PURPOSE Prcedure t guide clinicians in the safe insertin and remval f an indwelling subcutaneus catheter and administratin f medicatins via the device. POLICY STATEMENTS Administratin f subcutaneus medicatins requires a prescriber s rder. The decisin t use an indwelling subcutaneus catheter is made in cllabratin with the patient/caregiver and the prescriber. The indwelling subcutaneus catheter is t be replaced at least every 7 days r mre ften if any prblems arise such as: pain, discmfrt, redness, leakage, bleeding, swelling, r bruising /hematmas at insertin site kinked catheter r ther bstructins lse adhesive dressing: if the dressing is nt secure, there is the pssibility that the catheter will mve and the medicatin will nt be delivered apprpriately in the subcutaneus tissue deteriratin in drug levels r ther parameters withut bvius cause may indicate that medicatin is nt being delivered apprpriately withdrawn catheter liphypertrphy r fat cushin at the catheter tip Needles used t inject via the catheter must be f the smallest gauge pssible (27-31) and nt exceed 8 mm (3/8 ) in length. A new insufln is placed if required prir t remval f an ld ne t ensure rtatin f sites. SITE APPLICABILITY Applicable t all clinical areas. PRACTICE LEVEL/COMPETENCIES Insertin/remval f an indwelling subcutaneus catheter and medicatin administratin via the catheter are fundatinal pediatirc nursing skills and are practiced nce the RN has the required educatin and has had learning validated at the bedside with the apprpriate clinical supprt persn. EQUIPMENT Insertin: Insufln catheter with dressing supplied chlrhexidine/alchl wipe Lcal anaesthetic cream and tegaderm as required sharps cntainer Medicatin administratin: medicatin in syringe 27-31 gauge needle. Length f needle nt t exceed 8 mm (3/8") chlrhexidine/alchl swab Remval: Gauze pad and adhesive bandage if needed PROCEDURE: INSERTION 1. ASSESS if the use f an indwelling subcutaneus catheter (Insufln ) is indicated based n: a. frequency f subcutaneus therapy: daily r mre ften b. adequate subcutaneus tissue present: use Ratinale The use f an indwelling subcutaneus catheter (Insufln ) fr the administratin f frequent subcutaneus injectins has been shwn t reduce the pain f repeated injectins in bth diabetic and nndiabetic ppulatins. Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 1 f 6 Annymus
Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. f an indwelling subcutaneus catheter is dependant n the amunt f subcutaneus tissue present in the patient. NOTE: Generally children shuld weigh at least 2 kg in rder t effectively use the Insufln catheter. Children receiving heparin r lw mlecular weight heparin (LMWH) wh weight less than 5 kg must nt use an Insufln catheter. c. vlume f medicatin t be administered: As the dead space vlume f the Insufln catheter is 0.0075 ml, it is unnecessary t flush the Insufln befre r after use unless mre than 10% f the dse will be lst in the dead space. In this situatin cnsult the prescriber and pharmacy as a small amunt f cmpatible slutin may be cnsidered t flush the medicatin. d. medicatin t be administered. Any medicatin that can be given subcutaneusly, can be given via a subcutaneus indwelling catheter including: Children with very little subcutaneus tissue are nt gd candidates fr use f Insufln as drug absrptin varies with repeated dses in the same lcatin. Sufficient subcutaneus tissue must be present t supprt the catheter. Hematmas will ccur regardless f placement when standard heparin r LMWH are used. T prevent hematmas it is recmmended that 5 minutes f firm pressure be applied t the administratin site fllwing each dse. Due t the catheter dead space vlume, size f the insufln catheter and high incidence f hematmas, use f the device fr delivery f enxaparin is discuraged in babies under 5 kg. Yung children display a strnger preference fr Insufln than lder children. With increasing age, the individual's persnal chice is influenced by factrs ther than pain and cmfrt and these include a desire nt t have visible reminders f their disease. cytsine arabinside desmpressin (DDAVP) erythrpietin G-CSF heparin insulin interfern lw mlecular weight heparin (LMWH) (e.g. enxaparin) mrphine e. patient's preference 2. ASSEMBLE equipment. Facilitates cmpletin f prcedure in a timely manner. 3. PERFORM hand hygiene. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. 4. IDENTIFY patient using 2 client identifiers (e.g. name, DOB, MRN) and EXPLAIN prcedure. 5. SELECT apprpriate injectin site: center third f lateral aspect f upper arm center third f anterir thigh abdmen NOTE: the Insufln catheter shuld nt be placed near a scar, bruise, skin lesin/abrasin r within a 5 cm radius f the umbilicus as this may increase pain and Failure t crrectly identify patients prir t prcedures may result in errrs. Reduces child and family s anxiety. Evaluates and reinfrces understanding f previusly taught infrmatin and cnfirms cnsent fr medicatin administratin. Sites shuld cntain adequate subcutaneus tissue t accmmdate medicatin t be administered. Cnsider age and develpmental level f the child when selecting apprpriate insertin site. CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 2 f 6 Annymus
