Clinical Guidelines (Nursing)

Subcutaneous catheter devices management of insuflon and BD safTIntima devices

  • Note: This guideline is currently under review.  

    Introduction

    Subcutaneous medication administration is a common route of administration of medications in both the hospital and community settings. Subcutaneous infusion of medications can be used in a variety of scenarios; one such situation is in palliative care, to optimise the delivery of medications to provide appropriate symptom management. It is often used in patients who are unable to take medication by mouth, those that have poor gut absorption, nausea and vomiting or those that require a continuous infusion in the community. Indwelling subcutaneous catheter devices may assist in medication delivery and decrease trauma, distress and discomfort for the patient.

    An Insuflon™ is an indwelling subcutaneous catheter used for administration of medication subcutaneously. Medications commonly administered via an Insuflon™ include Granulocyte Colony Stimulating Factor (GCSF), Cytabarine (Ara-CTM), Enoxaparin (ClexaneTM), Insulin and Morphine.
    This catheter system requires a needle and syringe to administer the medication through the device.

    A BD Saf-T-Intima™ is a needleless closed indwelling subcutaneous catheter system, which is used for subcutaneous administration of medications, either as a continuous infusion or for breakthrough/bolus doses. Medications commonly administered via a BD Saf-T-Intima™ can include opoids, benzodiazepines and anti-emetics.
    This device can be attached to a syringe driver for continuous infusions of prescribed medications either on an Alaris Asena GH MK III (inpatient use) or a NikiT 34 (for either inpatient or outpatient use).

     
    The BD Saf-T-Intima™ is a device that may at times also be used as an intravenous catheter system in some hospital and community settings.

     

    Nursing CPG Subcut Insuflon packaging

    Aim

    The aim of this guideline is to provide nursing and medical staff with an overview of the use and management of Indwelling Subcutaneous Catheter devices utilised at the Royal Children’s Hospital, Melbourne.

    Definition of terms

    • Subcutaneous –under the skin1
    • Continuous infusion – a background infusion of medications that is given over a specific period, for example over 24 hours
    • Bolus/breakthrough dose – this includes regular or prn medications that are administered. If the patient has a continuous subcutaneous infusion via a BD Saf-T-Intima™, breakthrough subcutaneous medications should be administered via a different BD Saf-T-Intima

    Assessment

    A physical assessment of the patient is required to select an insertion site

    • The indwelling subcutaneous catheter device must be inserted into an area where there is adequate subcutaneous tissue
    •  Areas commonly used include:
      •  the anterior abdominal wall (considered site of choice)
      •  the anterior aspect of the upper arms
      •  the anterior aspect of the thigh

      Subcutaneous Catheter devices insertion area

      • Areas to avoid include
        •  Skin folds or areas where clothing may rub or constrict the flow of medication in the indwelling subcutaneous device
        •  Skin that is oedematous, obviously bruised or hard, red, broken or swollen, or where there is infection
        •  Directly over a tumour or areas that have recently been irritated or irradiated
        •  Over a bony area or joint
      •  Other considerations in choosing a site may include;
        •  the age of the child (as example, do not insert in the lower abdomen if the child is in nappies)
        •  the person who will administer the medication (for example, if the patient is to self administer, position the hub of the Insuflon™ device for ease of access for the patient)
        •  patient and/or caregiver preference
        •  for neonates receiving anticoagulant medications (eg. Clexane), consideration should be given to the appropriateness of using an indwelling device versus rotating injection sites

      Insertion of the indwelling subcutaneous catheter device

      Management

      • Ongoing assessment includes at least
        • Insuflon™ - once daily observation of the Insuflon™ insertion site for potential complications. The Insuflon™ insertion site must also be inspected prior to administration of medication via this device
        • BD Saf-T-IntimaTM - at least four hourly inspection of the BD Saf-T-IntimaTM insertion site for potential complications is recommended. The BD Saf-T-IntimaTM insertion site must also be inspected prior to bolus/breakthrough doses of medication
      •  It is recommended that an InsuflonTM is changed every 7 to 10 days (maximum insertion time should be 10 days) or more frequently if indicated or if complications are noted.
      • The BD Saf-T-IntimaTM can be left insitu for up to 14 days, but may need to be changed more frequently if indicated or if complications are noted.
      •  Potential complications may include
        • Infection
        • Discomfort
        • Difficulty injecting medication
        • Blockage
        • Redness
        • Inflammation
        • Exudates
        • Bruising and bleeding
        • Pain
        • Leakage
      •  Other considerations include
        •  Some medications may increase the need for more frequent catheter changes, as examples
          •  low molecular weight heparin (ClexaneTM) – may increase bruising or bleeding at the site
          •  ketamine- may cause redness and irritation at the site more quickly than other medications
          •  insulin- may contribute to the breakdown of adipose tissue at the site
      •  Some medications may cause pain at the site whilst injecting (for example GCSF and ClexaneTM). Consider:
        •  gently rubbing/”tickling” the site whilst administering the medication
        •  applying ice to the site for 5 minutes prior to injecting the medication
        •  distraction techniques for the patient such as blowing bubbles may be appropriate
        •  the application of pressure following administration of ClexaneTM may also reduce the experience of pain, as well as minimising bruising
      •  The application of Angel/Emla cream prior to injecting the medication via the indwelling subcutaneous catheter device should not be required

      Management of complications

      • The indwelling subcutaneous catheter device should be removed and a new one placed at a different site
      • Any of the above complications should be documented in the Progress Notes
      • If premature removal and/or resiting of a subcutaneous device is required (eg due to excessive bruising if the patient is being administered ClexaneTM via the insuflon), please contact the managing medical team to discuss further management
      • Other considerations;
        • Do not reinsert the needle if the indwelling subcutaneous catheter device is dislodged/withdrawn, repeat the procedure with a new catheter
        • Do not bend the needle prior to insertion
        • Never reinsert the needle into the catheter as this could shear the catheter
        • Do not use scissors at or near the insertion site of the indwelling subcutaneous catheter device
        • Remove the white clamp from the BD Saf-T-IntimaTM to stop accidental clamping of the line
        • For smaller infants receiving ClexaneTM via an insuflon, consider inserting 2 insuflons (ie one in each thigh) and rotate dose administration between catheters. This will minimise the risk of significant bruising at the catheter site.

