FEATURE COMMENT
Intravenous versus subcutaneous access for palliative care patients Janice Gabriel Potential complications of peripheral vascular access devices
Abstract
The subcutaneous route for medication administration can prove highly effective both in terms of reliability and clinical outcomes. It is also well tolerated by patients for whom the enteral route is not an option. This extended feature comment reviews the advantages and disadvantages of both the intravenous and subcutaneous routes of medication administration for patients requiring palliation. Key words: Palliative care ■ Peripheral vascular access devices ■ Subcutaneous access Parenteral therapy ■ Infusion-related complications ■ Device securement
■
Consideration of parental routes When an individual is unable to take medication(s) and/or fluids via an oral route, consideration needs to be given to what medications(s) need to be administered via a parenteral route in order to manage their condition. For those individuals nearing the end of life, the ultimate aim of their management is to keep them comfortable by controlling their symptoms (Twycross et al, 2009; Twycross and Wilcock, 2011). The common conditions occurring in this group of individuals include (Twycross et al, 2009; Twycross and Wilcock, 2011): ■■ Nausea and vomiting ■■ Pain ■■ Breathlessness ■■ Agitation ■■ Dysphagia. While the intravenous route can be used to deliver medications to manage these problems, Janice Gabriel is Strategic Clinical Networks Manager, NHS England (Wessex), Southampton
S20
the siting of peripheral cannulae can be a challenge for both the health professional and the patient. This can be a consequence of the patient’s current condition and/or previous venous access attempts and include (Twycross and Wilcock, 2011; Gabriel, 2012): ■■ Oedematous tissue ■■ Poor venous access ■■ Fragile skin ■■ Obesity ■■ Emaciation ■■ Inability to secure an intravenous access device (for example a restless/confused patient). Assessment of the patient’s clinical condition as well as intended therapy will ensure the most appropriate route and method of medication(s) is identified (Royal College of Nursing (RCN), 2010; Gabriel, 2013).
Subcutaneous access Subcutaneous infusion devices involve either a hollow bore steel needle or cannula being inserted under the patient’s skin using an aseptic procedure (Pratt et al, 2007; Gabriel 2012). Such devices are then secured in position and attached to an infusion device. This can involve a simple syringe for a oneoff bolus administration, following which the infusion device is removed. More commonly, the infusion device will be attached to a syringe driver (pump) for continuous infusions of
Box 1. Potential complications of a peripheral vascular access device Potential complication
Reason
Mechanical phlebitis
Irritation to the tunica intima caused by the VAD i.e. insufficient space for blood to flow between the VAD and tunica intima
Chemical phlebitis
Irritation to the tunica intima from the infusate
Infective phlebitis
Infection introduced through the cannulation site into the vein resulting in irritation to the tunica intima.
VAD occlusion
■ Can
Fibrin sheath/tails
Development of fibrin/tail around the VAD, which can prevent infusion and/or aspiration from the VAD
Device migration
Insufficient/loss of stabilisation of VAD leading to device migration as well as potential for infiltration of the infusate into surrounding tissues.
Patient comfort
Majority of VADs are sited in an individual’s arm veins, therefore imposing limitations on movement.
be a consequence of either blood reflux into the lumen of the VAD causing total or partial obstruction ■ Can result from precipitation of infusates
Source: Ingram and Lavery, 2005; Royal College of Nursing, 2010; Gabriel, 2011; 2013
© 2014 MA Healthcare Ltd
T
he aims of this comment are to provide nurses with an overview of the subcutaneous administration route, and how it compares to the intravenous route for individuals requiring parenteral administration of medications for palliation. Complications are discussed, as well as securement to mitigate the potential for device migration and provide patient comfort. Readers will come away with increased awareness of the specific considerations for patients requiring palliative care.
As vascular access devices (VADs) reside within the lumen of a blood vessel, they are subject to a broader range of potential complications compared with a subcutaneous device. The more common complications of peripheral VADs are summarised in Box 1. In addition, loss of vascular access can lead to a delay in administration of the patient’s medication(s), which can result in distress for the patient as a consequence of insufficient/ absence of medication for symptom control. Reinsertion of a VAD will also involve additional resources, not just from materials but also as a consequence of health professionals’ time (Gabriel, 2013).
