Guidelines for the Use of the MS16A Syringe Driver - Palliative Care ...

Guidelines for the Use of the MS16A SyringeDriverThese are Guidelines only – you have a professionalresponsibility to be trained and competent to use theMS16A Syringe Driver, and to appropriately assessand review the clinical needs of the patientAuthor:Nicky Ryan, Palliative Care Team; Marion Khan,Practice Development TeamDate of issue: March 2008Version: 1Owner:Palliative Care TeamPublisher:Ms Nichola Greenwood, Medical Governance ManagerReview date: March 2009

Guidelines for the Use of the MS16A Syringe DriverContentsPage1 The MS16A Syringe Driver anddelivery of subcutaneous medication:Indications for UseAdvantages of UseContraindications to Use 32 Guidelines for Insertion ofYellow Side-Ported Saf-T-IntimaCannula 4Table 1: Guidelines for insertion of theSaf-t-Intima Cannula 43 The Graseby MS16A syringe driver 63.1 Measuring and setting the rate of theMS16A syringe driver 6Figure 1: Measurement of millimetre(mm) fluid volume in luer lock syringe 63.2 Calculating rate of infusion of thesyringe driver 7Figure 2: The MS 16A Syringe Driver 73.3 Setting up of the syringe driver 73.4 Risk assessment 103.5 Using two syringe drivers 103.6 Changing prescription and medication 113.7 Changing insertion sites, lines andcannula 113.8 Care and monitoring of patients 123.9 Checking the syringe driver 123.10 Problem solving the syringe driver 123.11 Discontinuing the syringe driver 134 Documentation and record keeping 135 Complications 146 Other Related Issues 157 References 15Appendix 1: Risk Assessment 172

1. The MS16A Syringe Driver and delivery of subcutaneousmedication:Indications for useFor control of symptoms:- Pain- Nausea and vomiting- Restlessness- Increased secretions- Pain unrelieved by oralmedication orintermittent injectionPatients unable to swallow orabsorb oral medication:- Intractable nausea andvomiting- Gastro-intestinalobstruction/malabsorption- Mouth, throat, oesophageallesions- Profoundweakness/unconsciousnessAdvantages of use- Constant plasma drug levels resulting in increased comfortand confidence- Absorption of drugs more reliable- Change only every 24 hours- More effective assessment of symptom control.Contraindications to use- Infection and broken skin at infusion sites- Patients with clotting disorders because of risk of bleeding atthe infusion site- Patients who have poor tissue perfusion- Peripheral vascular disease of lower extremities- Pre-existing oedema.(Ferry et al 1999, Sasson and Shvartzman 2001, Jackson 2004)3

2. Guidelines for Insertion of Yellow Side-PortedSaf-T-Intima CannulaIt is essential with any procedure, invasive or not, to discussfully with patients the intervention required and obtain theirinformed consent to continue. Before commencement ofsubcutaneous therapy, the nurse must ensure that he or sheis confident that the prescription and prescribed therapy aresuitable for this route. No nurse must undertake anyprocedure or practice for which he or she has not receivedadequate training and assessment of competence (Nursingand Midwifery Council (NMC) 2004). Guidelines for insertionare outlined in Table 1.Table 1. Guidelines for insertion of the Saf-t-Intima CannulaActionExplain procedure to patient and obtaininformed verbal consent (if possible).Consider site selection, involving patientin decision if possible.Wash hands and wear clean gloves.Clean selected insertion site with topicalcleaning agent and allow to dry.Remove white stopper from side armand prime line with infusion syringe.Attach bionector.Grasp “pebbled” side of the cannulawings, pinching wings firmly together.This locks the needle and prevents isfrom retracting during insertionEnsure the needle is bevel-sideuppermost. If the bevel-side is notuppermost, open the wings and gentlytwist the white shield until the needle iscorrectly positionedGently pinch the skin into a fold. Inpatients with greater adipose tissue, itmay be necessary to keep the skin flatto ensure the needle is inserted into theRationaleTo ensure patient aware of, and consentsto, proposed procedure.To select the appropriate infusion siteand encourage patient concordance andtolerance.To minimise risk of infection.To ensure pre-insertion skin disinfection.To remove air from line to reduce the riskof air embolism. Ensure medications aredelivered as soon as the syringe driverstarts.To ensure effective insertion of needleinto subcutaneous tissueTo guide the needle through the tissueand reduce patient discomfort.To lift the subcutaneous layer away fromthe muscle layer4

