Rot{-j-

ffic

ERNffiI\rE

INFUS.i6N.: iSS DEVTCES

''

T A /hen intravenous (IV) access cannot be obtained because of lack of time, inadequate skills, or patient l/\/ Y Y condition, vascular access by subcutaneous or in..traoSl(.,ous

..

administration are alternative infusion options.

$, corrrr,rv,u$
ovERvlEw

Continuous subcutaneous infusion (CSI) is a useful route for the administration of selected medications. CSI can provide a comfortable, less expensive alternative to traditional IV administraforming capillary networks that supply nutrients an(l rFrt!l tion or intramuscular (IM) injections, and can provide patients wastes (Cuzell and Workman,2006). the added flexibility of receiving prescribed therapies without [*"^fiedications and fluids are absorbed into tl're blooilctt having to endure venipuncture attempts or painful IM iniections. I through the network of capillaries and blood vt'sst'll, iitl< CSI should be considered an option for patients experiencing the i neors tissue is less vascular than muscle tissue, so tltr" rilt* following: limited or no venous access, inability to tolerate the I action is slower than intramuscular or intravenous ;rtltttt*r.t burdens of oral therapies (numerous pills), oral therapies not as I tion 1r.. Figure 10-1). effective for symptom control or disease management (peak and I trough effect), those with a single venous access device (VAD) CONTINUOUS SUBCUTANEOUS THERAPI ES and incompatible medications, those with medications adaptable to CSI, and patients without a functioning gastrointestinal There are two maior categories of continuous irrl tract. CSI can be effectively administered in a variety of patient therapies: (1) continuous subcutaneous infusiorr oi 1*"c#. settings: home care, long-term care, intermediate care, acute and (2) hypodermoclysis, or "clysis." care/hospitals, and hospice environments. CSI is used in many settings because it enables patients to manage their illness and/ Continuous subcutoneous infusion or pain without the risks and expenses involved with IV medication administration (Perry and Potter, 2006). The goal of giving medication by iontinuous suhcr fusion (CSI) is to attain appropdate blood levch of and achieve the desired symptom control or mall STRUCTURE OF THE SKIN: A BRIEF REVIEW

dermis is the layer of connective tissue between the epitL r,,it and fat layer (also known as the subcutaneous tissue laycr r I lr,. -,dermis is an interwoven network of collagen and elastir lrl,' ir that give the skin flexibility and strength. The dermis .rlr, ' , ,,, tains a network of capillaries, lymph vessels, and sens()rv rr, , ' ,,i that promotes oxygen and heat exchange and the tran\riri ..i, 'ii of sensation (Cuzell and Workman, 20O6). 'l'he subcrrl,rr,, "=: layer covers muscle and bone, is the site for fat forrnirti,,r, ,,idi storage, provides heat insulation for the body, arrd lrr,,1 :,i+ protection against inlury by absorbing shock and p:l(!ilir,E ! ternal structures. The thickness of the subcutaneous Ia\'t'r ' rr with body surface area, age, and gender. Many [;loo,l r"' pass through the fatty layer and extend into the clcrrtr*l

the outermost protective layer, the skin is the largest organ of the body. It plays a maior role in homeostasis by serving as a barrier to organisms, regulating body temperature, and maintaining fluid and electrolyte balance. Changes in the skin can aiso communicate information about a person's health and well-being (Cuzell and Workman, 2006). The thinnest outer layer is the epidermis, less.than 1 millimeter (mm) thick; it is
As able to act effectively as the protective barrier between the body and environment. The epidermis does not have a separate blood supply, but receives nutdents from the dermis by diffusion.'l'he

without the risks, expense, or inconvenicn('q1 pies. The most common medications infused vi* are opioids (morphine, hydromorphone, and management), insulin (diabetes management), ment of preterm labor), deferoxamine mesylat( (iftifi antiemetics, and steroids. Other medications ulr+.i care given by CSI include midazolam, halolt:tlr,ll:11 scine (Negro et al, 2OO2). Recently, clodronal(', ilt methadone have been added to this list; how(,vi1ri ti notable for causing a high incidence of tisstrr lttilai
ease

2005).

