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PR24: Subcutaneous Butterfly Placement

Applicable To

Introduction

To provide guidelines to paramedics for the establishment of a subcutaneous (SQ) injection site and for the safe and, accurate intermittent administration of medications via subcutaneous injection site to the palliative care population for pain and symptom management when other routes are not possible or established.

Indications

Contraindications

Procedure

1. Consult with EPOS prior to establishing a SQ route and prior to administering medication/fluids via a SQ line.
2. Gather your equipment, perform hand hygiene, and don clean gloves.
3. Select the subcutaneous site:
   1. Note: site must be changed every 7 days to maintain patency and sites rotated to avoid tissue damage)
4. Cleanse site (circular area 5-8 cm) with chlorhexidine/alcohol swab and allow to dry. 
5. Remove slide clamp from the subcutaneous butterfly if preferred, as clamp is not required after insertion.
6. Remove the vent plug and attach a needleless connector/luerlock to the side Y port.
7. Prime the set with medication (additional 0.4 mL for priming the set including the luerlock).
8. Rotate the white safety shield 360º to loosen the needle.  Ensure the bevel is up and catheter is not extended over the needle tip/bevel.
9. Pinch the textured yellow wings together, textured side down
10. Gently pinch the skin fold and insert the needle at a 30-45 degree angle to the full length of the needle.
11. Hold the wings flat on the skin firmly (do not hold the centre bar).  Pull back on the white safety shield in a straight continuous motion until the safety shield separates leaving the cap.
12. Apply an opsite sterile transparent dressing.  Loop the extension set and secure in place.
    1. Optional: can place gauze under the port to protect the skin from pressure.
13. Label the dressing: Record the name of medication and concentration, date and time of insertion, your initials, and your designation.
14. Record insertion on Siren documentation including the following:
    1. Date & time, drug, concentration, dose, route
    2. Injection site and catheter size
    3.  Site assessment
    4. Patient’s response to procedure and any patient/family education or any other pertinent actions or observations
    5. Individual who inserted the catheter and administered the medication

Notes

General Directives:

• Do NOT flush tubing (medication remaining in tubing will be given during the next administration).
• Consult with EPOS prior to establishing a SQ route and prior to administering medication/fluids via a SQ line.
• The site should be assessed for redness, bruising, swelling, tenderness, leakage or discharge.  Re-site if any of these are present.
• The subcutaneous site is to be changed every 7 days or sooner to maintain patency. If two sites are being used, then two separate locations should be used (Rotate sites).
• To help optimize medication absorption and patient comfort, the maximum amount of medication to be administered at one time/site is 2 mL.  If greater volume is required, two sites can be used to deliver the required amount.  Must wait 30 min between doses at the same site.
• Note* More than one SQ site is required for multiple medications.
• Sites for catheter insertion are to be rotated to avoid tissue damage.
• If blood appears in the tubing, remove and discard the subcutaneous set and select a new injection site.

Equipment & Materials

• #24 gauge butterfly needle
• Chlorhexidine 2% or 70% Isopropyl alcohol swab
• Transparent dressing (eg. Opsite or Tegaderm)
• Tape
• Non sterile gloves/latex free
• Needleless butterfly syringe with luer lock containing medication dose ordered, plus an additional 0.4 mL of the medication for priming the needle and tubing set, at the time of initial dose administration
  • Volume may be different if using product other than Saf-T-intima and Baxter One Link Needle-free IV connector

Preferred Injection Sites

• Upper arms
• Abdomen
• Anterior aspect of thighs
• Above scapula
• Subclavicular chest wall

Note *Site should be easily accessible, free of lesions, away from large vessels, joints and bones, and away from edematous tissue that may alter medication absorption.

Resources

References

Provincial Health Services Authority (2013). BC Cancer Agency: Intermittent and Continuous medication administration via an established Subcutaneous Injection Site.

Provincial Health Services Authority (2009). BC Children’s Hospital Child and Youth Health Policy and Procedure manual: Continuous Subcutaneous Medication or Fluid Infusion.