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
Paul Shambroom/Science Photo Library
FEATURE COMMENT
Patient comfort, safety and clinical effectiveness are paramount to choosing the appropriate administration route for medication
Advantages
Disadvantages
Reduced infusion-related complications compared with a VAD (see Box 1)
Can only be used for infusion of small volumes
Greater range of insertion sites as non-reliant on venous access
Not all medications can be delivered subcutaneously
Increased patient comfort (less physical restrictions compared with a peripheral VAD) Reliable method for medication delivery Less specialist skills required for insertion Source: Twycross and Wilcock, 2011; Gabriel, 2012
prescribed medication(s). The infusion device is then secured with a sterile, adhesive dressing. Ideally, this dressing should have a transparent window over the device insertion site, which will allow ease of observation for the health professional to assess for any potential signs of potential of potential complications, such as inflammation, without having to disturb the dressing (RCN, 2010; Gabriel, 2012). The potential advantages and disadvantages of a
S22
subcutaneous infusion device are summarised in Box 2.
Conclusion When considering the most appropriate administration route for any medication, patient comfort, safety and clinical effectiveness are the prime considerations. Where the intravenous route can accommodate larger infusion and medication
Gabriel J (2012) Venepuncture and cannulation: considering the ageing vein. Br J Nurs 21(2): S22-8 Gabriel J (2012) Subcutaneous infusion in palliative care: the neria soft infusion set. Br J Nurs 21(21): S14-8 Gabriel J (2013) Long-term central venous access device selection. Nurs Times 109(39): 12-5 Ingram P, Lavery I (2005) Peripheral intravenous therapy: key risks and implications for practice. Nurs Stand 19(46): 55-64 Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England. J Hosp Infect 65(Suppl 1): S1-64 Royal College of Nursing (2010) Standards for Infusion Therapy, 3rd edn. RCN, London. http://tinyurl.com/ ncf6lhm (accessed 6 January 2014) Twycross R, Wilcock A (2011) Palliative Care Formulary, 4th edn. palliativedrugs. com Ltd, Nottingham Twycross R, Wilcock A, Stark Toller C (2009) Symptom Management in Advanced Cancer, 4th edn. palliativedrugs. com Ltd, Nottingham
© 2014 MA Healthcare Ltd
volumes, it is not without its potential complications. The subcutaneous route can be an effective method of medication delivery for many patients requiring palliation of symptoms. Subcutaneous infusion devices are simple to site, pose a more limited range of infusion-related complications compared with the vascular access route and, importantly, they BJN are more comfortable for the patient.
Box 2. Potential advantages and disadvantages of a subcutaneous infusion device
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
Intravenous versus subcutaneous access for palliative care patients Janice Gabriel Potential complications of peripheral vascular access devices
Abstract
The subcutaneous route for medication administration can prove highly effective both in terms of reliability and clinical outcomes. It is also well tolerated by patients for whom the enteral route is not an option. This extended feature comment reviews the advantages and disadvantages of both the intravenous and subcutaneous routes of medication administration for patients requiring palliation. Key words: Palliative care ■ Peripheral vascular access devices ■ Subcutaneous access Parenteral therapy ■ Infusion-related complications ■ Device securement
■
Consideration of parental routes When an individual is unable to take medication(s) and/or fluids via an oral route, consideration needs to be given to what medications(s) need to be administered via a parenteral route in order to manage their condition. For those individuals nearing the end of life, the ultimate aim of their management is to keep them comfortable by controlling their symptoms (Twycross et al, 2009; Twycross and Wilcock, 2011). The common conditions occurring in this group of individuals include (Twycross et al, 2009; Twycross and Wilcock, 2011): ■■ Nausea and vomiting ■■ Pain ■■ Breathlessness ■■ Agitation ■■ Dysphagia. While the intravenous route can be used to deliver medications to manage these problems, Janice Gabriel is Strategic Clinical Networks Manager, NHS England (Wessex), Southampton
S20
the siting of peripheral cannulae can be a challenge for both the health professional and the patient. This can be a consequence of the patient’s current condition and/or previous venous access attempts and include (Twycross and Wilcock, 2011; Gabriel, 2012): ■■ Oedematous tissue ■■ Poor venous access ■■ Fragile skin ■■ Obesity ■■ Emaciation ■■ Inability to secure an intravenous access device (for example a restless/confused patient). Assessment of the patient’s clinical condition as well as intended therapy will ensure the most appropriate route and method of medication(s) is identified (Royal College of Nursing (RCN), 2010; Gabriel, 2013).