516

CHAPTER

26

Alternative Infusion Access Devices

5't7

Advantages/Disadvanta ges The following are advantages of administering medication by CSI: (1) medications are absqlbed directly into the bloodstream.

Advantages/Disadvantages

n rlrrateq raplory ror parn ancl symptom management; (3) bur_ dens of oral therapy are relieved (e.g., numerous pills, inconsistent medication effects); (4) central nervous system
De

arro

effects associated with interm

nal tract is not required; (6) bioavailability and

are available to patients with lim; + ited or nonexistent venous access, or those that have a single VAD with other incompatible medications; (8) it is generally less expensive and less time-consuming than venipuncture,

(7) therapies

and may be considered less invasive by patients (Neafsey, 2005; Weissman, 2005); (9) clinicians can easily learn the procedure (does not require venipuncture); and (10) it can be safely administered in a variety of patient care settings, including the home @hillips, 20O5). The maior disadvantage of giving medication by CSI is that

The following are advantages of hypodermoclysis: (1) it can be administered, after training, in a variety of patient care settings, including the home; (2) it appears to be well accepted by patients and is cost-effective when compared to IV therapy (Slesak et al, 2003); (3) it avoids the need to transfer the patient to another setting; and (4) it does not require venipuncture. The following are disadvantages: (1) local site discomfort or edema, (2) limited application in certain patient conditions, and (3) not effective in emaciated or hypoalbuminemic patients who are edematous. Hypodermoclysis is contraindicated in emergency situations and for patients needing immediate fluid replacement, patients needing large-volume fluid replacement, and patients who require electrolyte-free or hypertonic solutions (Walsh, 2005). Patients with bleeding disorders or skin conditions limiting suitable sites for access device placement are not candidates for hypodermoclysis (Walsh, 2005). Hypodermoclysis is also contraindicated when the patient may be at increased risk for pulmonary congestion or edema, such as severe congestive heart failure (Sasson and Shvartzman, 2001).

ASSESSMENT OF PAilENT BEFORE THERAPY r

of medication decreases (Perryand Potter, 2006). Other disadvantages include local discomfort at the infusion site and limited medication choices because of pharmacokinetics and medication properties. Also, the onset of action for medication gven by CSI is slower than that when IV adminis-

In addition to other nursing. assessments, the patient receiving following assessment parameters evaluated before therapy is initiated:
CSI should have the

tration is used; as compared to

for
immediate onset of

of action
when

the tissues, such as exercise, loCal application of hot or cold compresses, or altered body temperafure, influences the rate of
drug absorption (Perry and Potter, 2006). CSI is contraindicated in patients with conditions resulting in decreased local tissue perfusion, such as circulatory shock, hypothermia, and occlusive vascular disease (Perry and Potter, 2006).

Verify physician's order for patient's name, drug name, type of medication, dosage, and route of administration against the medication administration record (MAR). r Collect drug information necessary to administer drug safely, including action, purpose, side effects, safe dosage range, and nursing implications. Verify that medication can be given through this route. o Assess the patient's medical history, drug allergies, and medication history. . Assess for factors that m

Hypodermodysis
ysis, or "clysis," is the infusion of isotonic fluids

. .

Because of severe adverse reactions related to the misuse of electrolyte-free or hypertonic solutions in the 1950s, hypodermoclysis was almost completely discontinued. Since the late 1980s, this method has been increasingly rediscovered as an

