INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) INSERTION, MEDICATION ADMINISTRATION and REMOVAL PURPOSE POLICY STATEMENTS SITE APPLICABILITY

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1 INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) UROSE rocedure to guide clinicians in the safe insertion and removal of an indwelling subcutaneous catheter and administration of medications via the device OLICY STATEMENTS Administration of subcutaneous medications requires a prescriber s order. The decision to use an indwelling subcutaneous catheter is made in collaboration with the patient/caregiver and the prescriber. The indwelling subcutaneous catheter is to be replaced at least every 7 days or more often if any problems arise such as: pain, discomfort, redness, leakage, bleeding, swelling, or bruising /hematomas at insertion site kinked catheter or other obstructions loose adhesive dressing: if the dressing is not secure, there is the possibility that the catheter will move and the medication will not be delivered appropriately in the subcutaneous tissue deterioration in drug levels or other parameters without obvious cause may indicate that medication is not being delivered appropriately withdrawn catheter lipohypertrophy or fat cushion at the catheter tip Needles used to inject via the catheter must be of the smallest gauge possible (27-31) and not exceed 8 mm (3/8 ) in length. A new insuflon is placed if required prior to removal of an old one to ensure rotation of sites. SITE ALICABILITY Applicable to all clinical areas. RACTICE LEVEL/COMETENCIES Insertion/removal of an indwelling subcutaneous catheter and medication administration via the catheter are foundational pediatric nursing skills and are practiced once the RN has the required education and has had learning validated at the bedside with the appropriate clinical support person. EQUIMENT Insertion: o Insuflon catheter with dressing supplied o Transparent occlusive dressing (ie: Tegaderm or IV 3000) o chlorhexidine/alcohol wipe o local anaesthetic cream and tegaderm as required o sharps container Medication administration: o medication in syringe o gauge needle. Length of needle not to exceed 8 mm (3/8") o chlorhexidine/alcohol swab Removal: o Gauze pad and adhesive bandage if needed ROCEDURE: INSERTION 1. ASSESS if the use of an indwelling subcutaneous catheter (Insuflon ) is indicated based on: a. frequency of subcutaneous therapy: daily or more often Rationale The use of an indwelling subcutaneous catheter (Insuflon ) for the administration of frequent subcutaneous injections has been shown to reduce the pain of repeated injections in both diabetic and CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 1 of 7

2 catheter. INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) b. adequate subcutaneous tissue present: use of nondiabetic populations. an indwelling subcutaneous catheter is Children with very little subcutaneous tissue are not dependant on the amount of subcutaneous good candidates for use of Insuflon as drug tissue present in the patient. absorption varies with repeated doses in the same NOTE: Generally children should weigh at location. USufficient subcutaneous tissue must be least 2 kg in order to effectively use the presentu to support the catheter. Insuflon Children receiving heparin or low molecular weight heparin (LMWH) who weight less than 5 kg must not use an Insuflon catheter. c. volume of medication to be administered: As the dead space volume of the Insuflon catheter is ml, it is unnecessary to flush the Insuflon before or after use unless more than 10% of the dose will be lost in the dead space. In this situation consult the prescriber and pharmacy as a small amount of compatible solution may be considered to flush the medication. d. medication to be administered. Any medication that can be given subcutaneously, can be given via a subcutaneous indwelling catheter including: i. cytosine arabinoside ii. desmopressin (DDAV) iii. erythropoietin iv. G-CSF v. heparin vi. insulin vii. interferon viii. low molecular weight heparin (LMWH) (e.g. enoxaparin) ix. morphine * If using for enoxaparin or heparin, it is important to insert at least two Hematomas will occur regardless of placement when standard heparin or LMWH are used. To prevent hematomas it is recommended that 5 minutes of firm pressure be applied to the administration site following each dose and that at least two Insuflons are placed in order to rotate injection sites. Due to the catheter dead space volume, size of the insuflon catheter and high incidence of hematomas, use of the device for delivery of enoxaparin is discouraged in babies under 5 kg. Young children display a stronger preference for Insuflon than older children. With increasing age, the individual's personal choice is influenced by factors other than pain and comfort and these include a desire not to have visible reminders of their disease. Insuflons in order to safety rotate the site of injection e. patient's preference 2. ASSEMBLE equipment. Facilitates completion of procedure in a timely manner. 3. ERFORM hand hygiene. Routine Infection Control practices; reduces 4. IDENTIFY patient using 2 client identifiers (e.g. name, DOB, MRN) and EXLAIN procedure. 5. SELECT appropriate injection site: a. center third of lateral aspect of upper arm Failure to correctly identify patients prior to procedures may result in errors. Reduces child and family s anxiety. Evaluates and reinforces understanding of previously taught information and confirms consent for medication administration. Sites should contain adequate subcutaneous tissue to accommodate medication to be administered. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 2 of 7

