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García-López I, Chocarro-González L, Martín-Romero I, Vázquez-Sánchez JM, Avilés-Martínez M, Martino-Alba R. Pediatric Palliative Care at Home: A Prospective Study on Subcutaneous Drug Administration. J Pain Symptom Manage 2023; 66:e319-e326. [PMID: 37244525 DOI: 10.1016/j.jpainsymman.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
CONTEXT The subcutaneous route is a useful alternative for drug administration in palliative care. Although there is scientific evidence on its use in adult patients, the literature in pediatric palliative care is almost nonexistent. OBJECTIVES To describe the experience of a pediatric palliative care unit (PPCU) with in-home subcutaneous drug administration symptom control. METHODS Prospective observational study of patients receiving home-based subcutaneous treatment administered as part of a PPCU treatment regimen over 16 months. Analysis includes demographic and clinical variables and treatment received. RESULTS Fifty-four different subcutaneous lines were inserted in the 15 patients included, mainly in the thigh (85.2%). The median time of needle in situ was 5.5 days (range: 1-36 days). A single drug was administered in 55.7% of treatments. The most frequently used drugs were morphine chloride (82%) and midazolam (55.7%). Continuous subcutaneous infusion was the predominant administration route (96.7%), with infusion rates oscillating between 0.1 mL/h and 1.5 mL/h. A statistically significant relationship was found between the maximum infusion rate and induration onset. Of the 54 lines placed, 29 (53.7%) had an associated complication requiring line removal. The primary cause for removal was insertion-site induration (46.3%). Subcutaneous lines were mainly used to manage pain, dyspnea, and epileptic seizures. CONCLUSION In the pediatric palliative care patients studied, the subcutaneous route is most frequently used for administering morphine and midazolam in continuous infusion. The main complication was induration, especially with longer dwell times or higher infusion rates. However, further studies are required to optimize management and prevent complications.
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Affiliation(s)
- Isabel García-López
- Pharmacy Department (I.G-L., I.M-R.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
| | - Lourdes Chocarro-González
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Irene Martín-Romero
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Juan Manuel Vázquez-Sánchez
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - María Avilés-Martínez
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ricardo Martino-Alba
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Samboni-Méndez M, Benavides-Ruiz MM, Piamba-Valencia AM, Sánchez-Duque JA. [Subcutaneous analgesia in elderly palliative home care]. Semergen 2023; 49:101975. [PMID: 37079957 DOI: 10.1016/j.semerg.2023.101975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 04/22/2023]
Affiliation(s)
- M Samboni-Méndez
- Programa de Medicina del Dolor y Cuidados Paliativos, Facultad de Medicina y Ciencias de la Salud, Universidad Militar Nueva Granada, Bogotá D.C., Colombia; Grupo de Investigación GeriaUNAL - Griego. Programa de Geriatría, Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D.C., Colombia
| | - M M Benavides-Ruiz
- Grupo de investigación Salud, Familia y Sociedad. Programa de Medicina Familiar, Departamento de Medicina Social y Salud Familiar, Facultad de Ciencias de la Salud, Universidad del Cauca, Popayán, Cauca, Colombia
| | - A M Piamba-Valencia
- Grupo de investigación Salud, Familia y Sociedad. Programa de Medicina Familiar, Departamento de Medicina Social y Salud Familiar, Facultad de Ciencias de la Salud, Universidad del Cauca, Popayán, Cauca, Colombia
| | - J A Sánchez-Duque
- Grupo de Investigación GeriaUNAL - Griego. Programa de Geriatría, Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D.C., Colombia; Grupo de Investigación Epidemiología, Salud y Violencia. Departamento de Medicina Comunitaria, Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira, Risaralda, Colombia.
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Rodríguez-Campos L, León MX, Bastidas A, Consuegra C, Umbacia MA, García A, Rodrígues D, Bruera E. Subcutaneous Administration of Medications and Fluids by Nonprofessional Caregivers at Home. J Palliat Med 2022; 26:497-502. [PMID: 36260386 DOI: 10.1089/jpm.2022.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Patients requiring home-based palliative care have advanced complex illnesses with functional limitations and decline. This retrospective study reviewed caregiver administration of subcutaneous (SQ) medications and fluids when symptom control could not be achieved using the oral route. Methods: Medical records from September 1, 2017 to February 28, 2018 were reviewed for 272 consecutive patients who received SQ administration of medications or fluids at a home-based palliative care program. We analyzed the clinical characteristics of patients and caregivers, medications administered, and catheter outcomes. Results: Patients' median age was 74 years, and 163 (60%) were women. The most common cancer diagnoses were stomach 26 (12%), lung 22 (10%), and colorectal 20 (9%). Dementia 24 (44%), cerebrovascular disease 9 (16%), and congestive heart failure 7 (13%) were the most frequent nonmalignant diseases. Poor symptom control 162 (60%) and impaired oral intake 107 (39%) were the most common indications for an SQ route of administration. Nonprofessional caregivers trained by a nurse administered medications to 218 patients (80%). During interventions, the patients received a mean of 4 medications (±2 standard deviation). A total of 903 catheters were inserted, 15/732 (2%) catheters handled by nonprofessional caregivers caused a local infection, compared with 3/171 (1.8%) of catheters handled by nurses. Hydromorphone was the most common opioid used (57%), followed by morphine (35%). The median length of stay in the program was 24 days (interquartile range: 11-60). Conclusions: SQ administration of medications and fluids by nonprofessional caregivers trained by health care professionals is feasible and promising, but additional testing is needed.
