Syringe Infusion Pumps: a Comprehensive Overview and Considerations for Use at Low Delivery Rates

Syringe Infusion Pumps: A Comprehensive Overview and Considerations for Use at Low Delivery Rates

Released November 2, 2020 | Expires November 1, 2023

FACULTY

Nathaniel M. Sims, M.D. Sylvia Okrzesik, Pharm.D., BCPPS Research Faculty, Department of Anesthesia, Pediatric Clinical Pharmacist‐PICU/NICU/ED Critical Care, and Pain Medicine Massachusetts General Hospital Massachusetts General Hospital Coordinator, Longitudinal Advanced Pharmacy Associate Professor, Anesthesiology Practice (LAPP) Program Harvard Medical School Boston, Massachusetts Boston, Massachusetts Kimberly Whalen, R.N., M.S., CCRN Christopher Colvin, MHSc Nursing Practice Specialist Clinical Engineer Massachusetts General Hospital Massachusetts General Hospital Boston, Massachusetts Boston, Massachusetts Healthcare Human Factors & Instructional Design Physicians, Nurses, and others access CME/CNE: Consultant www.mycme.com/courses/syringe-infusion-pumps- Toronto, Ontario, Canada a-comprehensive-overview-7345 Pharmacists access CPE: elearning.ashp.org/ products/8373 ACCREDITATION The American Society of Health‐System Pharmacists designates this enduring material for a maximum of Accreditation for Pharmacists 1.5 AMA PRA Category 1 Credits™. Physicians The American Society of Health‐System should claim only the credit commensurate with the Pharmacists is accredited by the extent of their participation in the activity. Accreditation Council for Pharmacy Education as a provider of continuing pharmacy Accreditation for Nurses education. This nursing continuing professional development activity was approved by the Maryland Nurses ACPE #: 0204‐0000‐20‐429‐H05‐P Association, which is an accredited approver by the 1.5 hr, application‐based American Nurses Credentialing Center’s Accreditation for Physicians Commission on Accreditation. The American Society of Health System Pharmacists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

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© Massachusetts General Hospital. All rights reserved. 28 SYRINGE INFUSION PUMPS: A Comprehensive Overview & Considerations for Use at Low Delivery Rates High Level Course Summary When using syringe infusion pumps to deliver at low infusion rates there can be delivery issues that arise from the inherent nature of how the system operates. 2016 FDA Safety Communication noted fluid flow continuity/uniformity concerns when using syringe infusion pump at low delivery rates.

What are these issues? Startup Delays (i.e., slack, breakout force, compliance) Post-occlusion Boluses Flow Uniformity Concerns During Delivery (e.g. stick-slip flow) Temporary Delivery Deviations Due to Height Changes Occlusion Alarm Delays Gravity Siphoning

What are some steps you can take to mitigate these issues? Most of these issues are more pronounced when ...

Delivering at low flow rates Using larger syringe sizes (pump mechanisms moving slower) (greater compliance and less linear travel of the plunger head) Therefore... Therefore...

Adopt standardized concentrations Consider how you select the (e.g. ASHP’s Standardize4Safety) optimal syringe size A fixed selection of concentrations, carefully chosen, to support all While larger syringe sizes require changing less often, they can make patient groups and ensure options exist which will not necessitate the syringe pump issues more severe (especially at low flow rates). use of flow rates below the pump’s minimum recommended flow rate Furthermore, remain cognizant of your pump’s recommended minimum (per specified syringe size). flow rate and minimum programmable rate as this can vary by syringe size and manufacturer.

Implement a decision support tool that helps identify For a given flow rate, select a small syringe size that will not result in the standard concentration option that yields the an unduly short changeover interval and is of a size that promotes optimal flow rate. uniform flow at the given rate (i.e. the rate is at or above the minimum (e.g. MGH’s guideline document) recommended flow rate for that specific syringe size and brand). A guideline that helps identify which of the standardized concentrations result in the optimal flow rate given the ordered dose rate, patient weight, patient’s fluid tolerance, and pump capability considerations. This may also identify when to use a large volume pump versus a syringe pump.

By doing these 3 things you will already be doing a lot to help minimize many of the issues discussed. See next page for additional steps you could be taking...

... continued from previous page

What are some steps you can take to mitigate these issues?

These additional practices will help further reduce delivery irregularities that you may face ...

Prime on the pump prior to Minimize startup and rate change delays by priming on the pump to remove mechanical slack and limit starting the patient’s infusion breakout force and syringe/tubing compliance related delays.

Compliance properties of the syringe and IV tubing can result in a delay before the occlusion alarm sounds AND creates the potential for post-occlusion boluses. Selection of syringe sizes and IV tubing with low compliance can minimize delays and limit post-occlusion bolus size. If an occlusion alarm occurs, recognize the risk of a post-occlusion bolus and determine the best way to handle it. This may mean Be aware of delays arising from removing the syringe from the pump, venting the built up fluid via an in-line vent/stopcock/access valve, occlusion detection and or disconnecting the line from the patient prior to clearing the occlusion. However, be aware that you may potential post-occlusion then be facing startup delay issues when re-starting. boluses Before implementing a practice for managing post-occlusion boluses, please discuss the options with your infection prevention team to ensure whatever practice you use balances bolus, startup delay, and contamination concerns.

Avoid changing the height of Changing the relative height of the pump during an infusion can result in temporary increases and the pump relative to the patient decreased in fluid delivery due to the compliance of the syringe and IV tubing. during an infusion

When you need to change the syringe (i.e. it is almost empty or you have reached you hospital’s predefined Minimize syringe changeover change interval), consider how the interruption of flow could impact the patient. A new infusion will have to delays by preparing a second, contend with startup delay considerations (i.e. slack, breakout force, compliance). Therefore, consider already running, infusion, and preparing the replacement infusion on a new pump prior to the changeover and allowing it to run and adopting a suitable best prac- overcome the startup delay. Once ready for changeover, quickly transition the patient to receive flow from tice protocol this new pump.

Smaller bore (e.g. microbore) tubing sets tend to be less compliant, limiting compliance related issues, and have a smaller priming volume, helping to minimize drug waste. However, the increased fluid resistance in Consider the use of smaller smaller diameter tubing, when combined with high flow rates, may lead to increased fluid pressure which diameter IV tubing sets, but can impede flow and trigger occlusion alerts. Therefore, the maximum fluid flow rate may be limited in verify the set will permit flow at smaller diameter tubing, so you will need to verify that the tubing you select will permit flow at any higher the rates you expect to use. flow rates you expect to use. Furthermore, avoid chaining small bore IV tubing sets together to create long, extension setups as this will also increase fluid resistance, potentially leading to flow issues and occlusion alerts.

In order for all your actions to be effective, your institution’s biomedical engineering department should be regularly testing all the different sizes of syringe within your specific model of syringe pump. They should be looking to validate that startup is quick and delivery is uniform across a range of flow rates.