3 as INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) b. center third of anterior thigh c. abdomen NOTE: the Insuflon catheter should not be placed near a scar, bruise, skin lesion/abrasion or within a 5 cm radius of the umbilicus as this may increase pain and also affect the absorption rate of subcutaneous medications injected. 6. If desired, ALY local anesthetic cream to the site minutes prior to insertion. 7. OBTAIN help of second nurse as needed. Consider age and developmental level of the child when selecting appropriate insertion site. Decreases pain at injection site. 8. ERFORM hand hygiene and DON clean gloves. Routine Infection Control practices; reduces 9. REMOVE tegaderm and local anesthetic cream if Decreases risk of infection. used and CLEAN site (circular area approximately 5-8 cm) with chlorhexidine/alcohol swab and allow skin to dry for seconds 10. OEN the package containing the Insuflon and dressing by pulling the paper lid from 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 insertion. finger and remove the protective cap. LACE the cap in the rear of the grip as shown: 12. INCH the skin at the site of insertion. INSERT the Insuflon far as possible at a 20- to 45-degree angle to the skin surface i.e. towards the shoulder joint in the arm, towards the hip in the leg, horizontal and towards the umbilicus in the abdomen. This should be done in one quick, smooth movement with the bevel up. Isolates the subcutaneous tissue and decreases the possibility of inserting the catheter into the muscle. The angle of insertion is dependent on the amount of subcutaneous tissue the child has and will vary from patient to patient. Use a smaller angle/shallower insertion for patients with less subcutaneous tissue. Insertion horizontally into abdomen avoids skin folds and cloth lines that may kink/damage cannula. If Insuflon insertion is too slow there is a risk of the catheter "crimping" or peeling back from the needle. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 3 of 7

4 and INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) 13. REMOVE the needle by holding the catheter hub firmly and pulling the needle out slowly, leaving the catheter in place. NOTE: Do not reinsert the needle if catheter is dislodged/withdrawn. Repeat the procedure with a new Insuflon. Care must be taken to prevent catheter withdrawing during placement. 14. DISOSE needle in sharps container immediately. revents potential accidental needlestick injury. 15. SECURE the Insuflon by applying the dressing Built in see-through window allows for visual supplied from the catheter end first, ensuring the inspection of the injection site. insertion site is visible through the plastic window and the hub is open to air. Totally adhere dressing to skin to prevent bacteria from entering insertion site. 16. LACE a transparent dressing on top of the Insuflon white dressing supplied To further SECURE the Insuflon and prevent bacteria from entering insertion site 17. WRITE the date of insertion on the dressing. If patient is receiving more than 1 medication via insuflon, a second device is to be inserted. Indicate on dressing which medication is being injected via each device. Communication to others to ensure device is changed regularly and to prevent administration of incompatible medications via same device. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 4 of 7

5 INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) 18. DISOSE used supplies and equipment in appropriate container. 19. REMOVE gloves and ERFORM hand hygiene. Routine Infection Control practices; reduces 20. MONITOR insertion site for any pain, redness, discomfort, leakage, bleeding, bruising/hematoma or swelling. If any adverse reactions occur, remove device and replace as appropriate. ROCEDURE: MEDICATION ADMINISTRATION 1. CHECK chart for prescriber's order which specifies the drug name, indication, dosage, route and frequency of administration. Allows early identification and prompt intervention for adverse reactions Rationale Medication orders that meet safe prescribing practices promote patient safety. 2. ASSEMBLE equipment. Facilitates completion of task in timely manner. 3. IDENTIFY patient using 2 client identifiers and ENSURE patient and family understand what medication is being given and why and how, any possible side effects and that questions are answered. 4. INSECT Insuflon insertion site for presence of ANY pain, discomfort, redness, leakage, bleeding, swelling, or bruising /hematomas (palpate site for small lumps beneath skin surface) and inspect catheter to determine if it has pulled out from the skin. If any problems identified, RELACE the Failure to correctly identify patients prior to procedures may result in errors. Reduces child and family s anxiety. Evaluates and reinforces understanding of previously taught information and confirms consent for medication administration. Administering medication doses when any complication is present will exacerbate the problem. If catheter has pulled out, medication will likely not be delivered subcutaneously when injecting. Insuflon catheter prior to administering the dose. 5. ERFORM hand hygiene. Routine Infection Control practices; reduces 6. CLEAN the transparent dressing over the hub of Decreases risk of infection. catheter with chlorhexidine/alcohol swab and allow to dry for seconds= 7. INSERT syringe needle into the Insuflon hub. The A longer needle could possibly damage the catheter. needle must penetrate the membrane by at least 3 mm (1/8") and not more than 8 mm (3/8"). Do not use excessive force to insert the needle. 8. INJECT the medication slowly then remove the A slow injection will help to reduce site irritation needle. caused by the medication. 9. ALY firm pressure to site for at least 5 minutes Minimizes bruising. following administration of heparin or LMWH ( e.g. enoxaparin). 10. DISOSE used supplies and equipment in Routine Infection Control practices; reduces appropriate container. ERFORM hand hygiene. transmission of microorganisms ROCEDURE: REMOVAL Rationale 1. ERFORM hand hygiene and DON clean gloves. Routine Infection Control practices; reduces 2. IDENTIFY patient using 2 client identifiers and Failure to correctly identify patients prior to EXLAIN procedure. procedures may result in errors. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 5 of 7

