The Use Of Subcutaneous Infusions With Terminal Patients


When the oral route is unavailable, the subcutaneous route is the preferred method. Intravenous is more invasive and are no more effective and the injections can be very painful to patients. The subcutaneous route is not reserved only for the dying patient, but should be considered anytime a patient cannot take fluids or medications by mouth. This route helps the patient be more comfortable.

The main reasons for continuous subcutaneous infusions for the terminal patients are nausea and vomiting, inability to swallow (dysphagia), extreme weakness or if a patient is unconsciousness. This route of giving fluids is easily used at home during the last days of life if the patient is unable to manage oral medications. The use of the subcutaneous infusions in terminal care is a major advance, especially to help control symptoms so the patient can be home.

This route of administering fluids is safer and the patient can still be ambulant. It allows the ability to give fluids and or medications, with no risk of air embolus and less risk of infection. When pain medications are given, such as morphine, the patient does not develop a tolerance to them as they can with the IV morphine.

In 1979, a portable pump was developed by Wright. Later that year, Russel suggested that the infusions could be used with terminal malignant disease. The use of the subcutaneous infusions are rarely required just for pain control. The only contraindication to the use of these infusions are if the patient has severe thrombocytopenia.

Thrombocytopenia is when the blood has an abnormally low amount of platelets. This can cause mild to serious bleeding. This bleeding can occur inside the body or underneath the skin or surface of the skin.

Special needles are used for the subcutaneous infusions. Sub Q Sets are available with a 27 gauge x 1/2 cm needles and come 30/case. There are different sizes and lengths to accommodate different patients and some sets, such as the Medtronic sets, are also used for the Insulin Pump patients.

The preparation of the family and patient is very important. Most patients do not have a problem with the infusions and quickly adapt to them. The infusion pump is small, unobtrusive, and easy to use. Many patients soon forget that it is even there. The cannula can be left in for 72 hours or longer, if there is not inflammation or redness.

The different facilities and hospices have protocols to follow for the insertion and care of the infusions. The comfort of the patient is the main idea for the subcutaneous infusions and should always be the main focus.


Patient Nutrition By Enteral Feedings


Maintaining good nutrition is of the up most importance for all patients. If a person is ill, recovering from surgery or has an unexplained weight loss, the body has to work extra hard to restore good health. The body needs protein, fat, carbohydrates, vitamins, minerals, and water, in order to maintain and build body tissue and provide energy for body functions.

The patient usually gets these nutrients from eating a balanced diet. However, because of special problems, the patient may require receiving this nutrition in a liquid form through a tube. If this happens, a formula is calculated specifically for the individual patient in order to maintain their nutritional needs.

A majority of patients have a naso-gastric enteric feeding tube placed through the nose, reaching the stomach or small intestine. There are different size tubes to accommodate the difference in the sizes of the patients. Wolf-Pak has pumps for the continuous feedings and syringes for the water flushes.

After insertion of the tube, the physician will order the feedings or will ask the dietician to consult on the feedings. There are two different methods of feeding that can be given to the patient through these tubes. Bolus feedings is when there is a large amount of formula administered over a 15-30 minute time. This feeding is repeated several times a day, according to the orders. The other method is to use a machine, such as a Kangaroo Pump, and give the formula over an 8-24 hour period.

A different method of receiving feedings, is through a gastrostomy feeding tube. This tube is inserted by the physician through the abdomen into the stomach. With this method, the tube bypasses the esophagus and mouth. The feedings can be given through the gastrostomy tube the same way, by bolus or by continous feedings.

In certain cases, the physician may feel that it is necessary to place a jejunostomy tube. This tube in placed through the abdomen also, but goes directly into the small intestine or the jejunum. Feedings done with this tube bypasses the esophagus, mouth, and the stomach. The feedings given through the jejunostomy tube are usually given by the continuous method.

Even though the tube feedings are given, there is also need for plain water flushes to be given with a syringe 6 times a day. The orders by the physician or the dietician should include the tube feeding and the water flush amount. To help prevent reflux, keep the head of the bed elevated 30 degrees or more.

The patient should always be checked for residual stomach contents before starting tube feedings, unless the feeding tube used does not allow for this. If the patient is on continuous feeding, it is suggested that they be checked every 8 hours for residual stomach content. Typically, if the residual content is less than 250 ml, put the fluid back into the feeding tube and resume the feeding as scheduled.

If the residual content is greater than 250 ml and less than 400 ml, put the fluid back into the feeding tube and resume the tube feeding and recheck after 4 hours. At that time, if the residual content is greater than 250 ml, stop the feeding and call the physician. If the residual content is greater than 400 ml at any time, stop the feeding immediately and call the physician. Do not put the feeding back into the feeding tube.

If a continuous feeding is being given be sure to keep the pump plugged into the wall outlet to keep the battery charged. The battery typically last for 18 hours. Make yourself familiar with the protocols and policies of the facility for the administration of the enteral tube feeding. The main concern is the safety and the nutritional status of the patient.