125 ml/hr. Over 24 hours, up to 1.5 L can be delivered at one site or 3 L using two sites. Hyaluronidase, an enzyrne, may or may not be added to facilitate absorption (Remington and

to

altemative therapy for IV rehydration, especially in the frelds of geriatdc and palliative medicine (Slesak et al, 2003). In longtelm care, the common treatment for patients unable to take adequate fluids by mouth is infusion of IV solutions (Remington and Hultman, 2007), which often necessitates moving the patient to a different level of care, such as the clinic or hospital. With hypodermoclysis, isotonic fluids are infused into the subcutaneous space through a small gauge needle inserted at various sites, including the thighs, back, abdomen, and arms. Fluids can be infused using gravity or a pump at rates of 20

adequacy of the patient's subcutaneous tissue and skin condition to determine appropriate site. Assess patient/family knowledge regarding medication to be received and readiness to learn self-administration. Assess the patient's symptoms before initiating the medication therapy. (Norr: When administering analgesia, assess the patient's level of pain using the appropriate pain scale [Perry and Potter, 2006].) The advanced practice nurse, physician, or pharmacist determines drug dose based on the amount of pain medication the patient used in 24 hours. An equianalgesic chart is used to convert IV, IM, and oral medication doses to CSI doses (Paserc,2N2). Check the compatibility of any medications combined in the infusions.

INITIATION OF CONTINUOUS SUBCT'TANEOUS INFUSION

Site Seledion
Before initiation of therapy, carefully assess the patient's skin

adequary

of

subcutaneous tissue stores.

Hultman,2007).

5',|8

SECTION
commonl

Iurusrors Nunsrwc Pnacrrcr

recommend avoiding the chest wall to prevent iatrogenic lung puncture during needle insertion (Weissman, 2OO5).

used for subcutaneous injec-

tion and the outer

Site selection will depend on the patient's activity level, subcutaneous tissue stores, and the type of medication required. For example, p4!n medications delivered to ambulatory palisgls are best delivered in the upper chest (infraclavicular area) to aI-

Equipment/Supplies
Gather all equipment and supplies before initiating the irrlrr sion. An electronic infusion device (EID) is required for all nrt r ication infusions. The EID must have a lock-out interval featrrr, bolus dosing options, and appropriate clinical safety alarrrr'. For subcutaneous infusions of isotonic fluids, an EID or adtl ,,rr flow regulator may be used to control the fluid infusion r:rt,' Other general supplies include aseptic nonsterile gloves, .r,l ministration sets, transparent semipermeable membrane ('l \\lr dressings, tape, gauze pads, alcohol wipes, skin disinfect;rrrt. and a subcutaneous access device (e.g., over-the-needle cii I I r( 1, r or prepackaged subcutaneous set) (Figure 26-2). Commcrt i,rllr prepared start kits contain the basic supplies; however, a lrrrrr niquet is not needed since venipuncture is not required.
I .

(ull. tll '[e scipula area may inhibit the patient @r from pulling at the site (Anderson and Shreve, 2004). Insulin is absorbed most consistently in the abdomen; thus a site in the abdomen away from the belt line is preferred for a continuous insulin intusion (Perry and Potter, 2006). Ggmll&Jltsg;hsxtJd
be located and areas

void bony prominences, irritated or infected sites, and sites around

tumors, deep creases, recently radiated areas, and other skin lesions. CSI is not eontraindicated for cachectic patients (Pasero,

eral subcutaneous tissue (Perry and Potter, 2006). Some sources

Patient preporation After the orders from an authorized prescriber 2vs

v1'1;lrrrl

the equipment and supplies are assembled, and the patit'rrl r: properly identified following organizational guidelincs. t 'r' is taken to provide privacy and to explain all procedult: ,rr,,i rationales to the patient and/or family. Educational tllrllri rl. are provided, if applicable, and time is allowed for qucrlt,,ri:
and answers. Ensure the patient's readiness by assisting tlr, 1'* tient to a position of comfort. If initiating an opioid itllrrrtlri for pain management, assess the patient's pain ratin.g lrcl,liF starting the subcutaneous infusion.

Site

preporotion

According to th.e Infrsion Nursing Standards of Practicc " technique shall be used and standard precautions Hand hygt$n{i ierved for rmed before and after all patient care contact._Sitc

tion for CSI is f the skin is visibly soiled, wash the selected sits wi{li
and water before applying skin disinfectants and fcillox nizational guidelines for site preparation. Excess lruh clipped with scissors or removed with single-use sut pers that have disposable clipper heads.

Device selection
FIGURE
Perry
AG'.

