2 Basic Infusion System Fluid container Drip chamber Roller Clamp Flow by gravityFlow controlled by roller clampDifficult to set and control infusion rateDrip chamberShow infusion setRoller Clamp
3 Infusion Pumps What are they? What do they do? Usually electrically powered infusion devicesWhat do they do?Use pumping action to infuse fluids, medication or nutrients into patientSuitable for intravenous, subcutaneous, enteral and epidural infusions
4 Infusion Pumps Why are they used? What are they used for? To provide accurate and controllable flow over a prescribed period or on demandWhat are they used for?Wide range of drugs and therapies includingChemotherapyPain managementTotal parental nutritionAnaesthesia/sedationEtc. etc.
7 Syringe Pump: Most widely used syringe pump in NGD, Alaris Asena Top - control buttons and display showing flow rate and volume delivered by pump. Chance to look at setting up a pump later.Syringe plunger connected to syringe pump carriage and held in place by the syringe plunger clamp.As motor turns, carriage moves, plunger depressed, fluid infusedSyringe clamp – two purposes.Holds syringe in placeDetects size and manufacturer from diameter. If incorrect, will get error in rate calculation. Important to confirm size AND manufacturer before starting infusion.Important that any label attached to syringe kept well clear of the syringe clamp or should not obscure the scale, as this need to be read while infusion being given.
8 Syringe Pumps Generally used for low volume, low flow rate infusions Good short term accuracyLong start up time at low flow ratesPrime and purge line before connecting to patientAlarms: End/near end of infusion; drive disengaged, occlusion, battery lowSpecialised syringe pumps for ambulatory use, PCA, sedation, insulin etcLong start up time i.e. delay between starting infusion and patient receiving medication.Caused by mechanical backlash/slack in pump drive.To reduce start upPrime line before installing syringe in pumpBefore connecting line to patient, use pump’s purge facility to take up the mechanical slack.
10 Most widely used volumetric pump in NG is Alaris Signature LHS control and displays, large display showing flow rate in ml/h, smaller displaying giving additional information again not discussing in detailRHS is the dedicated infusion set – show, built-in flow clamp
11 Cam followers (fingers) LatchCam followers (fingers)Pressure sensorAir in line detector
12 Volumetric PumpsPreferred for medium and high flow rates and large volumesGenerally not suitable for rates < 5ml/hVariable short term accuracyAlarms: Latch/door open, set out, occlusion, battery low, air-in-lineSpecialised volumetric pumps for ambulatory use, epidural infusions etc.
13 Infusion Pump Incidents 700 incidents/year reported to MHRA, including 10 deaths20% Device related (e.g. design, failures etc)27% User error53% Not established (majority user error)Many incidents not reported e.g. 6 Trusts, 321 incidentsMedicines & Healthcare products Regulatory Agency (England & Wales)Scotland, SHS, no statistics published
14 Reporting IncidentsAll incidents should be reported on a Clinical Adverse Patient Incident FormAim is to reduce risk in future, not to apportion blameWhere an infusion pump is involved, the pump and its disposables must be retained, and Clinical Physics informed.
15 What Goes Wrong? Medication Errors Prescription Preparation of infusion solutionCalculation of rate of infusion
16 In NG, std infusion pump prescription and medication sheet used in attempt to reduce medication errors
17 What Goes Wrong? Medication Errors Prescription Preparation of infusion solutionCalculation of rate of infusionSetting up infusion pump/unfamiliarity
18 2 version of this ambulatory battery operated pump. Simple pump, no syringe size detection, so as it cannot know the volume of fluid contained in the syringe, it is calibrated in mm of syringe movement. If that doesn’t make dose calculations difficult enough, we have two version of same pump: mm/hr and mm/day (24hr). Only obvious difference is colour.Confusion between these two models of pump have led to a number of fatalities in UKIn GGH a senior experience ward manager, unable to find a pump from her own unit, borrowed one from another unit
19 … and it wasn’t realised it was blue (mm/hr) instead of the normal green (mm/24Hr) pump. Result – pt got 24 times prescribe dose rate. No fatality this time, close run incident.If you accidentally use a BLUE 1hr pump instead of a GREEN 24 hour pump, you will deliver the drug at 24 times the intended rate.
20 What Goes Wrong? Medication Errors Prescription Preparation of infusion solutionCalculation of rate of infusionSetting up infusion pump/unfamiliarityDo not use a model you have not been trained and are deemed competent to use
21 What goes wrong? Free flow by gravity/siphoning What is it: Uncontrolled fluid flow by gravity from syringe or bag.Has resulted in a significant number of fatalities, none yet in North Glasgow.
