83Although intravenous (IV) infusion of medications and fluids is the most common type of home infusion therapy, the home infusion nurse also encounters patients who require subcutaneous (SC) and intraspinal infusions. SC infusion therapy is increasingly common, while intraspinal infusions are less common but clearly a high-risk type of infusion that demands clinician competency and organizational policies and procedures. Competency includes knowledge of anatomy and physiology, infusion administration, and management techniques aimed at maintaining access and reducing the risk of complications (Gorski et al., 2016, p. S118).
After reading this chapter, the reader will be able to:
■ Identify indications for SC and intraspinal infusions
■ Discuss SC and intraspinal access device care and management
■ Identify potential complications
SC TISSUE ACCESS AND INFUSION
SC administration of medications or fluids is an increasingly common infusion route in home infusion therapy. A number of medications may be administered via the SC route including opioid infusions for pain management, immunoglobulin therapy, ondansetron, deferoxamine, and terbutaline. Although rarely administered as SC in current 84home infusion practice, SC administration of the antibiotics ceftriaxone and ertapenem appear to be bioequivalent to IV administration (Arthur, 2015; Jin et al., 2015). In a study of palliative care practice, the most commonly SC-administered medications were hydromorphone, haloperidol, and midazolam; however, the administration method studied was bolus SC delivery rather than infusion (Bartz et al., 2014). A systematic review was undertaken to analyze the advantages and disadvantages of SC, IV, and intramuscular administration in head-to-head comparative studies (Jin et al., 2015). The researchers suggest that when safety and efficacy of two injection routes are equivalent (e.g., IV and SC), clinicians should give more consideration to patient preference and pharmacoeconomics to promote optimal treatment adherence, improve patient experience or satisfaction, and reduce overall health care costs.
Advantages to the SC route include ease of access compared to cannulating a vein—most patients have adequate SC tissue with a variety of available locations—and minimal skill is required allowing some patients and caregivers to learn SC access (Arthur, 2015). Limitations and potential contraindications to the SC route may include poor circulation, limited SC tissue, and bleeding or coagulation disorders.
With IV administration, medications or fluids are injected directly into the bloodstream and there is no need for tissue absorption that is required with SC injection. Although there is a slower rate of achieving the maximum concentration of a medication, there is similar bioavailability by both the SC and the IV administration routes (Arthur, 2015). Human recombinant hyaluronidase (HRH) is a medication that can be used to facilitate and hasten the absorption of SC fluids or medications. The HRH is injected just before or with the SC agent. The current INS standards recommend consideration of hyaluronidase to facilitate the dispersion and absorption of hydration fluids and other SC-administered drugs (Gorski et al., 2016, p. S123).
Fast Facts in a Nutshell
The SC tissue is located beneath the dermal layer of the skin and contains blood vessels, nerves, and adipose tissue. Fat tissue in the SC tissue contains numerous blood vessels allowing for diffusion of the SC fluids into the circulation (Figure 6.1).
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Figure 6.1 Anatomy of subcutaneous tissue. Source: Young, O’Dowd, and Woodford (2014). Used with permission.
PATIENT SELECTION CONSIDERATIONS
General guidelines for home SC infusion in relation to the patient include:
■ The patient and family are motivated and willing and capable of participating in self-infusion management.
■ The patient is clinically stable.
■ The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.
■ Reimbursement is verified.
More specific guidelines for patients who may be candidates for SC infusion include:
■ Patients with limited or difficult venous access and the prescribed medication or fluid is appropriate for SC administration.
■ Patients with evidence of moderate dehydration: SC infusion is an alternative to IV administration of isotonic fluids. SC infusion of isotonic hydration fluids is called “hypodermoclysis.” 86Hypodermoclysis is generally indicated as a short-term infusion therapy, generally for 2 to 3 days or less (see Chapter 8).
■ Patients requiring pain management: SC infusion of opioid drugs (e.g., morphine and hydromorphone) for pain management is a common practice in palliative care and hospice settings (see Chapter 12).
■ Patients requiring immunoglobulin therapy: SC infusion is an option for some patients (see Chapter 14).
COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING
Site Assessment and Device Placement
Site Selection
■ Any area where there is adequate SC tissue and the skin is intact (no evidence of bruising, irritation, or scarring) can be used.
■ Most common sites are abdomen (avoid area around navel because of blood vessel proximity), anterior thighs, subclavicular chest wall, upper back, and upper arm.
Site Preparation
■ Wash visibly dirty skin with soap and water.
■ Skin antisepsis: Antiseptic agents are the same as those used for IV preparation, including chlorhexidine–alcohol solutions, 70% alcohol, or povidone-iodine (Gorski et al., 2016).
Device/Type Placement
■ Review and follow the manufacturer’s directions for use with any device.
■ Use small gauge (24–27 gauge) infusion device.
■ If using an over-the-needle catheter, enter the SC tissue at a 30- to 45-degree angle, depending on the thickness of the tissue.
■ Specially designed SC sets are inserted at a 90-degree angle.
■ Aspirate to ensure that there is no blood return, which confirms that the device is in the tissue and not in a small blood vessel (Gorski et al., 2016).
Dressing and Securement
■ A transparent semipermeable dressing is placed over the site, which allows for continuous site observation and assessment.
87Infusion Guidelines
Administration Rates and Methods
■ Hypodermoclysis: Use of a manual flow regulator is recommended (see Chapter 7); an infusion rate of 1,500 mL over 24 hours, which is approximately 60 mL per hour. More than one site may be simultaneously used for larger volumes.
■ Medication administration: Use an electronic infusion device. Although the optimal upper limit of an SC infusion rate is unknown, an infusion rate of 3 to 5 mL per hour is common (Gorski et al., 2016).
■ SC immunoglobulin administration: Syringe pumps are often used; in some cases, patients are taught to manually push the infusion (Gorski et al., 2016, p. S123).
Site Rotation
■ Hypodermoclysis: Change the site after 1.5 to 2 L of fluid have been administered in a single site. Depending on tolerance and site assessment, the site may need to be rotated earlier.
■ Medication administration: Every 7 days and as clinically indicated, based on the integrity of the access site.
■ SC immunoglobulin administration: Limit infusion volume to no more than 30 mL per site (see Chapter 14).
■ Assessment of individual patient tolerance is an important aspect when considering frequency of site rotation.
Monitoring for Complications
Complications related to SC infusions are generally minor. Some edema is expected with hypodermoclysis but will subside as the fluid is absorbed. The infusion rate may need to be reduced. The use of a plastic-type device instead of a steel needle should be considered. Monitor the SC access site with each home visit:
■ Observe site for erythema, swelling, leaking of fluid, bleeding, bruising, or patient complaints of burning or itching at the site (Gorski et al., 2016).
■ The most common problem is local inflammation/pain/discomfort at the needle site; may be caused by highly concentrated drug solutions or too rapid infusion rate. Intervene by increasing the frequency of site rotation, changing concentration or infusion 88rates. Treat inflammation with cool compresses, and avoid harsh soaps or lotions in the area.
■ HRH reactions: Redness, pain, anaphylactic-like or allergic reactions.
PATIENT EDUCATION: KEY POINTS
■ SC access device
■ Plan of care for infusion therapy
■ Check site at least twice per day
■ Report any redness, swelling, or pain to the nurse
■ SC access device placement, site rotation procedure, and infusion management if self-administration is the goal of care
INTRASPINAL CATHETERS
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