Common sites {or subcutaneous injections. (From Potter Bosic nursing: essentiols for proctice, ed 6, St Louis, 2007, Mosby.)

26-I

PA,

Currently, there are three device options for taneous tissue for infusion of medications or i (l) stainless steel winged needles, (2) over-the-needle

FIGURE

26-2

A,

Medtronic standard and micro catheter

B, Medkonic

Sof-Set. (From Applied Medical Technology,

Cambridge, United Kingdom.)

CHAITTER 26

Alternative Infusion Access

Devices

5i9
re_

education and safe work practices for handling needles and

FIGURE

25-I

Sutse-Set. (Courtesy Baxter lntemarional, tnc., Deerfield, tll.)

'r'.r,
and (3) subcutaneous

-r'tSqg)Ltt
Sof_set, Sutr-e_Set). Tra-

Devlce plocement
Insert the subcutaneous device according to the manufactur_ er's instructions. Over-the-needle catheters are placed into the subcutaneous tissue at approximately a 30_ to 4Sdegree

On""
tain subcutaneous

irtl:lorr r.trleg.,

care provider. A small gauge over_the_needle catheter (usually 24 gauge) can provide safe and comfortable access into the subcutaneous tissue-

to the patient or inadvertent needlestick iniury to the health

eters (e.g., Vialonru, Teflon@) have been used with reports of increased patient comfort, and decreased risk of tissue

devices are intended for short-term duration IV infusions, usually 1 to 4 hours, or a single dose of medication. Over_the-needle cath_

access

for infusion. However, these

o oO-

d"_"g"

angle depending on the thickness of the subcutaneous tissue. Prepackaged subcutaneous access devices are inserted at a gO_ degree angle. These devices are manufactured at specific lengths t6 optimize access to the subcutaneous tissue, depending on the thickness of the subcutaneous layer.

Device secutement ond dressing

Subcutaneous access devices are secured with ta

9o-degree angre over-the-needle catheter. Th-ese devices are made in a 6- or 9-mm length for optimal access to the subcu_ taneous tissue (Figure 26-3). Aspecial infusion set is now avail_ able exclusively for hypodermoclysis. The Aqua_C Hydration system (Norfork Medical, skokie, Ilt) combineiintusion tubing urith an integrated flow regulator spiked into a solution co.rtuirl er. The access device is called a .,clysis strip,, and has two 25_ or Z7-gauge, GmmJong needles placed 1.5 inches apart on an adhesive vinyl strip attached to the end of the tubing (Figure 26-4) (Walsh,2oo5). The needle design allows two sites to be accessed with one device and minimizes the risk of improper needle placement. Using the Aqua-C Hydration system, the maximum infusion rate can be achieved with a single administration setup. The use of a specialized set for hypodermoclysis may also decrease the possibility of mistaking the subcutaneous infusion for an intravenous infusion (Walsh, 2005). According to the Infusion Nursing Stanitards of practice (2006a),_1he se!g&ec[ conlipgous subcutaneous access devrce should be6T e rnd ,rr uaaurr. tha , National Institute of Occupational Safety and Health (NIOSH, 1999) reports that hollow-bore needles incur the greatest risks of needlestick iniuries to health care workers. Of nearly 5000 percutaneous iniuries reported by hospitals participating in CDC studies betweenJune 1995 andJuly L99S) eZVowere asso_ ciated with hollow-bore needles, primarily hypodermic needles attached to syringes (29%) and winged_stee.l needles (13y0). Data from these studies showed that approximately 3g06 of iniuries occur during use and 42o/o occur-after use and befoie disposal OIIOSH, 1999). Recommendations for avoiding poten_ tial needlestick iniuries include eliminating unnecessary use of needles, using devices with safety featuris, and promoting

Currentln prepackaged subcutaneous access devices are commercially available with a 9O_degree angle needle or a

*
tify subcutaneous infusionsSTTE

labels are available to iden-

Monitoring

ASSESSMENT AND MAINTENANCE

will depend on the patient care setting, the type of medication, whether medications or solutions are Ueing infused, and the overall condition of the patient,s skin andsubcutaneous tis_
rn an acute care settins, to twice dailv or dailw in rtra hnmo tional policies should address