als affect the absrptin rate f subcutaneus medicatins injected. 6. If desired, APPLY lcal anesthetic cream t the site 30-60 minutes prir t insertin. 7. OBTAIN help f secnd nurse as needed. Decreases pain at injectin site. 8. PERFORM hand hygiene and DON clean glves. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. 9. REMOVE tegaderm and lcal anesthetic cream if Decreases risk f infectin. used and CLEAN site (circular area apprximately 5-8 cm) with chlrhexidine/alchl swab and allw skin t dry. 10. OPEN the package cntaining the Insufln and dressing by pulling the paper lid frm the plastic package. Ensure that the pack is undamaged and sterile and within the expiry date. 11. HOLD the catheter hub between the thumb and index Facilitates insertin. finger and remve the prtective cap. PLACE the cap in the rear f the grip as shwn: 12. PINCH the skin at the site f insertin. INSERT the Insufln as far as pssible at a 20- t 45-degree angle t the skin surface i.e. twards the shulder jint in the arm, twards the hip in the leg, hrizntal and twards the umbilicus in the abdmen. This shuld be dne in ne quick, smth mvement with the bevel up. Islates the subcutaneus tissue and decreases the pssibility f inserting the catheter int the muscle. The angle f insertin is dependent n the amunt f subcutaneus tissue the child has and will vary frm patient t patient. Use a smaller angle/shallwer insertin fr patients with less subcutaneus tissue. Insertin hrizntally int abdmen avids skin flds and clth lines that may kink/damage cannula. If Insufln insertin is t slw there is a risk f the catheter "crimping" r peeling back frm the needle. Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. 13. REMOVE the needle by hlding the catheter hub Care must be taken t prevent catheter withdrawing CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 3 f 6 Annymus
firmly and pulling the needle ut slwly, leaving the catheter in place. NOTE: D nt reinsert the needle if catheter is disldged/withdrawn. Repeat the prcedure with a new Insufln. during placement. 14. DISPOSE needle in sharps cntainer immediately. Prevents ptential accidental needlestick injury. 14. SECURE the Insufln by applying the dressing Built in see-thrugh windw allws fr visual supplied frm the catheter end first, ensuring the inspectin f the injectin site. insertin site is visible thrugh the plastic windw and the hub is pen t air. Ttally adhere dressing t skin t prevent bacteria frm entering insertin site. Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. 15. WRITE the date f insertin n the dressing. If patient is receiving mre than 1 medicatin via insufln, a secnd device is t be inserted. Indicate n dressing which medicatin is being injected via each device. 16. DISPOSE used supplies and equipment in apprpriate cntainer. 17. REMOVE glves and PERFORM hand hygiene. 18. MONITOR insertin site fr any pain, redness, discmfrt, leakage, bleeding, bruising/hematma r swelling. If any adverse reactins ccur, remve device and replace as apprpriate. PROCEDURE: MEDICATION ADMINISTRATION 1. CHECK chart fr prescriber's rder which specifies the drug name, indicatin, dsage, rute and frequency f administratin. Cmmunicatin t thers t ensure device is changed regularly and t prevent administratin f incmpatible medicatins via same device. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. Allws early identificatin and prmpt interventin fr adverse reactins Ratinale Medicatin rders that meet safe prescribing practices prmte patient safety. 2. ASSEMBLE equipment. Facilitates cmpletin f task in timely manner. 3. IDENTIFY patient using 2 client identifiers and ENSURE patient and family understand what Failure t crrectly identify patients prir t prcedures may result in errrs. medicatin is being given and why and hw, any Reduces child and family s anxiety. Evaluates and pssible side effects and that questins are reinfrces understanding f previusly taught answered. CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 4 f 6 Annymus
Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. 4. INSPECT insufln insertin site fr presence f ANY pain, discmfrt, redness, leakage, bleeding, swelling, r bruising /hematmas (palpate site fr small lumps beneath skin surface) and inspect catheter t determine if it has pulled ut frm the skin. If any prblems identified, REPLACE the Insufln catheter prir t administering the dse. infrmatin and cnfirms cnsent fr medicatin administratin. Administering medicatin dses when any cmplicatin is present will exacerbate the prblem. If catheter has pulled ut, medicatin will likely nt be delivered subcutaneusly when injecting. 5. PERFORM hand hygiene. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. 6. CLEAN membrane f catheter with Decreases risk f infectin. chlrhexidine/alchl swab and allw t dry. 7. INSERT syringe needle int the Insufln hub. The needle must penetrate the membrane by at least 3 mm (1/8") and nt mre than 8 mm (3/8"). D nt use excessive frce t insert the needle. A lnger needle culd pssibly damage the catheter. 8. INJECT the medicatin slwly then remve the needle. 9. APPLY firm pressure t site fr at least 5 minutes fllwing administratin f heparin r LMWH ( e.g. enxaparin). A slw injectin will help t reduce site irritatin caused by the medicatin. Minimizes bruising. 10. DISPOSE used supplies and equipment in apprpriate cntainer. PERFORM hand hygiene. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms PROCEDURE: REMOVAL Ratinale 1. PERFORM hand hygiene and DON clean glves. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. 2. IDENTIFY patient using 2 client identifiers and EXPLAIN prcedure. Failure t crrectly identify patients prir t prcedures may result in errrs. 3. PEEL OFF the adhesive dressing, beginning at the catheter end and then REMOVE catheter. APPLY pressure with gauze pad as needed. 4. ASSESS site and place adhesive bandage as needed. 5. DISPOSE used supplies and equipment in apprpriate cntainer. REMOVE glves and PERFORM hand hygiene DOCUMENTATION Reduces child and family s anxiety. Evaluates and reinfrces understanding f previusly taught infrmatin and cnfirms cnsent fr medicatin administratin. Facilitates smth remval f catheter. Minimizes bruising. Rutine Infectin Cntrl practices; reduces transmissin f micrrganisms. DOCUMENT n apprpriate recrd(s): i.e. patient flwsheet, nursing ntes, MAR date and time f insertin site f insertin date and time f remval reasn fr remval site assessments date and time f medicatin administratin CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 5 f 6 Annymus
REFERENCES drug, dse, rute patient's respnse t prcedures unexpected utcmes and related treatment patient/family educatin any ther pertinent actins r bservatins Black, K. and Bauman, M. Insufln Care, Insertin & Remval Patient Care Guideline. Stllery Children's Hspital, Child Health Prgram, Alberta Health Services. Revised Nvember 2008. de Jng, M.E.A, Carbiere, T. and van den Heuvel-Eibrink, M.M. (2006). the Use f an Insufln Device fr the Administratin f G-CSF in Pediatric Cancer Patients. Supprtive Care in Cancer, 14(1): 98-100. Dyer, S.L., Cllins, C.T., Baghurst, P., Saxn, B. and Meachan, B. (2004). Insufln Versus Subcutaneus Injectin fr Cytkine Administratin in Children and Adlescents: A Randmized Crssver Study. Jurnal f Pediatric Onclgy Nurses, 21(2):79-86. Insufln Insertin Prcedure. The Ryal Children's Hspital Melburne. Retrieved February 14, 2013 frm: http://www.rch.rg.au/rchcpg/index.cfm?dc_id=11663. Insufln : Directins fr use. IntraPump Infusin Systems. Revised 31/01/05. Retrieved February 14, 2013 frm: http://www.intrapump.cm/insufln.html. Malwany, J.I., Mnagle, P., Knppert, D.C., Lee, D.S.C., Wu, J., McCusker, P., Massictte, M.P., Williams, S. and Chan, A.K.C. (2008). Enxaparin fr Nenatal Thrmbsis: A Call fr a Higher Dse in Nenates. Thrmbsis Research, 122(6):826-830. Malwany, J.I., Knppert, D.C., Chan, A.K.C, Pepelassis, D., and Lee, D.S. (2007). Enxaparin use in the nenatal intensive care unit: experience ver 8 years. Pharmactherapy, 27(9):1263-71. Mnagle, P., Chan, A.K.C., deveber, G. and Massictte, M.P. (2006). Pediatric Thrmbemblism and Strke, third Editin. BC Decker Inc, Hamiltn, Ontari. Russ, K., Gerber, A., Alvisetti, M., Hug, M. and Bernet, V. (2007). Lng-term subcutaneus mrphine administratin after surgery in newbrns. Jurnal f Perinatal Medicine, 35(1):79-81. Shereck, E. (2008). Insufln Plicy. In P. DeZrzi (Ed.). Vancuver. Refer t nline versin Print cpy may nt be current Discard after use The fllwing infrmatin, i.e. guideline/educatinal material/plicy r prcedure, has been develped fr use nly within BC Children's Hspital (BC Children's) and BC Wmen's Hspital and Health Centre (BC Wmen's). Agencies ther than BC Children's r BC Wmen's shuld use this infrmatin as a guideline fr reference purpses nly. All materials are the prperty f BC Children's and BC Wmen's and may nly be reprinted in whle r in part with ur expressed permissin. Cntact PlicyCrdinatr@cw.bc.ca with questins. CM.03.26 BC Children s Hspital Child & Yuth Health Plicy and Prcedure Manual Page 6 f 6 Annymus