Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center.

BACKGROUND: Continuous subcutaneous infusion (CSCI) via ambulatory infusion pump (AIP) is a valuable method of pain control in palliative care. When using CSCI, low-dose methadone as add-on to other opioids might be an option in complex pain situations. This study aimed to investigate the effects, and adverse effects, of CSCI for pain control in dying patients, with particular interest in methadone use. METHODS: This was an observational cohort study. Imminently dying patients with pain, admitted to specialized palliative inpatient wards and introduced on CSCI, were monitored daily by staff for symptoms (Integrated Palliative Care Outcome Scale - IPOS), sedation (Richmond Agitation and Sedation Scale - RASS), performance status (Eastern Cooperative Oncology Group - ECOG) and delirium (Confusion Assessment Method - CAM). RESULTS: Ninety-three patients with a median survival of 4 days were included. Of the 47 patients who survived ≥3 days, the proportion of patients with severe/overwhelming pain decreased from 45 to 19% (p < 0.001) after starting CSCI, with only a moderate increase in morphine equivalent daily dose of opioids (MEDD). Alertness was marginally decreased (1 point on the 10-point RASS scale, p = 0.001), whereas performance status and prevalence of delirium, regardless of age, remained unchanged. Both patients with methadone as add-on (MET, n = 13) and patients with only other opioids (NMET, n = 34), improved in pain control (p < 0.05 and 0.001, respectively), despite that MET patients had higher pain scores at baseline (p < 0.05) and were on a higher MEDD (240 mg vs.133 mg). No serious adverse effects demanding treatment stop were reported. CONCLUSIONS: CSCI via AIP is an effective way to reduce pain in dying patients without increased adverse effects. Add-on methadone may be beneficial in patients with severe complex pain.

An evaluation of continuous subcutaneous infusions across seven NHS acute hospitals: is there potential for 48-hour infusions?

BACKGROUND: Continuous subcutaneous infusions (CSCIs) are commonly used in the United Kingdom as a way of administering medication to patients requiring symptom control when the oral route is compromised. These infusions are typically administered over 24 h due to currently available safety data. The ability to deliver prescribed medication by CSCI over 48 h may have numerous benefits in both patient care and health service resource utilisation. This service evaluation aims to identify the frequency at which CSCI prescriptions are altered at NHS Acute Hospitals. METHODS: Pharmacists or members of palliative care teams at seven acute NHS hospitals recorded anonymised prescription data relating to the drug combination(s), doses, diluent and compatibility of CSCIs containing two or more drugs on a daily basis for a minimum of 2 days, to a maximum of 7 days. RESULTS: A total of 1301 prescriptions from 288 patients were recorded across the seven sites, yielding 584 discrete drug combinations. Of the 584 combinations, 91% (n = 533) included an opioid. The 10 most-common CSCI drug combinations represented 37% of the combinations recorded. Median duration of an unchanged CSCI prescription across all sites was 2 days. CONCLUSION: Data suggests medication delivered by CSCI over 48 h may be a viable option. Before a clinical feasibility study can be undertaken, a pharmacoeconomic assessment and robust chemical and microbiological stability data will be required, as will the assessment of the perceptions from clinical staff, patients and their families on the acceptability of such a change in practice.

Effectiveness of Continuous Subcutaneous Insulin Infusion on Parental Quality of Life and Glycemic Control Among Children With T1D: Meta-Analysis.

BACKGROUND: Type 1 diabetes (T1D) is one of the most common chronic diseases in childhood. Daily diabetes management poses a major challenge for parents. Intensive insulin therapy using continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) are recommended for patients with T1D, but evidence for their effectiveness on parental quality of life (QOL) and glycemic control among children with T1D is inconclusive. OBJECTIVES: A systematic review was conducted to determine the best available evidence regarding the effectiveness of CSII compared to MDI on parental QOL and glycemic control among children with T1D. METHODS: Studies in English and Chinese from 1978 to March 2015 were identified by searching electronic databases, published references, and unpublished studies. Randomized controlled trials (RCTs) comparing CSII with MDI related to parental QOL and glycemic control (HbA1c) among patients aged 18 years or below with T1D were included. Secondary outcomes were episodes of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA). RESULTS: Seven RCTs were identified. Parental QOL was reported in two studies, with one study reporting no significant improvement in the CSII group and one reporting a significant reduction in diabetes-related worry in the CSII group but increased frequency of stress relating to child medical care in the MDI group. Meta-analysis of seven RCTs involving 220 patients demonstrated that CSII was associated with significant decrease in HbA1c level (MD = -0.24%, 95% CI = -0.41 to -0.07, p = .006) compared to MDI. There were no significant differences in episodes of SH and DKA between the CSII and MDI groups. LINKING EVIDENCE TO ACTION: CSII slightly reduced HbA1c by .24% compared to MDI. Based on two RCTs with small sample sizes, there is insufficient evidence to draw any conclusions on the beneficial effects of CSII compared with MDI on parental QOL among children with T1D. More RCTs with larger samples are needed.

