Clysis Pain and Symptom Management

SQ Infusions
Ambercare Education Department – adapted from
various sources – including EPERC and HospiScript Services and NIH – 12/2013
Explain the Subcutaneous Butterfly Procedure
Indications of use
Procedure for insertion
S/sx of infection; cannula misplacement, or overuse of site
Process for administering more than one medication
Amount of medication to be administered at one time
Medications that can be given via the SQ route (butterfly)
– and medications not recommended via this route
• Sites of administration
• Hydration therapy
• Advantages / Disadvantages
• Sublingual
• Administration of concentrate solution (Morphine, Methadone, or
• Immediate Release Tablets (Methadone, Morphine, Oxycodone,
and Hydromorphone) may be crushed and given with a very small
amount of liquid
• Rectal
• Insertion of IR and ER tablets with a water based lubricant
(morphine, Oxycodone, Hydromorphone and Methadone)
• Subcutaneous
• Individual site injection or butterfly placement (Morphine,
Hydromorphone, Methadone)
Options for Pain
Management Modalities
• Intravenous
• Generally seen in an GIP setting with PICC line or port
access (PCA may also be utilized in this setting)
• IV push
• Transdermal
• Application of fentanyl patch
Options for Pain
Management Continued
• SL:
• SL space can comfortably hold an approximate maximum volume of
1.5 ml per dose (patient dependent)
• PR:
• May be restricted by blockage of rectal vault due to disease process
• SC:
• Volumes > 2 ml are not recommended to be INJECTED at one site
(excluding flush)
• IV:
• Patent vein access
• TD:
• Should only be utilized in patients with STABLE pain. Patches are
easily titrated and CANNOT provide QUICK onset of drug action in
a pain crisis!
Limitations with all
routes of administration
• The butterfly, wing-tip, or scalp needle is useful
for providing medications via the subcutaneous
(SQ) route. The SQ route of medication
administration provides appropriate management
of symptoms for patients who are unable to take
medications through other routes of
SQ butterfly procedure DEFINTION
• Circumstances that preclude or compromise oral
• Dysphagia – due to neuromuscular weakness or mechanical
• Decrease LOC
• Intestinal obstruction
• Nausea and vomiting (intractable)
• Symptom control crisis requiring rapid and reliable
medication administration and absorption
• Poor or variable compliance issues:
• Dementia
• Agitated delirium, with paranoia and non-compliance
• Personality issues
• Alcohol swabs
• Butterfly or wing-tipped catheter, 25 - 27 gauge
• Transparent adhesive dressing
• Luer-lock injection cap
• Tape
• Gloves
• Sharps Container
Procedure for Inserting
SQ Butterfly – Equipment
Localized heat
Localized inflammation
Pain, Tenderness, Hardness, Burning, Swelling,
Scarring, Itching, Bruising, unresolved
blanching, or necrosis
Monitoring for adverse
s/sx at SQ site
• Establish an additional SQ site for each new
medication or if there is a change in the
concentration of the current medication. Label
each site as to which medication is to be
administered at that site
Administering more than
one medication
• Equipment Needed:
• 3cc Syringe
• Alcohol swabs
• Medication
• Gloves
Instilling Medications
through SQ Butterfly
(Intermittent push)
• Equipment Needed:
• Alcohol Swabs
• Medication in appropriate IV bag or Syringe
(based on pump used)
• Continuous Infusion Pump (Curlin PCA pump)
• 3 cc syringe with 1 cc of normal saline
• Tubing
Initiating a Continuous SQ
Infusion (basal rate)
0.9% or 0.45% (NS or ½ NS)
2.5% or 5% Dextrose (D5W)
Dexamethasone (steroid)
Diphenhydramine (benadryl)
Fentanyl (opioid)
Furosemide (loop diuretic)
Glycopyrrolate (robinul – AC)
Haloperidol (haldol)
Heparin (anticoagulant)
Hydromorphone (Dilaudid)
Sufentanil (sufenta – general)
Ketamine (anesthetic)
Lorazepam (benzo - ativan)
Metoclopramide (reglan)
Methadone (pain)
Midazolam (versed)
Morphine (opioid agonist)
Naloxone (narcan - antag)
Octreotide (sandostatin)
Phenobarbital (seizures)
Ranitidine (zantac)
Meds given SQ route via SQ
Chlorpromazine (anti-psychotic)
Diazepam (benzodiazepine)
Hydroxyzine (atarax)
Hypertonic solutions (3% Na+Cl)
Prochlorperazine (compazine)
Meds NOT recommended
for SQ route per SQ
• Outer arm (not recommended for hypodermoclysis)!
• Abdomen (avoid in presence of tense abdominal
distention such as ascites)
• Thigh
• Subclavicular area (avoid when patient has lung
disease or is active (r/f pneumothorax)
• Upper back (use when other sites are unsuitable
and/or when patient is confused)
Possible SQ insertion
Areas with lymphedema or edema
Areas that have TOO LITTLE SQ tissue
Areas with broken skin
Skin sites that have recently been irradiated
Sites with infection or inflammation present
Areas of bony prominences
Tumor sites
Skin folds
SQ Insertion sites to be

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