subcutaneous layer.Insert the needle subcutaneously at anangle of approximately 45 degrees.Open the wings (pebbled side down) flatagainst the skinThere must be no evidence of bloodpresent in the giving set or cannula oninsertion or during treatment.To ensure the secure entry of the needleinto the subcutaneous tissue.To ensure correct positioning of thecannulaThis indicates a capillary has beenpunctured. The device should beremoved and resited.Apply firm finger-tip pressure over thewings of the cannula (avoiding thecentre where the needle retracts) andsimultaneously grasp the pebbled endof the white shield and pull in a straightcontinuous motion until the needle hasfully withdrawn into the colouredcylinder and pops offGently remove the coloured cylinderfrom the cannula port, if it has notreleased spontaneously, exposing theadapter with the rubber bungPlace any resultant sharps in sharpsbin.Remove rubber bung and connectVygon infusion set, open clampApply IV 3000 over insertion site.Adjust medication delivery rate asprescribed.Complete necessary nursingdocumentation and line labels detailingdate/time of insertion; insertion site anddevice used. Complete and sign DrugChart.To remove the insertion needle andactivate the safety mechanism.To ensure safety needle mechanism asworked effectively.To reduce the risk of needlestick injury.To maintain closed circuitTo ensure secure fixation, allow for siteobservation and moisture vapourpermeability.To ensure timely and effective delivery ofprescription.Good record keeping helps protect thewelfare of the patient, promotes bettercommunication and ensures thedissemination of information betweenhealth professionals.(Dawkins and Pugh 2003, RCN 2005)5

3. The Graseby MS16A syringe driver (Figure 2)3.1 Measuring and setting the rate of the MS16A syringe driver(Figure 1)The total fluid to be infused should be measured in millimetres (mm)and the rate set in millimetres per hour (mm/hr) for the MS16A (blue).The MS16A (blue) Graseby syringe driver will deliver 48mm of fluidover 24hrs at a rate of 2mm per hour. The length of 48mm is used tocalculate the rate per hour setting, i.e. 2mm/hr x 24hrs= 48mmThe length of liquid in the syringe is measured using the mm scale onthe side of the machine. If the length of liquid in the syringe is 48mm,it will be delivered over 24hrs at a rate of 2mm per hour (Figure 4).Different brands of syringes give different total volumes of fluid whenmeasured at 48mm. This is why the volume in syringes is measuredin mm to ensure the prescribed medication delivery over 24hrs.Within the Trust, BD Plastipak luer lock syringes must be used for10ml and 20ml syringes, and Terumo luer lock syringes for 30mls.Figure 1: Measurement of millimetre (mm) fluid volume in luerlock syringeIf the total volume of required fluid becomes greater than 48mm inlength in the 10ml syringe then change the fluid to a 20ml syringe,and measure the 20ml syringe length to 48mm adding in extradiluent as needed to bring the volume up to 48mm. 30ml syringescan also be used, but care must be taken to ensure that thesyringe in this case is the Terumo due to the barrel width of thesyringe. The rate remains set at 2mm/hr for MS16A (blue).6

3.2 Calculating rate of infusion of the syringe driverIn the MS16A (blue) syringe driver, the following rates of infusionapply:48mm set at 2mm runs for 24hrs48mm set at 4mm runs for 12hrsFigure 2: The MS 16A Syringe Driver3.3 Setting up of the syringe driverAction• Check service date of syringedriver• Check driver and plastictransparent cover is cleanedusing a detergent wipe beforeuseRationale• To ensure syringe driver is inworking order and safe touse• To reduce risk of crosscontaminationand infection7