Achieving successful subcutaneous access in palliative patients.

Subcutaneous administration of medications is a well-recognised route for delivering prescribed therapies, in particular analgesia for patients requiring palliative care. Technological advancements in infusion devices and dressings can result in well-tolerated and effective methods for continuous infusions for this group of individuals. This article discusses how technological developments are resulting in subcutaneous access devices that are easy to insert and can meet the needs of a growing patient population, as well as complying with the latest guidelines on sharps safety. Combining these with staff education could result in improved patient care.

Nursing knowledge and practices regarding subcutaneous fluid administration.

OBJECTIVE:: To describe the evidence in the literature regarding the knowledge and practices of the nursing team about subcutaneous administration of drugs and fluids in adults. METHOD:: Integrative review of the literature using the descriptors "nursing", "hypodermoclysis", "drug administration routes", "adult health," and "knowledge," in English, Spanish, and Portuguese, with no publication deadline. Of the 569 articles found, eight made up the sample. RESULTS:: A predominance of international journals (75%) with more than five years of publication (62.5%). The analysis of the methodological characteristics showed a predominance of literature reviews (25%), quantitative studies (62.5%), cross-sectional studies (50%), and non-experimental studies (50%). CONCLUSION:: Although it is an old technique with proven efficacy, hypodermoclysis is still little used, a puzzling fact due to its advantages and indications for any age. OBJETIVO:: descrever as evidências, na literatura, sobre os conhecimentos e as práticas da equipe de enfermagem na administração de medicamentos e de fluidos por via subcutânea no adulto. MÉTODO:: revisão integrativa da literatura utilizando os descritores enfermagem, hipodermóclise, vias de administração de medicamentos, saúde do adulto e conhecimento; nos idiomas inglês, espanhol e português, sem data limite de publicação. Dos 569 artigos encontrados, oito compuseram a amostra. RESULTADOS:: predomínio de revistas internacionais (75%) e com mais de cinco anos de publicação (62,5%). Ao analisarem-se as características metodológicas, predominaram: revisões de literatura (25%), estudos quantitativos (62,5%), estudos transversais (50%) e não-experimentais (50%). CONCLUSÃO:: apesar de se tratar de uma técnica antiga com eficácia comprovada, a hipodermóclise ainda é pouco utilizada, fato incoerente pelas suas vantagens e suas indicações para qualquer idade.

Nursing knowledge and practices regarding subcutaneous fluid administration / Conocimientos y prácticas de enfermería en la administración de fluidos por vía subcutánea / Conhecimentos e práticas da enfermagem na administração de fluidos por via subcutânea

ABSTRACT Objective: To describe the evidence in the literature regarding the knowledge and practices of the nursing team about subcutaneous administration of drugs and fluids in adults. Method: Integrative review of the literature using the descriptors "nursing", "hypodermoclysis", "drug administration routes", "adult health," and "knowledge," in English, Spanish, and Portuguese, with no publication deadline. Of the 569 articles found, eight made up the sample. Results: A predominance of international journals (75%) with more than five years of publication (62.5%). The analysis of the methodological characteristics showed a predominance of literature reviews (25%), quantitative studies (62.5%), cross-sectional studies (50%), and non-experimental studies (50%). Conclusion: Although it is an old technique with proven efficacy, hypodermoclysis is still little used, a puzzling fact due to its advantages and indications for any age.

RESUMEN Objetivo: Describir las evidencias, en la literatura, acerca de los conocimientos y prácticas del equipo de enfermería sobre administración de medicamentos y fluidos por vía subcutánea en adultos. Método: Revisión integrativa de la literatura, utilizando los descriptores: enfermería, hipodermoclisis, vías de administración de medicamentos, salud del adulto y conocimiento; en idiomas inglés, español y portugués, sin fecha límite de publicación. Fueron encontrados 569 artículos, de los cuales 8 integraron la muestra. Resultados: Predominio de revistas internacionales (75%), y con más de cinco años de publicación (62,5%). Al analizarse las características metodológicas, predominaron: revisiones de literatura (25%), estudios cuantitativos (62,5%), estudios transversales (50%) y no experimentales (50%). Conclusión: A pesar de tratarse de una técnica antigua de comprobada eficacia, la hipodermoclisis es aún poco utilizada, hecho inexplicable, dadas sus ventajas e indicaciones para cualquier edad.

