Subcutaneous Medication Administration in Palliative Care

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Subcutaneous Medication Administration in
Palliative Care

• Amy Mohler, MD
• Hospice and Palliative Care of
• Western Colorado

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Historically

• 1914
• First published report of subcutaneous fluids
  (hypodermoclysis) given to pediatric patients
• 1970s
• Palliative care physicians in the United Kingdom
  began using continuous subcutaneous infusions
  (CSI) for pain management

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Indications for CSI

• Pain Management
• Nausea and vomiting
• Terminal restlessness
• Diuresis
• Secretions
• Seizures
• Hydration

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Evidence

• Randomized trial comparing 3 methods of
  postoperative analgesia in gynecology patients
  patient-controlled intravenous, scheduled
  intravenous, and scheduled subcutaneous.
  AmJofOBGyn Nov. 2007472.e1-472.37

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Evidence

• 130 pts undergoing major transabdominal
  gynecologic operation
• Randomized to
• PCA
• IV
• SQ
• Primary Endpoint
• Patient self assessment of pain at 12, 24 and
  48hrs
• Secondary Endpoint
• Patient satisfaction

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Evidence

• No statistically significant difference among the
  groups.
• Median pain scores for the IV and SQ groups were
  equal at all time points.

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Hours since arrival on nursing unit
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Patient Selection

• Inability to give oral medications
• Dysphagia/inability to swallow
• Nausea/vomiting
• Intestinal obstruction

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Why CSI and not IV?

• CSI pros
• Ease of placement
• Less painful
• Lower site infections
• Cost effective
• Pharmacokinetic equivalency to IV
• Low infusion volumes

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Why CSI and not IV?

• CSI cons
• Equipment acquisition
• Nursing education
• Pharmacy education

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Why CSI and not IV?

• Contraindications
• Broken skin
• Cellulitis
• ?Severe bleeding d/o
• ?Anasarca

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Which drugs are appropriate?

• Pain Management
• Morphine, Hydromorphone
• Nausea and vomiting
• Haloperidol, Dexamethasone
• Terminal restlessness
• Haloperidol, Lorazepam

• Diuresis
• Furosemide
• Secretions
• Glycopyrrolate
• Seizures
• Lorazepam, Midazolam
• Hydration
• 0.9NS

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What dose

• SQ IV

PO IV
Morphine (mg) 20 7
Hydromorphone (mg) 5 1
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Infusion rate

• CSI
• 3ml/hr
• Hypodermoclysis
• 500ml boluses
• 55ml/hr

• Can have more than one site

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CSI site placement
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Risks

• Fluid overload
• Site infection

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Case Study

• 68yo woman with metastatic breast cancer
• Pain well controlled on MSContin 60mg po q12h
• Declining and no longer able to take po meds
• Team feels she a candidate for a SQ infusion

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Case Study

• 120mg qD of po morphine
• 3 to convert to SQ morphine
• 40mg qD
• 24 to get hourly rate
• 1.7mg/hr continuous rate of SQ morphine

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Benefits of CSI for St. Marys Patients

• Timely symptom management
• Any patient
• Comfort
• Seamless admission and discharge process
• Standard of care in Palliative Medicine
• Cost effective

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