• Insert new 9v battery andpress ‘Start’ button• Check medications onsyringe driver prescriptionchart are correctly prescribedand signed• To activate syringe driver andensure it is working bysilencing the alarm andinitiating the light to flash• To confirm and ensureappropriate drugs areprescribed correctly and arecompatible• Explain procedure to patientand obtain informed verbalconsent (if possible).• A Lock Box risk assessmentform (Appendix 1) should becompleted regarding the safeadministration of medicinesvia the syringe driver.Identified risk should berecorded and discussed withthe appropriate professionals(see Section 3.4).• Wash hands according toInfection Control Policy.Ensure all the equipment hasbeen cleaned prior to use.Check compatibility of drugsand diluent.If concerned please speakwith Palliative Care Team,Medicines Information, GP orprescriber. Out of hours,contact St Leonard’sHospice. There should be no morethan three different drugsin one syringe, due toincreased risk ofincompatibility andconcentration of drugs. Mix drugs with diluents• To ensure patient aware of,and consents to, proposedprocedure.• Careful explanation isnecessary to allay fears andanxieties regarding changingof medication route andmedications used. To ensuresafe administration ofprescribed medication.• To reduce risk of infection• Correct drugs aredelivered according toprescription.• Reduce possibility ofincompatibility.8

and dilute up to 48mm andmeasure against syringedriver gauge. (See Figure2) Dilute with water forinjection or sodiumchloride 0.9% dependingon which diluent is mostcompatible with drugsprescribed. Use ampoule breaker ifavailable to avoid sharpsinjury• Complete additive labelwith information regardingpatients name, date ofbirth/hospital unit number,drugs, dosage, diluent,date and time, andsignature. Attach label tothe syringe trying toensure the syringemeasures can be seen.• Priming of line-Remember on initialpriming of line, the infusionwill finish 2 or 3 hoursearlier (use only 100cmsclamped tubing) This isbecause part of thesyringe contents remainunused in the tubing untila new syringe is set up.• Select appropriate site• Applying syringe anddriver to patientCheck the identity of thepatient as outlined in the‘Positive Patient• Ensures correctmedication given to correctpatient, and enablesvisible check of syringeflow• Good siting will allow evenabsorption of drugswithout discomfort topatient.• Ensure correct patientreceives treatment. Ensureprocedure for insertion iscorrectly followed9

Identification Policy’(2008)Using SAF-T-Intima givingset, insert and secure asdescribed in Section 2.Document on themonitoring section of thesyringe driver drug chartthe area used for siting,the date and the time.• Recheck drug chart andcheck against label.• Confirm correctprescription3.4 Risk assessmentA risk assessment must be carried out on all patients who requirea syringe driver to deliver medications. Appendix 1 is the approvedrisk assessment tool. The aim of the risk assessment is to identifywhich patients may be at risk of accidental or intentional drugoverdose from tampering of the syringe driver. If the riskassessment indicates that the patient requires a lock box thesecan be obtained from the Palliative Care Team. Out of hours, thelock box can be obtained from the Emergency Drug Cupboard.During use, the lock box keys should be kept with the ControlledDrug keys.3.5 Using two syringe driversIf two syringe drivers are to be used on one patient, extra careshould be taken:• The same type of syringe driver must be used if two driversare needed for one patient to reduce the risk of error.• Ensure each syringe driver prescription is clearly identifiedon drug chart.• Ensure prescription chart drugs and labels are checkedcarefully to ensure correct drugs used for each syringe driver• Use separate documentation for each syringe driver10

