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When switching from oral to subcutaneous route of administration, calculate the starting dose using the previous oral 24-hour requirement as a start dose and titrate up or down according to response. A PO:SC conversion ratio of 1:1 is generally used.
N.B. administration via the subcutaneous route is unlicensed.
Subcutaneous infusion average dose range is 80-120mg over 24 hours. However, doses as high as 240mg/24 hours may be required in some patients. Doses greater than 240mg/24 hour need consultant (palliative or cardiology) advice. Doses greater than 240mg/24 hours may need two syringe drivers due to infusion volume.
Setting up the syringe driver
- Follow local policies and procedures for syringe driver and subcutaneous medicines.
- Drug stability – exposure to light may cause degradation and discoloration, the solution should not be used if a yellow colour is present.
Formulation and compatibilities
- Solution for injection comes in 10mg/ml, 20mg/2ml or 50mg/5ml ampoules
- Diluent: 0.9% sodium chloride
- Furosemide must not be diluted in glucose solutions
- Furosemide is incompatible with most drugs via CSCI – A second CSCI may be needed to administer concomitant medicines required to treat other symptoms
‘Rescue’ bolus doses of subcutaneous furosemide may also be considered, particularly in cases of more acute decompensation or where pulmonary oedema is suspected.
Recommendations for infusion sites
- Upper chest/Upper anterior aspects of arms.
- Sites are restricted in heart failure patients; oedematous areas, bony prominences and areas of tissue damage should be avoided since absorption may be reduced.
- If there is very poor peripheral perfusion in the terminal stage, subcutaneous absorption may be limited and alternative measures such as opioids, anti-muscarinic medicines, buccal nitrates or sedation may be needed to alleviate terminal pulmonary oedema.
Monitoring of CSCI furosemide
- Site of administration for any signs of irritation or infection.
- Symptoms – only monitor bloods if likely to change management – weight may be used for monitoring but not appropriate if dying.
- Monitor for signs of postural hypotension and consider checking blood pressure.
Patient Selection
Inclusion criteria
- End stage heart failure approaching end of life – last 2 weeks (NYHA class 4)
- Symptoms of SOB/severe oedema
- If the patient is under the care of a cardiologist must have discussion with team
- GP willing to support if in community or planning discharge to a community setting
- Oral medications not working/not tolerated/not able to swallow
- Patient choice for symptom management
Exclusion criteria
No absolute contraindications but may wish to be cautious in:
- Renal failure
- Liver failure
- Anuria
- Electrolyte disturbance
- Dehydration
In these cases, discuss further with Consultant in Palliative Medicine.
Roles and responsibilities
Consultant in cardiology or palliative medicine with support of clinical nurse specialists
- Assess heart failure patient symptoms with regard to appropriateness of subcutaneous furosemide use, considering any contraindications.
- Initiate and titrate the dosage regime for CSCI furosemide.
- Assess response and side effects.
- Arrange shared care with GP when patient is managed on a stable regimen.
- Provide clear instructions to the GP, heart failure CNS, palliative CNS, district nurses, and other health professionals involved in the patient’s care. The patient will have a copy of this letter and advice.
General Practitioner
- Review the patient at regular agreed intervals to monitor control of symptoms.
- Liaise with the community and specialist nurses as appropriate to provide ongoing patient care.
- Refer to specialist when symptoms fail to respond to the CSCI furosemide.
District nursing team/Community nursing team
- Ensure they have the knowledge and understanding of the use of furosemide via CSCI.
- Administer the diuretic as prescribed.
- Be aware of when and how to contact relevant health professional(s) for advice and support regarding subcutaneous furosemide concerns to ensure continuity of care in a timely manner.
- Follow the local policy and guidance on syringe drivers.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.