A randomized trial of winged Vialon cannulae and metal butterfly needles

The use of metal or plastic needles in continuous subcutaneous infusion in a hospice setting

Objectives. Battery-driven portable syringe drivers are a convenient method for administering many drugs by continuous subcutaneous infusion (CSCI) to patients who cannot swallow medications. At the St. Clare Hospice, nurses usually use plastic needles to minimize needlestick injury but sometimes have patients transferred to metal needles. This study retrospectively examines this practice and its effectiveness.

Methods. The duration of audit was four months. During this period, there were 40 patients (23 women, 17 men), who required their medications delivered by CSCI. A total number of 74 sites were used. Metal or plastic needle CSCIs connected with one-hour release Graseby ® Syringe Drivers were used. The syringes were set to deliver 2 mm/hour. The maximum volume syringe used was 50 ml. The data were collected retrospectively.

Analysis and results. Sixteen patients (21.6 percent) developed minor complications (13 plastic, three metal). Among them, 16 showed inflammation. Two patients (3.5 percent) showed slight bleeding. Only one patient (1.7 percent) showed local infection (metal). In 14 patients (18.9 percent), the needle was reinserted due to various reasons, including needles pulled out by patients or needles falling out due to unknown reasons. There were no needlestick injuries reported, and the staff members reported that all problems encountered were easy to identify and resolve.

Conclusion. Plastic needle CSCI prevents needlestick injury and gives minimum distress to the patients. More research is needed to determine the local side effects of drugs used and the strategies to resolve these problems.

The use of subcutaneous infusion in medication administration

The subcutaneous administration of medications is an area that receives little attention compared with other types of parenteral therapy. Parenteral administration is used by many thousands of patients who self-administer their medication on a daily basis-for example, those using insulin to manage diabetes, recipients of some types of hormone therapy and so on. It is also an effective route for the continuous administration of medication(s) in individuals who are terminally ill. Patients approaching the end of their life may be unable to tolerate the administration of oral medication to control their symptoms and make them more comfortable. This paper will discuss how subcutaneous infusion can be used to deliver these medications, but at the same time how important the selection of the most appropriate subcutaneous infusion device is to the overall comfort of the patient, and to reduce the potential for sharps-related injuries to healthcare workers. Appropriate device selection, together with its management, is an important contributing factor to patient safety and comfort. It will diminish the potential for premature device loss, which can lead to repeated insertion procedures for the patient, as well as delaying their medication. There is also a resource implication for the NHS, as the replacement of any device involves the use of additional equipment and staff time. Additionally, the use of any infusion device poses a risk to healthcare workers of acquiring a bloodborne infection should they experience a percutaneous injury. Knowledge of what equipment is available will reduce the potential risk to these staff.

Subcutaneous infusion in palliative care: the neria soft infusion set

Patients approaching the end of their life may be unable to tolerate the administration of oral medication owing to their underlying disease and/or symptoms, such as nausea and vomiting. Subcutaneous infusion is an alternative route of administration that offers several advantages over oral and intravenous routes. This product focus article provides an overview of subcutaneous infusion, including how the selection of the most appropriate infusion device can greatly contribute to the overall comfort of the patient. This in turn minimises the potential for premature device loss, which can lead to repeated insertion procedures for the patient, increases the potential for infection, and has resource implications. The article then describes the neria soft infusion set, as well as providing case studies of its use.

Subcutaneous infusion in palliative care: the neria soft infusion set

Patients approaching the end of their life may be unable to tolerate the administration of oral medication owing to their underlying disease and/or symptoms, such as nausea and vomiting. Subcutaneous infusion is an alternative route of administration that offers a number of advantages over oral and intravenous routes. This product focus article provides an overview of subcutaneous infusion, including how the selection of the most appropriate infusion device can greatly contribute to the overall comfort of the patient. This in turn minimises the potential for premature device loss, which can lead to repeated insertion procedures for the patient, increases the potential for infection, and has resource implications. The article then describes the recently developed neria soft infusion set, as well as providing case studies of its use.

Improving practice using action research: resolving the problem of kinking with non-metal cannulae

In one UK hospice, inpatient unit records showed that over 8 years 12 needlestick injuries related to continuous subcutaneous infusion of medication occurred. Following a change-over to Teflon cannulae no further incidents were reported. However, when the more sensitive and accurate McKinley T34 syringe drivers were introduced in 2007 a new problem of recurrent occlusion alarm sounding manifested. Investigation revealed that the Teflon cannulae were often kinking, delaying medication delivery and necessitating re-siting of the cannula. The action research approach was used to find an alternative device to improve practice and ensure that both staff and patients were safeguarded. This paper explains how that process was followed until a satisfactory alternative was sourced and evidenced, including an account of the problems that were experienced along the way.

