs • Secondary Endpoint • Patient satisfaction

  6. Evidence • No statistically significant difference among the groups. • Median pain scores for the IV and SQ groups were equal at all time points.

  7. Hours since arrival on nursing unit

  8. Patient Selection • Inability to give oral medications • Dysphagia/inability to swallow • Nausea/vomiting • Intestinal obstruction

  9. Why CSI and not IV? • CSI pros • Ease of placement • Less painful • Lower site infections • Cost effective • Pharmacokinetic equivalency to IV • Low infusion volumes

  10. Why CSI and not IV? • CSI cons • Equipment acquisition • Nursing education • Pharmacy education

  11. Why CSI and not IV? • Contraindications • Broken skin • Cellulitis • ?Severe bleeding d/o • ?Anasarca

  12. Pain Management Morphine, Hydromorphone Nausea and vomiting Haloperidol, Dexamethasone Terminal restlessness Haloperidol, Lorazepam Diuresis Furosemide Secretions Glycopyrrolate Seizures Lorazepam, Midazolam Hydration 0.9%NS Which drugs are appropriate?

  13. What dose • SQ = IV

  14. CSI 3ml/hr Hypodermoclysis 500ml boluses 55ml/hr Can have more than one site Infusion rate

  15. CSI site placement

  16. Risks • Fluid overload • Site infection

  17. Case Study • 68yo woman with metastatic breast cancer • Pain well controlled on MSContin 60mg po q12h • Declining and no longer able to take po meds • Team feels she a candidate for a SQ infusion

  18. Case Study • 120mg qD of po morphine ÷ 3 to convert to SQ morphine 40mg qD ÷ 24 to get hourly rate 1.7mg/hr continuous rate of SQ morphine

  19. Benefits of CSI for St. Mary’s Patients • Timely symptom management • Any patient • Comfort • Seamless admission and discharge process • Standard of care in Palliative Medicine • Cost effective

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