22 Free Flow in Volumetric Pumps If fluid container is a few inches above heart level, free flow by gravity can occur if:Pump latch/door open. Always close roller clamp before removing set from pump.Latch open – demo on 597
25 Free Flow in Volumetric Pumps If fluid container is a few inches above heart level, free flow by gravity can occur if:Pump latch/door opened. Always close roller clamp before removing set from pump.Infusion set not correctly loadedInfusion set not inserted correctly – demo on 597, show next slide at same time
27 Free Flow in Volumetric Pumps If fluid container is a few inches above heart level, free flow by gravity can occur if:Pump latch/door opened. Always close roller clamp before removing set from pump.Infusion set not correctly loadedDamage to set resulting in an air leakLatch open – demo on 597Infusion set not inserted correctly – demo on 597
28 Free Flow in Syringe Pumps If pump is a few inches above heart level, free flow by gravity can occur if:Syringe not correctly located and secured to pump. Check syringe barrel clamp, barrel flange and plunger located correctly and secured.
29 What happens if syringe is not correctly secured, plunger is allowed to move – DEMO free flow Also mention particular hazard of MS16A/26. No alarms, syringe only held in by rubber band, easily dislodged
30 Free Flow in Syringe Pumps If pump is a few inches above heart level, free flow by gravity can occur if:Syringe not correctly located and secured to pump. Check syringe barrel clamp, barrel flange and plunger located correctly and securedSyringe removed from pump. Always close clamp first.
32 Free Flow in Syringe Pumps If pump is a few inches above heart level, free flow by gravity can occur if:Syringe not correctly located and secured to pump. Check syringe barrel clamp, barrel flange and plunger located correctly and securedSyringe removed from pump. Always close clamp first.Air leak caused by crack in syringe, plunger seal leak, loose luer connection, distortion of barrel/plunger.
33 Luer lock syringe, reduces chance of air leak Always user an anti free flow (or anti-syphon) setDEMO
34 To prevent free flowNever remove syringe or set from pump whilst connected to patient, without closing the clamp first (or checking it is closed)Always use a set with an anti free flow device (not available for Alaris/IVAC 59 series)Check set or syringe is correctly loadedCheck drip chamber on volumetric pump for unexpected flow after set loading and during infusionKeep syringe pump near to or below infusion site
35 What Goes Wrong? INTERRUPTION TO THERAPY Occlusion Alarms/Post occlusion bolusAir in line Alarms
36 What Goes Wrong? Occlusion alarm (all pumps) Occurs when pump is unable to sustain set flow rate and pressure in line increasesCaused by partial or complete blockage in delivery tubing (kinked tube, clamp or tap closed) or cannula (clotted off, position changed)
37 Occlusion Alarm Time to alarm Dependent on occlusion pressure level (usually variable) and flow rateLow pressure, high flow rate 45 secondsHigh pressure, low flow rate 45 minutesNot instant, dependent on the occlusion pressure level which on most pumps is adjustable, and flow rate.
38 Occlusion Alarm Hazards Interruption to therapy Post occlusion bolus Problem with critical, fast acting drugs e.g. inotropesPost occlusion bolusInterruption to therapy – can be hazardous – e.g. laterPost occlusion bolus. Occlusion, pump continues to attempt to deliver fluid until preset pressure is reached and pump stops and alarms. Because of the compliance (give) of the set (tubing), tubing expands under the increasing pressure. When occlusion released (kink removed) extra fluid under pressure is released and delivered to patient as a bolus. In some fast acting drugs, that can prevent a hazard. Some modern pumps have a “backoff” facility, when occlusion occurs pump briefly runs backwards to reduce the pressure and potential bolus.
39 Tissuing (Extravasation) Extravasation occurs when fluid that should be delivered intravenously is inadvertently delivered into a tissue space.
40 Tissuing Cannot be detected by infusion pumps Usually little or no increase in pressureSecure and dress the catheter for stabilityCheck IV site frequently for tenderness, skin tightening, cooling and blanching
41 What Goes Wrong? Air-in-line Volumetric pumps have a risk of air being delivered due to poor priming of set, upstream leak or pumping action drawing air out of solutionVolumetric pumps have either a mechanism for preventing pumping of air or an air-in-line detector & alarm
42 Air-in-line Alarm Hazards Nuisance alarms Interruption to therapy Problem with critical, fast acting drugs e.g. inotropesRecent fatality in North Glasgow
43 What Goes Wrong? Tampering by patients/visitors/carers Keylock Lock box
46 What Goes Wrong? Equipment Faults Often occur as a result of damage due to fluid ingress or being dropped/knockedAlways return damaged pumps to Clinical Physics – never use or attempt to repairInfusion devices very reliable, faults rarely result in adverse incidents
47 TrainingThis presentation and demonstrations to follow are a general introduction ONLYBefore using any infusion device you MUST have received specific training for that model and be signed off as competent – over 50 models in North GlasgowOtherwise DO NOT USEUnable to