3.6 Changing prescription and medicationIf prescription medication and/or dosages are changed, a newsyringe and line must be set up and primed. The prescription chartshould be re-written with new medication and dosages. Themonitoring section of the syringe driver drug chart and labelling ofthe syringe should be completed accordingly.Rationale:This allows patient to get new drugs and dosage as soon aspossible. Documentation should be updated and completed toshow new delivery of drugs.3.7 Changing insertion sites, lines and cannulaWhen resiting or restarting an infusion, it is recommended that thesite selected is rotated using a figure-of-eight principle to maximisesite absorption. Frequency of resiting of the selected device isdependent on the manufacturer’s instructions; volume and type ofinfusate and local policies. It is reported in the literature (Brownand Worobec 2000, RCN 2005) that the time in situ of the devicecan vary between one to seven days, and must therefore beguided by regular site assessment and local policies.Record any site reaction on nursing documentation. If reactionoccurs again, may need to look at the compatibility of drugs andamount of diluent.The manufacturers instructions must be followed changingequipment:• Vygon 100cm line – every 24 hours and when the syringe ischanged• Saf-t-intima – Every 72 hours, after each infusion of 2 litresof fluid (see above) and if the area or site becomes inflamedor sore.• Syringe – each time a new syringe is made up11

3.8 Care and monitoring of patientsIt is the responsibility of healthcare professionals to monitorpatients at regular intervals in accordance with local protocols.Regular monitoring of patients enables healthcare professionals toevaluate the infusion site and assess patients’ tolerance andresponse to the intervention. This will enable prompt identificationand management of any complications.3.9 Checking the syringe driverThe following checks must be undertaken at least every 4 hoursAlso check• Check the syringe driver is still running• Light is flashing• Whirr sound can be heard• Syringe volume has decreased since last check andcontents clear• Syringe remains in place in driver• Correct rate• Record check on syringe driver documentation• The line for kinks and to ensure clamp is off• The site for signs of inflammation• The patient for symptom control3.10 Problem solving the syringe driverProblem: Indication for theproblem:Infusion running too Clamp may be on orslowtubing kinked, batterymay need changing. Sitemay be blocked orinflamedInfusion running toofastRate may be set wrongPatient may havetampered with syringeSolution:Unclamp line, unkinktubing, change battery,check site for blockage orinflammation and ifoccurred remove cannulaand resite.Check calculation andrate.Recheck reassessment12

driverThe light stays on The battery is low Change the battery assoon as possibleThe light stops The infusion may be Re-site syringe driver andflashingAlarm soundsblockedThis means the syringedriver has stopped. Thiscould be due to thefollowing:a. Syringe emptyb. Tubing kinkedc. Tubing is clampedchange the lineRenew syringe.Unkink or replace tubing.Unclamp tubing.If none of the above- change syringe driver and send for servicingSyringe drivers must be serviced annually.3.11 Discontinuing the syringe driverWhen the syringe driver is discontinued: -• Remove Saf-T-Intima and place in clinical waste. Applysterile dry dressing (if appropriate)• Discard syringe, its contents and line into sharps box inaccordance with hospital policy. Ensure to record the amountof discontinued medication on the prescription chart orchecklist• Clean driver and discard battery before storing away.4. Documentation and record keepingDocumentation of site selection and assessment is fundamental tothe care and monitoring of the patient receiving subcutaneousinfusions.Ensure the Syringe Driver Drug Chart [including MonitoringSections] are completed accurately in accordance with NMCrecord keeping guidelines. Documentation must be completed foreach syringe driver set up, when the syringe driver is changed,and at every drug round in the hospital.13

Rationale:• Maintain safe practice.• Maintain safe accuracy of drug delivery5. ComplicationsWith appropriate and correct usage, the risks and complicationsassociated with subcutaneous infusions are generally minimal andeasily resolved. Any complication that does arise, however,requires potential resiting and review of patient needs andprescription.ComplicationsAt insertion site:OedemaInfectionIrritationPain andinflammationAbscessPrevention & Management ofcomplicationsEnsure cannula inserted as per Section 2above, and cover and secure with steriledressing. Change equipment and rotatesites. If complications occur removecannula and resite. Treat patient symptomswith analgesia / antipyretics, may requireantibiotics / surgical intervention forabcess.Infusion induced:Drug incompatibility Ensure drugs are compatiblePatient drug allergies Ensure allergies identified prior toprescribing and allergy band in situ. Ifallergic reaction occurs, stop infusion treatsymptoms and document on alert sheetand in recordsCirculatory collapseStop infusion, support patient and summonmedical help.14