Apomorphine nodules in Parkinson's disease: best practice considerations

Apomorphine hydrochloride infusion therapy is used by approximately 1000 people with advanced Parkinson's disease in the UK (Britannia Pharmaceuticals Ltd, 2008). Subcutaneous nodules that develop as a result of these infusions can cause discomfort and may impact on the effectiveness of the drug therapy. Community nursing teams have a key role in supporting patients on apomorphine; they may be responsible for administering the drug, or supporting and empowering the patient or their carer to administer the infusion. A recent randomized controlled pilot study by a research group at the University of Hertfordshire investigated the use of therapeutic ultrasound for the treatment of apomorphine nodules. A number of observations about apomorphine nodules and the technique used to site infusions were made which may help to promote safe and effective management of apomorphine therapy. This article is a collaboration between one of the researchers and a Parkinson's disease nurse specialist from the University College of London Hospitals NHS Foundation Trust. It draws on best practice observations from both research and clinical experience and puts them in context of published research. It summarizes best practice considerations for administering infusions, identifies the current treatment and management options that participants from the trial reported using on their nodules, emphasizes the need for standardized documentation and suggests a rating system that may be useful to document nodule severity.

The use of syringe drivers: a paediatric perspective

Successful symptom management in the palliative and terminal care of patients frequently involves the use of syringe drivers. A wealth of literature exists to support their use in the care of adult patients both within specialist palliative care inpatient units and in the community setting. However, little has been written regarding their use in the paediatric population. The purpose of this article is to examine specific issues concerning the use of syringe drivers when caring for children and young people in the terminal phase of illness.

Comparison of subcutaneous infusion needles for transfusion-dependent thalassemia patients by the intrapersonal cross-over assessment model

Needle-induced trauma is one of the major contributing factors for poor compliance in patients with thalassaemia major on iron chelation therapy. A new generation of needles is currently available on the market, but their theoretical advantages have not been tested clinically. We performed a study to compare the pros and cons of the representative prototypes from each of the new (Thalaset needle) and old (butterfly scalp vein needle) generations of needles. Patients with thalassemia major who had been receiving subcutaneous iron chelation therapy for at least 2 years were recruited. Patients using butterfly needles were instructed to switch to the newer form of needle (Thalaset) for 2.5 months and then to change back to butterfly needles for another 2.5 months. Comparison was done by the intrapersonal cross-over model using three identical sets of questionnaires collected at the beginning of the study and after the use of Thalaset and butterfly needles, respectively. Fifty-four (22 females; 32 males) patients were included in the statistical analysis. The median age was 24.1 years (range = 7.6-47.2 years). Local reactions such as pain, itchiness, tenderness, and swelling were significantly different among the three evaluation periods and were all in favor of the Thalaset needle (all with P < 0.001), even after adjusting for the intention-to-treat calculation. The Thalaset needle is significantly better than the butterfly needle in reducing needle-related trauma. It induced fewer local skin reactions such as pain, itchiness, tenderness, and swelling. However, recommendations for its routine clinical use require further cost-effectiveness analysis.

The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients

OBJECTIVE

To assess the effect of adding 1 mg dexamethasone to syringe drivers on the viability time of subcutaneous cannulation sites in palliative care patients.

DESIGN

Prospective, double-blind, randomised, controlled trial in which patients received half their daily infused medications plus 1 mg dexamethasone in 1 mL saline through one subcutaneous site (test site) and the other half of their medications plus 1 mL saline through another symmetrically placed site (control site).

PARTICIPANTS AND SETTING

Palliative care patients from the inpatient units at two hospices, recruited between 1999 and 2002.

MAIN OUTCOME MEASURE

Difference in time that the test and control sites remained viable.

RESULTS

38 patients consented and were randomised. Twenty did not complete the trial because their participation in the study finished before either site broke down. Eighteen patients either partially completed (at least one site broke down) or fully completed (both sites broke down) the trial. In these 18 patients, test sites lasted 3.6 days longer than control sites (95% CI, 1.5-5.8 days; P = 0.002). Twelve patients fully completed the trial. In this group, test sites lasted 3.9 days longer than control sites (95% CI, 0.6-7.2 days; P = 0.025).