Subcutaneous access Subcutaneous infusion devices involve either a hollow bore steel needle or cannula being inserted under the patient’s skin using an aseptic procedure (Pratt et al, 2007; Gabriel 2012). Such devices are then secured in position and attached to an infusion device. This can involve a simple syringe for a oneoff bolus administration, following which the infusion device is removed. More commonly, the infusion device will be attached to a syringe driver (pump) for continuous infusions of
Box 1. Potential complications of a peripheral vascular access device Potential complication
Reason
Mechanical phlebitis
Irritation to the tunica intima caused by the VAD i.e. insufficient space for blood to flow between the VAD and tunica intima
Chemical phlebitis
Irritation to the tunica intima from the infusate
Infective phlebitis
Infection introduced through the cannulation site into the vein resulting in irritation to the tunica intima.
VAD occlusion
■ Can
Fibrin sheath/tails
Development of fibrin/tail around the VAD, which can prevent infusion and/or aspiration from the VAD
Device migration
Insufficient/loss of stabilisation of VAD leading to device migration as well as potential for infiltration of the infusate into surrounding tissues.
Patient comfort
Majority of VADs are sited in an individual’s arm veins, therefore imposing limitations on movement.
be a consequence of either blood reflux into the lumen of the VAD causing total or partial obstruction ■ Can result from precipitation of infusates
Source: Ingram and Lavery, 2005; Royal College of Nursing, 2010; Gabriel, 2011; 2013
© 2014 MA Healthcare Ltd
T
he aims of this comment are to provide nurses with an overview of the subcutaneous administration route, and how it compares to the intravenous route for individuals requiring parenteral administration of medications for palliation. Complications are discussed, as well as securement to mitigate the potential for device migration and provide patient comfort. Readers will come away with increased awareness of the specific considerations for patients requiring palliative care.
As vascular access devices (VADs) reside within the lumen of a blood vessel, they are subject to a broader range of potential complications compared with a subcutaneous device. The more common complications of peripheral VADs are summarised in Box 1. In addition, loss of vascular access can lead to a delay in administration of the patient’s medication(s), which can result in distress for the patient as a consequence of insufficient/ absence of medication for symptom control. Reinsertion of a VAD will also involve additional resources, not just from materials but also as a consequence of health professionals’ time (Gabriel, 2013).
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
Paul Shambroom/Science Photo Library
FEATURE COMMENT
Patient comfort, safety and clinical effectiveness are paramount to choosing the appropriate administration route for medication
Advantages
Disadvantages
Reduced infusion-related complications compared with a VAD (see Box 1)
Can only be used for infusion of small volumes
Greater range of insertion sites as non-reliant on venous access
Not all medications can be delivered subcutaneously
Increased patient comfort (less physical restrictions compared with a peripheral VAD) Reliable method for medication delivery Less specialist skills required for insertion Source: Twycross and Wilcock, 2011; Gabriel, 2012
prescribed medication(s). The infusion device is then secured with a sterile, adhesive dressing. Ideally, this dressing should have a transparent window over the device insertion site, which will allow ease of observation for the health professional to assess for any potential signs of potential of potential complications, such as inflammation, without having to disturb the dressing (RCN, 2010; Gabriel, 2012). The potential advantages and disadvantages of a
S22
subcutaneous infusion device are summarised in Box 2.
Conclusion When considering the most appropriate administration route for any medication, patient comfort, safety and clinical effectiveness are the prime considerations. Where the intravenous route can accommodate larger infusion and medication
Gabriel J (2012) Venepuncture and cannulation: considering the ageing vein. Br J Nurs 21(2): S22-8 Gabriel J (2012) Subcutaneous infusion in palliative care: the neria soft infusion set. Br J Nurs 21(21): S14-8 Gabriel J (2013) Long-term central venous access device selection. Nurs Times 109(39): 12-5 Ingram P, Lavery I (2005) Peripheral intravenous therapy: key risks and implications for practice. Nurs Stand 19(46): 55-64 Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England. J Hosp Infect 65(Suppl 1): S1-64 Royal College of Nursing (2010) Standards for Infusion Therapy, 3rd edn. RCN, London. http://tinyurl.com/ ncf6lhm (accessed 6 January 2014) Twycross R, Wilcock A (2011) Palliative Care Formulary, 4th edn. palliativedrugs. com Ltd, Nottingham Twycross R, Wilcock A, Stark Toller C (2009) Symptom Management in Advanced Cancer, 4th edn. palliativedrugs. com Ltd, Nottingham
© 2014 MA Healthcare Ltd
volumes, it is not without its potential complications. The subcutaneous route can be an effective method of medication delivery for many patients requiring palliation of symptoms. Subcutaneous infusion devices are simple to site, pose a more limited range of infusion-related complications compared with the vascular access route and, importantly, they BJN are more comfortable for the patient.
Box 2. Potential advantages and disadvantages of a subcutaneous infusion device
British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