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Affiliation(s)
- Luisa Rodríguez-Campos
- Department of Anesthesia, Pain and Palliative Medicine, School of Medicine, Universidad de La Sabana, Chía, Colombia.,Universidad de La Sabana, Chía, Colombia
| | - Marta Ximena León
- Department of Anesthesia, Pain and Palliative Medicine, School of Medicine, Universidad de La Sabana, Chía, Colombia.,Universidad de La Sabana, Chía, Colombia.,IPS Cuidarte Tu Salud, Bogotá, Colombia
| | - Alirio Bastidas
- Universidad de La Sabana, Chía, Colombia.,Department of Epidemiology, School of Medicine, Universidad de La Sabana, Chía, Colombia
| | | | - María Alejandra Umbacia
- Department of Anesthesia, Pain and Palliative Medicine, School of Medicine, Universidad de La Sabana, Chía, Colombia.,Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Andrea García
- Department of Anesthesia, Pain and Palliative Medicine, School of Medicine, Universidad de La Sabana, Chía, Colombia.,Instituto Nacional de Cancerología, Bogotá, Colombia
| | | | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Xie X, Yang Y, Yang Y, Li Z, Zhang H, Chi Q, Cai X, Mei X. The development and evaluation of a subcutaneous infusion delivery system based on osmotic pump control and gas drive. Drug Deliv 2016; 23:2193-2204. [PMID: 25188841 DOI: 10.3109/10717544.2014.955617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A novel, self-administration drug delivery system for subcutaneous infusion was developed and evaluated. The device includes two main components: an osmotic tablet controlled gas actuator and a syringe catheter system. The sodium carbonate in the osmotic pump tablet will release into the surround citric acid solution and produce CO2 gas, which will drive the drug solution into subcutaneous tissue. The key formulation factors of the osmotic tablet that would influence the infusion profiles of the device were investigated by single factor exploration. The formulation was optimized via a response surface methodology. With an 18 ± 4 min of lag time, the delivery system was able to infuse at an approximate zero-order up to 5.90 ± 0.37 h with a precision of 9.0% RSD (n = 6). A linear correlation was found for the infusion profile and the fitting equation was Y = 0.014X - 0.004 (r = 0.998). A temperature change of 4 °C was found to modify the flow rate by about 12.0%. In vivo results demonstrated that the present subcutaneous infusion device was similar to the commercial infusion pump, and it could bring a long and constant ampicillin plasma level with minimized fluctuations.
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Affiliation(s)
- Xiangyang Xie
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China.,b Department of Pharmacy , Wuhan General Hospital of Guangzhou Military Command , Wuhan , PR China , and
| | - Yang Yang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Yanfang Yang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Zhiping Li
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Hui Zhang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Qiang Chi
- c Department of Pharmacy , The 215th Clinic of 406th Hospital of the Chinese People's Liberation Army , Dalian , China
| | - Xingshi Cai
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Xingguo Mei
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
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Doughty DV, Clawson CZ, Lambert W, Subramony JA. Understanding Subcutaneous Tissue Pressure for Engineering Injection Devices for Large-Volume Protein Delivery. J Pharm Sci 2016; 105:2105-13. [PMID: 27287520 DOI: 10.1016/j.xphs.2016.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
Subcutaneous injection allows for self-administration of monoclonal antibodies using prefilled syringes, autoinjectors, and on-body injector devices. However, subcutaneous injections are typically limited to 1 mL due to concerns of injection pain from volume, viscosity, and formulation characteristics. Back pressure can serve as an indicator for changes in subcutaneous mechanical properties leading to pain during injection. The purpose of this study was to investigate subcutaneous pressures and injection site reactions as a function of injection volume and flow rate. A pressure sensor in the fluid path recorded subcutaneous pressures in the abdomen of Yorkshire swine. The subcutaneous tissue accommodates large-volume injections and with little back pressure as long as low flow rates are used. A 1 mL injection in 10 seconds (360 mL/h flow rate) generated a pressure of 24.0 ± 3.4 kPa, whereas 10 mL delivered in 10 minutes (60 mL/h flow rate) generated a pressure of 7.4 ± 7.8 kPa. After the injection, the pressure decays to 0 over several seconds. The subcutaneous pressures and mechanical strain increased with increasing flow rate but not increasing dose volume. These data are useful for the design of injection devices to mitigate back pressure and pain during subcutaneous large-volume injection.