CONCLUSIONS

The addition of 1 mg dexamethasone to syringe drivers significantly extends the viability time of subcutaneous cannulation sites in palliative care patients.

Subcutaneous infusion: non-metal cannulae vs metal butterfly needles

This review aimed to evaluate the effectiveness of non-metal cannulae compared to metal butterfly needles in maintaining subcutaneous infusion sites in patients receiving palliative care. The Cochrane Library, Medline, Pre-Medline, Embase, CINAHL, Amed and Cancerlit were searched for relevant studies. Controlled trials comparing non-metal cannulae with metal butterfly needles for giving subcutaneous infusion to palliative care patients were included. The outcome considered was site duration in terms of hours of patency or until change was required. Four trials met the inclusion criteria although overall quality was poor due to low follow-up. Studies examined either Teflon or Vialon-coated catheters. All studies showed non-metal cannulae to be superior to metal. In individual studies estimates in mean increase in duration of the site range from 21 to 159 hours. It seems that non-metal cannulae are more effective in maintaining the duration of subcutaneous infusion sites than butterfly needles. Both types of non-metal catheter showed clear benefits. This review has not examined other outcomes but in general adverse effects lead to the removal of the catheter and so would be reflected in the outcome of considered. Although historically non-metal cannulae have been considerably more expensive there is now little difference between metal and Teflon-coated catheters. This review recommends the use of non-metal cannulae in preference to butterfly needles.

A prospective, within-patient comparison between metal butterfly needles and Teflon cannulae in subcutaneous infusion of drugs to terminally ill hospice patients

We performed a prospective study of hospice in-patients requiring a syringe driver (SD), to determine the site duration and tolerability of metal butterfly needles compared to Teflon cannulae. Using patients as their own control, prescribed medications were divided equally between two SDs (Graseby MS16a), for delivery over 24 h. A butterfly infusion (Flosafer, 25 gauge) was connected to one SD and a Teflon cannula (Abbocath-T, 24 gauge), to the second. These were inserted subcutaneously (s.c.) on opposite sides of the body at comparable sites; oedematous, broken or painful sites were excluded. SD sites were examined at 4-hourly intervals. The study was terminated when both devices had required resiting. Needle and cannula times were compared using the Wilcoxon signed rank test. Thirty patients entered the study, 13 males and 17 females, mean age (standard deviation): 70 (11) years. Thirteen patients completed the study. Nine patients died and eight patients discontinued the study before both needle and cannula had been resited. All 30 patients are included in the analysis. The time from insertion to resiting of the cannula was significantly longer than the needle: P < 0.0002, median (range) 93.5 (22.8-263.5) h versus 42.8 (7.5-162.3) h, respectively. The cost of the needle versus cannula is 1.93 Pounds versus 2.51 Pounds, respectively. Teflon cannulae have a median life span twice that of metal butterfly needles and are a cost-effective alternative for administration of medications by s.c. infusion in terminally ill patients.

Randomized controlled trials in palliative care: overcoming the obstacles

Problems associated with conducting randomized controlled trials (RCTs) in palliative care are well documented. Palliative care researchers commonly report difficulties with recruitment, attrition, and randomization. Despite these difficulties, there is a crucial need to enhance the evidence base of palliative care and RCTs are a recognized method for achieving this. Few publications to date have provided clear strategies for researchers considering RCTs in palliative care. This article presents an overview of the features of the RCT and reasons for using this research method. Problems with conducting RCTs are considered with discussion focusing on an approach for managing these hurdles. Examples are provided from an ongoing RCT investigating a support and information programme for lay caregivers of people receiving palliative care at home. The aim of the article is to provide a guide to conducting RCTs and to promote their use in palliative care when researchers are evaluating new interventions.

Subcutaneous drug infusions: a review of problems and solutions

Subcutaneous drug infusion using a portable syringe driver has had a significant impact on patient comfort in palliative care. It permits the continuous delivery of a range of drug therapies, so bypassing problems of dysphagia, weakness and the inability of many patients in the terminal phase to take oral medication. The devices are not problem-free, however. Mechanical problems, reactions at the infusion site and difficulties with the mixing of drugs in the syringe are all widely recognized. This article reviews some general issues with the operation of portable syringe drivers, and discusses a range of potential problems and their solutions.