The frequency of monitoring of the subcutaneous infusion site

=.,

;k

Site rotation

and restafied in a new location. A decrease in to

and Shreve, 2004).

apDears

subcutaneous site

Discontinuotion
Discontinuing a subcutaneous infusion is a simple procedure requiring only a gauze pad and light pressure to the site af_ ter the needle or catheter is removed. Needles or subcutaneous

access devices

with

sharps containers.

needles must be disposed of

in approved

POTENTIAT COM PLICATIONS

Potential com tions of CSI or

The Aqua-C Hydration set. (Courresy Norfolk Medical JlgUnF Products lnc., Skokie, lll.)

26-4

care, rotating infusion sites, and limiting or eliminating irdtating medications when possible.

SECTION V

PATINT ASSESSmqNT AND EDUCATION

._'-

Obtain and verify physiti'an

Veri{y patient's identity. Provide patient and/or family with educational material/ information regarding procedure.

l. ,

,:.; For continuous subcutaneou_s ipfusion Prepare equioment and'rn6ilication to be administered.

.:

lnform patient of impending needlestick.

Lift skin into small mound between thumb and index finger.

.5i.

Obtain patient's consent.

Assess patient. Place patient in reclining position.

,s,:ll fusion
',,.,11;-1

:,14i tnsert primed subcutaneous access device with attached insystem into the skin (30- to 9O-degree angle depend
ing on the type of device and thickness of the subcutaneous return rs site; repeat insertion procedure.
Stabilize access device. Secure connection junctions.

:tj::r:1t tiSSUe).

INSERTION SITE AND DEVICE SELECIION

Dress access site using transparent semipermeable membrane (TSM) dressing to allow for site observation

and palpation. lnitiate therapy. and comfort (and the medication ordered).
Label administration set and/or pump 'Subcutaneous

lnfusionl'
SITE CARE AND MAINTENANCE

Anterior chest wall (avoid in patients with cachexia) Lower abdomen Outer aspects of the arms and thigh

lnspect access site and equipment: Observe site for bleeding bruising inflammation, drainage, '.r.4.: edema, or cellulitis. .,,,,.,i H,lonitor patient for complaints regarding burning or itching ,1..,:,

1 . .,5

atsite'
Observe previous sites for signs of irritation or infection.

''ffif
.
Select access device with smallest gauge and shortest length necessary to establish subcutaneous access Over-theneedle catheter (22-24 gauge): lnsert at 3G to

ii,

,"ri! Change administration set immediately upon suspected :..-,;r:j conta mi nation ; otherwise, chan ge administration set, incl uding
add-on devices and tubing every 3 to 5 days as long as a
Change access site dressing immediately upon suspected .on,u*,nation; othenarise, change TSM dressing every 3 to

,,]:iil::; closed system is maintained.

l:fii
..::.'," ,1

,'r:..:: 5 days during site rotation'

45{egree angle depending on fiickness of subcutaneous tissue. Subcutaneous infusion set (25-27 gauge; specific lengths available to optimize access depending upon thickness of
subcutaneous tissue): lnsert at 90-degree angle.

i:: Rotate access site every 3 to 5 days. Select a new site at least ' I inch from previous site, preferably dependent on patient
comfort.
POST-INSERTION

INSERTION SITE PREPARATION Wash insertion site with antiseptic soap and water if skin is visibly soiled. Remove excess hair from insertion site, if necessary (do not shave).

l.

Do not flush subcutaneous access device.

Disinfect insertion site per organizational guidelines.

DEVTCE PTACEMENT

2. Discard used equipment and supplies. 5. Remove gloves. 4. Perform hand hygiene. . 5. Document all procedures, patient education, and patient
response to procedure in the patient s medical record.

AND INITIATION

Follow manufacturer's guidelines for access device placement. lnspect access device for defects.
From lnfusion Nurses Society: Policies ond procedures for infusion nursing, ed 3, Norwood, Mass, 20o6b, Author.