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Affiliation(s)
- Diane V Doughty
- Drug Delivery and Device Development, Biopharmaceutical Development, MedImmune LLC., Gaithersburg, Maryland 20878.
| | - Corbin Z Clawson
- Drug Delivery and Device Development, Biopharmaceutical Development, MedImmune LLC., Gaithersburg, Maryland 20878
| | - William Lambert
- Drug Delivery and Device Development, Biopharmaceutical Development, MedImmune LLC., Gaithersburg, Maryland 20878
| | - J Anand Subramony
- Drug Delivery and Device Development, Biopharmaceutical Development, MedImmune LLC., Gaithersburg, Maryland 20878
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Oosten AW, Abrantes JA, Jönsson S, de Bruijn P, Kuip EJM, Falcão A, van der Rijt CCD, Mathijssen RHJ. Treatment with subcutaneous and transdermal fentanyl: results from a population pharmacokinetic study in cancer patients. Eur J Clin Pharmacol 2016; 72:459-67. [PMID: 26762381 PMCID: PMC4792338 DOI: 10.1007/s00228-015-2005-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/28/2015] [Indexed: 11/17/2022]
Abstract
Purpose Transdermal fentanyl is effective for the treatment of moderate to severe cancer-related pain but is unsuitable for fast titration. In this setting, continuous subcutaneous fentanyl may be used. As data on the pharmacokinetics of continuous subcutaneous fentanyl are lacking, we studied the pharmacokinetics of subcutaneous and transdermal fentanyl. Furthermore, we evaluated rotations from the subcutaneous to the transdermal route. Methods Fifty-two patients treated with subcutaneous and/or transdermal fentanyl for moderate to severe cancer-related pain participated. A population pharmacokinetic model was developed and evaluated using non-linear mixed-effects modelling. For rotations from subcutaneous to transdermal fentanyl, a 1:1 dose conversion ratio was used while the subcutaneous infusion was continued for 12 h (with a 50 % tapering after 6 h). A 6-h scheme with 50 % tapering after 3 h was simulated using the final model. Results A one-compartment model with first-order elimination and separate first-order absorption processes for each route adequately described the data. The estimated apparent clearance of fentanyl was 49.6 L/h; the absorption rate constant for subcutaneous and transdermal fentanyl was 0.0358 and 0.0135 h−1, respectively. Moderate to large inter-individual and inter-occasion variability was found. Around rotation from subcutaneous to transdermal fentanyl, measured and simulated plasma fentanyl concentrations rose and increasing side effects were observed. Conclusions We describe the pharmacokinetics of subcutaneous and transdermal fentanyl in one patient cohort and report several findings that are relevant for clinical practice. Further research is warranted to study the optimal scheme for rotations from the subcutaneous to the transdermal route. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-2005-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Astrid W Oosten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands.
| | - João A Abrantes
- Department of Pharmacology, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,CNC-Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Evelien J M Kuip
- Department of Medical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Amílcar Falcão
- Department of Pharmacology, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,CNC-Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands.,Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
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Abstract
SummaryPatients with difficult venous access or oral intolerance and clinical situations with inadequate response to oral therapy have generated the need for alternative routes of delivery for drugs and fluids.The purpose of this study was to conduct a systematic review examining the evidence for subcutaneous (SC) administration of drugs and/or fluids.We used a broad search strategy using electronic databases CINAHL, EMBASE, PubMed and Cochrane library, key terms and ‘Medical Subject Headings’ (MeSH) such as ‘subcutaneous route’, ‘hypodermoclysis’ and the name/group of the most used drugs via this route (e.g. ‘ketorolac, morphine, ceftriaxone’, ‘analgesics, opioids, antibiotics’).We conclude that the SC route is an effective alternative for rehydration in patients with mild–moderate dehydration and offers a number of potential advantages in appropriately selected scenarios. Experience of administering drugs by this route suggests that it is well tolerated and is associated with minimal side-effects.
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Kestenbaum MG, Vilches AO, Messersmith S, Connor SR, Fine PG, Murphy B, Davis M, Muir JC. Alternative routes to oral opioid administration in palliative care: a review and clinical summary. PAIN MEDICINE 2014; 15:1129-53. [PMID: 24995406 DOI: 10.1111/pme.12464] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.
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D'Arcy Y. Is continuous subcutaneous infusion a good route for pain medication? Nursing 2010; 40:59-60. [PMID: 20844400 DOI: 10.1097/01.nurse.0000388322.36758.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Yvonne D'Arcy
- Suburban Hospital-Johns Hopkins Medicine, Bethesda, MD, USA
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