RESUMO Objetivo: descrever as evidências, na literatura, sobre os conhecimentos e as práticas da equipe de enfermagem na administração de medicamentos e de fluidos por via subcutânea no adulto. Método: revisão integrativa da literatura utilizando os descritores enfermagem, hipodermóclise, vias de administração de medicamentos, saúde do adulto e conhecimento; nos idiomas inglês, espanhol e português, sem data limite de publicação. Dos 569 artigos encontrados, oito compuseram a amostra. Resultados: predomínio de revistas internacionais (75%) e com mais de cinco anos de publicação (62,5%). Ao analisarem-se as características metodológicas, predominaram: revisões de literatura (25%), estudos quantitativos (62,5%), estudos transversais (50%) e não-experimentais (50%). Conclusão: apesar de se tratar de uma técnica antiga com eficácia comprovada, a hipodermóclise ainda é pouco utilizada, fato incoerente pelas suas vantagens e suas indicações para qualquer idade.

Identification of drug combinations administered by continuous subcutaneous infusion that require analysis for compatibility and stability.

BACKGROUND: A continuous subcutaneous infusion (CSCI) delivered via syringe pump is a method of drug administration used to maintain symptom control when a patient is no longer able to tolerate oral medication. Several classes of drugs, such as opioids, antiemetics, anticholinergics, antipsychotics and benzodiazepines are routinely administered by CSCI alone or in combinations. Previous studies attempting to identify the most-common CSCI combinations are now several years old and no longer reflect current clinical practice. The aim of this work was to review current clinical practice and identify CSCI drug combinations requiring analysis for chemical compatibility and stability. METHODS: UK pharmacy professionals involved in the delivery of care to palliative patients in hospitals and hospices were invited to enter CSCI combinations comprised of two or more drugs onto an electronic database over a 12-month period. In addition, a separate Delphi study with a panel of 15 expert healthcare professionals was completed to identify a maximum of five combinations of drugs used to treat more complex, but less commonly encountered symptoms unlikely to be identified by the national survey. RESULTS: A total of 57 individuals representing 33 separate palliative care services entered 1,945 drug combinations suitable for analysis, with 278 discrete combinations identified. The top 40 drug combinations represented nearly two-thirds of combinations recorded. A total of 23 different drugs were administered in combination and the median number of drugs in a combination was three. The Delphi study identified five combinations for the relief of complex or refractory symptoms. CONCLUSION: This study represents the first step towards developing authoritative national guidance on the administration of drugs by CSCI. Further work will ensure healthcare practitioners have the knowledge and confidence that a prescribed combination will be both safe and efficacious.

Understanding the role of the Parkinson's disease nurse specialist in the delivery of apomorphine therpy.

Optimal care of Parkinson's disease (PD) patients should involve a multidisciplinary team (MDT) of which a PD nurse specialist (PDNS) is a key member. The role of a PDNS is particularly prominent in the care of advanced PD patients suitable for apomorphine because, in addition to nursing skills, apomorphine treatment requires liaison, training, interaction and coordination with patients, caregivers and other members of the MDT as well as the interface with primary care physicians. The therapeutic success of apomorphine therapy depends not only upon the pharmacologic drug response, but also on how well the patient understands his/her disease and how to handle the therapy. In this respect, a PDNS is a vital member of the MDT who provides education and training, support, and is available for consultation when problems arise. In this article, we review the literature on the contribution of PDNSs in both continuous subcutaneous apomorphine infusion and intermittent subcutaneous apomorphine injection and highlight the various beneficial aspects of PDNS care, supported by scientific evidence when available. Despite a low level of published evidence, there is strong clinical evidence that the impact of PDNSs on the management of apomorphine therapy is vital and indispensable for the success of this treatment.

A Comparative Study of Intravenous Immunoglobulin and Subcutaneous Immunoglobulin in Adult Patients with Primary Immunodeficiency Diseases: A Systematic Review and Meta-Analysis.

Subcutaneous immunoglobulin (SCIG) is a new therapeutic procedure for patients with primary immunodeficiency (PI). This research is a systematic review of studies on the efficacy and safety of intravenous immunoglobulin (IVIG) and SCIG in adult patients with PI. This study includes a systematic review of cohorts and randomized clinical trials (24 articles) from 5 databases with no time limits. Random effects meta-analysis was performed for outcomes such as efficacy and safety. Standard mean difference (SMD) of serum immunoglobulin level was equal to 0.336 (P <0.01; 0.205-0.467) and the odds ratio (OR) of side effects was 0.497 (P=0.1; 0.180-1.371). The results indicate that SCIG leads to a higher level of immunoglobulin and a reduction in side effects but shows the same infection rate as IVIG. Our analysis shows that shifting from IVIG to SCIG therapy can have clinical benefits for PI patients.

