Ascitic and pleural taps

• Abdominal paracentesis to drain ascites is a relatively simple procedure. It can provide effective short term symptom relief using minimal equipment in people with uncomplicated ascites.
• Thoracocentesis to drain pleural effusions has a risk of pneumothorax or haemothorax. It only should be carried out with the immediate availability of x-ray and resuscitation equipment and the facility to insert a chest tube with underwater sealed drain if required.

Managing syringe drivers and pumps

• A syringe driver is a method of administering medications when a person is no longer able to swallow. Syringe drivers are battery operated pumps for delivering continuous infusions that usually run over 24 hours.

TIP - There is no pharmacological advantage of infusions via a syringe driver over other methods of medication administration, but syringe drivers are particularly valuable for patients in the community. If a syringe driver is unavailable, ensuring that parenteral medication is given regularly can achieve the same outcome.

• Until recently, Graseby syringe drivers have been the most widely used, but these are currently being withdrawn from the market in Australia. Many are still in use, however. Two different models of Graseby syringe driver are available.
• There is a risk of potentially serious medication error if staff are unfamiliar with the equipment, if different types of pumps or drivers are in use, or if staff members use different ways to calculate infusion rates. Procedures should be reviewed and standardised to minimise this possibility.
• Contact your local palliative care service for information about their current practice.

Reviewing medications in the deteriorating patient

(eg, largely bedbound, more time asleep, declining or fluctuating oral intake, declining or fluctuating conscious state).

• Think about polypharmacy: co-morbid medications (eg, for ischaemic heart disease, osteoporosis, prophylaxis for DVT etc) can be reduced and stopped as progression occurs and the goals of care change.
• Think about the route of administration of medications - losing the ability to swallow is an inevitable part of deterioration.
• Sometimes it is not possible to replace important medications usually taken orally, for example:
  • Aperients: consider judicious use of suppositories or other PR management
  • Adjuvant analgesics: residual pain may need to be covered by an increase in opioids or other medications such as low dose clonazepam
  • Antidepressants.
• Anticonvulsants for seizure control can be replaced with clonazepam 0.5 to 1mg subcutaneously or sublingually bd, and the dose increased if seizures occur.

More detailed information ...

Return to GP Home page

 

This page was created on 26 May 2009 and is due for review in May 2011.*