6 INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) 3. EEL OFF the adhesive dressings, beginning at the catheter end and then REMOVE catheter. ALY pressure with gauze pad as needed. 4. ASSESS site and place adhesive bandage as needed. 5. DISOSE used supplies and equipment in appropriate container. REMOVE gloves and ERFORM hand hygiene DOCUMENTATION Reduces child and family s anxiety. Evaluates and reinforces understanding of previously taught information and confirms consent for medication administration. Facilitates smooth removal of catheter. Minimizes bruising. Routine Infection Control practices; reduces DOCUMENT on appropriate record(s): i.e. patient flowsheet, nursing notes, MAR o date and time of insertion o site of insertion o date and time of removal o reason for removal o site assessments o date and time of medication administration o drug, dose, route o patient's response to procedures o unexpected outcomes and related treatment o patient/family education o any other pertinent actions or observations REFERENCES Black, K. and Bauman, M. Insuflon Care, Insertion & Removal atient Care Guideline. Stollery Children's Hospital, Child Health rogram, Alberta Health Services. Revised November de Jong, M.E.A, Carbiere, T. and van den Heuvel-Eibrink, M.M. (2006). the Use of an Insuflon Device for the Administration of G-CSF in ediatric Cancer atients. 14TSupportive Care in Cancer14T, 14(1): Dyer, S.L., Collins, C.T., Baghurst,., Saxon, B. and Meachan, B. (2004). Insuflon Versus Subcutaneous Injection for Cytokine Administration in Children and Adolescents: A Randomized Crossover Study. 14TJournal of ediatric Oncology Nurses, 14T21(2): Insuflon Insertion rocedure. The Royal Children's Hospital Melbourne. Retrieved February 14, 2013 from: 31TUhttp:// Insuflon : Directions for use. Intraump Infusion Systems. Revised 31/01/05. Retrieved February 14, 2013 from: 31TUhttp:// Malowany, J.I., Monagle,., Knoppert, D.C., Lee, D.S.C., Wu, J., McCusker,., Massicotte, M.., Williams, S. and Chan, A.K.C. (2008). Enoxaparin for Neonatal Thrombosis: A Call for a Higher Dose in Neonates. 14Thrombosis Research,14T 122(6): Malowany, J.I., Knoppert, D.C., Chan, A.K.C, epelassis, D., and Lee, D.S. (2007). Enoxaparin use in the neonatal intensive care unit: experience over 8 years. 14Tharmacotherapy14T, 27(9): Monagle,., Chan, A.K.C., deveber, G. and Massicotte, M.. (2006). ediatric Thromboembolism and Stroke, third Edition. BC Decker Inc, Hamilton, Ontario. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 6 of 7

7 INDWELLING SUBCUTANEOUS CATHETER (INSUFLON ) Rouss, K., Gerber, A., Alvisetti, M., Hug, M. and Bernet, V. (2007). Long-term subcutaneous morphine administration after surgery in newborns. 14TJournal of erinatal Medicine,14T 35(1): Shereck, E. (2008). Insuflon olicy. In. DeZorzi (Ed.). Vancouver. CM BC Children s Hospital Child & Youth Health olicy and rocedure Manual age 7 of 7