      Administration of medication

      • Ensure all medications given are recommended for subcutaneous use
      • Medications should be administered as per the Royal Children’s Hospital Medication Management Procedure http://ww2.rch.org.au/policy_rch/index.cfm?doc_id=6570
      • All medications administered should be recorded on the Medicine Administration Record (MAR)
      • For medication administration refer to the following;
      • Flushing medication
        • Insuflon
          • The dead space volume of the Insuflon™ catheter is approximately 0.0075 ml, it is unnecessary to flush the Insuflon™ before or after use
          • If the Insuflon™ is to be removed post administration of a subcutaneous medication, a minimum of 15-30 minutes should elapse before removal.
        • BD Saf-T-Intima
          • The dead space volume of the BD Saf-T-Intima™ catheter is approximately 0.25 ml, it is necessary to flush the BD Saf-T-Intima™ after the administration of bolus/breakthrough doses. Ensure the flush used is compatible with the subcutaneous medications administered via the BD Saf-T-Intima
          • If changing the BD Saf-T-Intima™ catheter being used for the continuous infusion, the new BD Saf-T-Intima™ can be primed with the medication from the syringe driver when priming the infusion tubing only if commencing a new syringe
      • Other considerations;
        • Insuflon
          • When two different subcutaneous medications are to be administered, it is recommended that two different Insuflon™ devices are inserted (ie: a separate Insuflon™ should be used for each medication). The two Insuflon™ devices should not be placed in the same areas, for example it is preferable that each Insuflon™ should be placed on a different limb, or alternatively opposite sides of the abdomen
        • BD Saf-T-Intima
          • If a BD Saf-T-Intima™ is inserted for a continuous infusion, it is recommended that a second BD Saf-T-Intima™ is inserted to use for breakthrough/bolus doses. The two BD Saf-T-Intima™ should not be placed in the same areas, for example it is preferable that each BD Saf-T-Intima™ should be placed on a different limb, or alternatively opposite sides of the abdomen. It is best practice to use one BD Saf-T-Intima™ site exclusively for continuous infusion and another BD Saf-T-Intima™ site for breakthrough doses
          • More than one medication can be used in a continuous infusion syringe, check medications compatibilities. If the device is being used for breakthrough or bolus doses place a red cap on both of the injection ports, do not use smart sites
      • Place all needles in a puncture-resistant, leak-proof sharps container

      Removal of the indwelling subcutaneous catheter device

      Documentation

      The following information should be in Progress Notes;

      • The date, procedure and site of insertion
      • Observation of insertion site for signs of complications
      • The date and reason for removal of the Insuflon™ or BD Saf-T-Intima
      • All medications administered should be recorded on the medication administration record (MAR)

      Special considerations

      Family centred care

      • The patient and/or caregivers will provide informed consent following discussion of the need for and management of an indwelling subcutaneous catheter device to deliver subcutaneous medications
      • The indwelling subcutaneous catheter device will be inserted with minimum discomfort to the patient, the use of topical anaesthetics and oral sucrose will be used based on patient age and preference
      • The insertion site will be chosen with participation from the patient and/or caregivers where appropriate

      Education needs

      • If a patient is being discharged with an Insuflon™ or BD Saf-T-Intima™ insitu, the patient and/or caregivers should be given instructions on the management of the device.

      Infection control

      • Ensure that the insertion site of the Insuflon™ is covered with the dressing supplied with the Insuflon™ from the catheter end first, ensuring the insertion site is visible through the plastic window and the hub is open to air.
      • A transparent occlusive dressing, for example tegaderm or opsite dressing, may be applied to further secure the Insuflon™, however ensure that the hub is not covered by the occlusive dressing (for example, cut occlusive dressing in half and reinforce Insuflon™ on either side of hub)
      • Ensure that the insertion site of the BD Saf-T-Intima™ is covered with a transparent occlusive dressing, for example tegaderm or opsite dressing, to allow visualisation of the insertion site
      • Adhere to aseptic technique when inserting indwelling subcutaneous catheter device and when administering medications

      Companion documents

      Palliative Care Resources

      Haematology Resources

      Insuflon™ product information http://www.unomedical.net/au/section17/section02/index.asp

      BD Saf-T-Intima™ product information

      Paediatric Pharmacopeia 13th Edition Online
      AMH Children’s Dosing Companion
      MIMS Online

      Evidence table

      Complete evidence table document available at http://www.rch.org.au/nursing/governance
      Click here to view the evidence table.

      References

      http://www.betterhealth.vic.gov.au/bhcv2/bhcsite.nsf/pages/bhc_medicaldictionary?open

      Document control

      Complete document control document available at http://www.rch.org.au/nursing/governance

       

      Please remember to read the disclaimer.

      The development of this nursing guideline was coordinated by Jacquie Barton, Liaison Nurse, Victorian Paediatric Palliative Care Program and Lisa Barrow, CNC, Kookaburra ward, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2014.