CllAPl'liR

26

Altcrnative Infusion Access Devices

521

adequacy of the intraosseous (IO) route (Papper, 7942; Tocan' tins et al, 1941) in the 1930s and 1940s popularized this method of fluid administration. Further studies led to the intraosseous
Versus Over-the-Needle

lnfusions
iar,,6! ro,steel winged needle infu-

infusions in patients receivwere made of Teflon6' in terms of duration i5uired changing. Although $ecau9e of low follow-up, 'ta,ba superior to metal l,,ijlean,,increases in dwell

it Hisie-rically, non:metal ,i,S te,ejbensive; howev,er,

inetal an d Tef on-co-Eted use,of non-metal.can. lneedle nf usion seb'.(fP, r@
I

route being routinely adapted by rflilitary personnel during World War II to establish viscular access in shock Patients with difficult IV access (Morrison, 1946). However, in the 1950s and 1960s the introduction of disposable medical supplies that allowed the prolonged use of intiavenous infusion while reducing the dsk of dislodgement quickly overshadowed the benefits of IO methodology and ih. .rr. of this technique declined sharply. It was not until the 1980s, when numerous studies quantified the ease and reliability of the IO method for pediatric patients, that the proceduie regained notoriety for that patient population' With iduu.r.., in pediatric resuscitation, IO access made a significant ,"upp"ururr.a and became a clinical standard of treatment in
pediatrics (Turkel, 1983; Orlowski, 1984). Additional studies in the late 1980s supported the overall reliabitity of intraosseous access for obtaining most laboratory values and aff,rmed that they were representative of the general circulation (Grisham and Gastings, 1991). The method was also validated as a viable one for administering virtually all infusates. These later studies opened the door for wider applica-

::

tion to the adult population with critical

access needs' Today IO methodology has been recognized by the Amedcan Heart Aisociation (AHA) as a standard of alternative vascular access and is cited in the algorithms for American Heart Association Advanced Cardiac Life Support (AC15) and Pediatric Advanced Life Support (PALS) treatment Protocols (AHA, 2006a,b)' It is a

valuable resource as an altemative method of vascular access when IV cannulation is not feasible or is delayed' A resurgence in use has also been supported by advancements in prehospital resuscitation and emergency medicine (Miller et al, 2005)'

INDICATIONS AND GONTRAINDICATIONS TOR USE

The indications for use of the IO route focus on urgent or emergent need for venous access. The treatment and resuscitation of difficult vaslatients experiencing shock, venous collapse, or for medical as a challenge noted been iular accesi have long personnel (Fowler et;l,2oo7). while intravenous access is the preferred administration route, if patient care is compromised L".urr" of inability to rapidly establish IV access, then the IO route should be considered. Recently published ACLS guidelines direct IO medication administration as a preferred route over the endotracheal route (AHA, 2006a,b). The new guidelines also

as the preferential placement versus that of a central VeO auring cardiopulmonary resuscitation (CPR) if peripheral

support IO
access is

-ry*@%fair rrvrnnossEous

AccESS

ovERvlEw It has been over

90 years since itll'ttsiott of fluids through the bone marrow (intraosseous infusion) was first demonstrated (Drinker et al, 1922). Subscquerrl rt'scarcl't demonstrating the

unobtainable. Intraosseous routes are temporary solutions to emergent patient situations. Intraosseous access is an effective route for fluid resuscitation; bolus, drug, and blood and blood product administration; and lab evaluation in all age groups- Any drug or fluid that is appropriate for IV administration can be given via the IO route (AHA buidelines, 20o6a,b). Generally, the volume of fluid given per minute is similar to the rate of fluids infused through a It-gurg" catheter (Mi11er et al, 2005). Studies by Orlowski (f S8a) ihow similar physiological effects and serum drug levels in comparison trials of intravenous and intraosseous routes' Almost u.ry d.,rg, blood product, or resuscitation solution such can be as O.9o/osodium chloride that can be given intravenously given by intraosseous infusion with comparable absorption and effectiveness (Fowler et al, 2007).