Instauración y seguimiento de la infusión continua de apomorfina / No disponible

La apomorfina en infusión continua es un tratamiento establecido para la enfermedad de Parkinson avanzada desde hace más de dos décadas. En este artículo revisamos los diversos métodos para la instauración de dicho tratamiento y proponemos una metodología de consenso para el inicio, así como para la modificación del tratamiento previo. Con todo ello se pretende homogeneizar y reducir la variabilidad de la práctica clínica (AU)

Continuous apomorphine infusion has been an established treatment for advanced Parkinson’s disease for over two decades. This article reviews the different methods for starting treatment and propose a consensus methodology for it, as well as for the modification of prior treatment, in order to standardize and reduce the variability of clinical practice (AU)

[Subcutaneous continuous apomorphine infusion: treatment initiation and follow up]. / Instauración y seguimiento de la infusión continua de apomorfina.

Continuous apomorphine infusion has been an established treatment for advanced Parkinson's disease for over two decades. This article reviews the different methods for starting treatment and propose a consensus methodology for it, as well as for the modification of prior treatment, in order to standardize and reduce the variability of clinical practice.

Indications and safety of intravenous and subcutaneous immunoglobulin therapy.

Immunoglobulin (Ig) therapy is an important method of treatment for a number of immunological, hematological, neurological and dermatological disorders. Over the years, the range of indications in which Ig therapy, either replacement or immunomodulatory, is effective has substantially increased. Although Ig therapy was originally limited to intramuscular injection, intravenous infusion has became the most frequent route of administration, followed by subcutaneous injection. This article presents current information on indications, mechanisms of action, efficacy and practical aspects of intravenous and subcutaneous Ig replacement/immunomodulatory therapy as well as associated adverse reactions.

Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy.

Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective.Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA(1c) levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon.Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA(1c) values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake.CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA(1c) or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure.CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up.

Repercusión en nuestra unidad del cambio de vía de administración de Epoetinum Alfa / The repercussion in our unit of a change in the form of administration of Epoetinum Alpha

Tras la publicación de la nota informativa de la Agencia Española del Medicamento, donde se contraindica la vía subcutánea para la administración de epoetinum alfa, en nuestra unidad cambiamos la vía de administración a intravenosa y diseñamos este estudio, donde se pretende comprobar las diferencias existentes entre ambas vías de administración. Realizamos un estudio prospectivo aleatorio de 24 semanas de duración a un total de 54 pacientes en programa de HD, que recibían dos inyecciones semanales por vía subcutánea y pasaron a prescripción de la misma dosis de epoetinum alfa por vía intravenosa, mediante 3 dosis semanales. Se monitorizaron a la 8, 16 y 24 semana del estudio los siguientes parámetros: dosis administradas, hemoglobina, ferritina sérica, número de administraciones semanales y coste del tratamiento según el precio de venta libre del producto e incluyendo el costo del trabajo de enfermería. Los resultados obtenidos confirman la menor eficacia de la vía de administración intravenosa de epoetinum alfa con respecto a la vía subcutánea. Produciéndose un aumento en las dosis administradas y en su frecuencia de administración semanal, para el tratamiento y mantenimiento de la anemia, incrementando con ello el coste del tratamiento (AU)

Following the publication of the informative note of the Agencia Española del Medicamento (Spanish Agency of Medicine), which does not recommend the use of the subcutaneous path in administering Epoetinum alpha, in our unit we changed the form of administration to intravenous and drew up this study, where we intended to check the differences between both forms of administration. We carried out a 24-week random prospective study on a total 54 patients on an HD programme, who received two injections a week subcutaneously and went over to a prescription of the same dose of epoetinum alpha intravenously, with 3 doses a week. In week 8, 16 and 24 of the study, the following parameters were monitored: doses administered, haemoglobin, serum ferritin, weekly number of administrations and the cost of the treatment according to the free sale price of the product and including the cost of the nursing work. The results achieved confirm the lesser effectiveness of the intravenous administration of epoetinum alpha with respect to the subcutaneous, causing an increase in the doses administered and the weekly administration frequency for the treatment and maintenance of the anaemia, thus increasing the cost of the treatment (AU)