CrystallisationObserve for crystallization within the line orsyringe. Management:1. Increase the volume to allow for morediluent by:Using a 20ml/30ml syringe for theprescription instead of 10mlMeasure again up to 48mmContinue to run at 2mm= 02mm/hr inMS16A(blue) for 24hrs OR2. Change to a 12 hourly regime by:Measure the syringe contents up to 48mmRun at 4mm= 04mm/hr in MS16A(blue) for12 hour regimeIt must be considered that the more serious complications ofabscess, allergies and circulatory collapse may be the result ofinappropriate prescribing or administration.6. Other Related IssuesADVICE and INFORMATION:Palliative Care Team Hospital – 01904 725835 are available foradvice between: Monday – Friday, 8.30am – 4.30pmOut of hours – advice can be sought from:St Leonard’s Hospice – 01904 7085537. ReferencesBrown MK, Worobec F (2000) Hyperdermoclysis: another way toreplace fluids. Nursing. 30, 5, 58-59Dawkins L, Pugh J (2003) Paper entitled “Guidelines for the use ofSaf-T-Intima for the Administration of Subcutaneous Infusions andBolus Medication”. Earl Mountbatten Hospice, Barnsley15

Ferry M, Dardaine V, Constans T (1999) Subcutaneous infusion orhypodermoclysis: a practical approach. Journal of the AmericanGeriatrics Society. 47, 1, 93-95.Sasson M, Shvartzman P (2001) Hypodermoclysis: an alternativeinfusion technique. American Family Physician. 64, 9, 1575-1578.Jackson A (2004) Subcutaneous Fluid Administration(Hypodermoclysis). Rotherham General Hospitals Trust,Rotherham.Nursing and Midwifery Council (2004) The NMC Code ofProfessional Conduct: Standards for Conduct, Performance andEthics. NMC, London.Royal College of Nursing (2005) Standards for Infusion Therapy.RCN, London.16

Appendix 1York Hospitals NHS Foundation TrustRisk Assessment for patients requiring syringe driverAim: The reduction of non-professional incidents of drug overdoseto patients, by accident or intentionPatient name:Ward:Codes: (M) = medium risk (H) = InitialFurtherhigh riskassessment assessmentSignature of nurse carrying outassessment:Date assessment carried out:Identification of risk factors Yes No Yes No1. Is the patient confused? (M)2. Is the patient agitated? (M)3. Does the patient interfere withequipment in general? (H)4. Has the patient a history ofattempted suicide, orexpressed a wish to self-harm?(H)5. Has the patient a history ofdrug abuse?6. If a syringe driver is in situ hasthe patient attempted to/dismantled it? (H)7. Has the patients delivered SDmedication to themselves? (H)8. If independently mobile, doesthe patient continually forget aSD is in situ, allowing it to fall?(M)9. On checking SD medication, isthere an unaccountablediscrepancy in amountdelivered? (H)17

Assessment results: Risk: Action:No and/or N/A to all Low Reassess if changequestionsoccursYes to 1 or 2 (M) ModerateMonitor over 1 st 24 hoursquestionsfor increased score thenPRN– Consider Lock boxYes to all (M) questions High Lockbox neededYes to 1 or more (H) Very highLockbox neededquestionsOutcome of Initial assessment:Lock box required? Yes No Lock box available? Yes No If no state action taken:Lock box in place? Yes No Date put in place:If no state reason:Removal of lock box: Date:Reason for removal:18

Outcome of further assessment:Lock box required? Yes No Lock box available? Yes No If no state action taken:Lock box in place? Yes No Date put in place:If no state reason:Removal of lock box: Date:Reason for removal:(Adapted with courtesy of St Leonards’ Hospice)19