PallConsult

Support for clinicians

delivering end-of-life care

A practical handbook for

health professionals:
How to safely set up a SurefuserTM+ infusion
device, commence and monitor the infusion in
a palliative care setting

Endorsed by the Statewide Palliative Care Directors’ Group.

June 2021, V1.0
Copyright
This document is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0
Australia licence. To view a copy of this licence visit:
https://creativecommons.org/licenses/by-nc-nd/3.0/au/
Brisbane South Palliative Care Collaborative, 2021
In essence, you are free to copy, distribute and transmit the work in its current form for non-commercial
purposes. You must attribute the work in the manner specified by the authors. You must not alter,
transform, or build on this work.
Acknowledgements
This handbook was coordinated by Metro South Palliative Care Service and developed by Brisbane
South Palliative Care Collaborative (BSPCC) as a part of the PallConsult project. It includes adapted
resources obtained from Nipro Australia Pty Ltd, Nepean Health (video).
Brisbane South Palliative Care Collaborative acknowledges and thanks all the health professionals who
contributed to the development of this handbook.
Funding statement
PallConsult is funded by Queensland Health.
Suggested reference:
Brisbane South Palliative Care Collaborative. A practical handbook for health professionals: How to safely
set up the SurefuserTM+ infusion device, commence and monitor an infusion in a palliative care setting.
Brisbane: Brisbane South Palliative Care Collaborative; 2021.
Enquiries
All enquiries about this document should be directed to:
Brisbane South Palliative Care Collaborative
E: pallconsult@health.qld.gov.au
Disclaimer
This handbook is intended as a guide for health professionals to assist with safely setting-up a
SurefuserTM+ infusion device and commencing and monitoring the infusion in a palliative care setting.
While Brisbane South Palliative Care Collaborative has exercised due care in ensuring the accuracy of
the material contained in the handbook, the handbook is a guide to appropriate practice, and is subject
to the clinician’s judgement and local organisation policies and procedures.
Brisbane South Palliative Care Collaborative does not accept any liability for any injury, loss, or damage
incurred by use of, or reliance upon, the information provided within this handbook.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Components of the learning package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Additional resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Assumed knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
About the SurefuserTM+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Choosing the correct size device in the palliative care setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Managing the SurefuserTM+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Securing the flow controller and subcutaneous cannula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The light weight carry pouch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Strategies for safe use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Managing monitoring requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Monitoring labels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Monitoring the infusion over time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
In the hospital or residential aged care facility setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Community setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Educating the person and their family/carer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Medicine orders and documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Medicine compatibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Disposing of the SurefuserTM+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
A step-by-step guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3
Introduction
Continuous subcutaneous infusions (CSCIs) of medicine(s) are a common and accepted practice in
palliative care for assisting with the management of pain and other symptoms when other routes of
administration are inappropriate or ineffective. Most CSCI devices, including the NIKI T34TM require a
registered nurse (RN) to visit daily and refill the syringe in the pump with medicine(s).
In some rural and remote areas, RNs are not available to visit a person’s home daily, particularly on
the weekend. This can significantly impact some aspects of end-of-life care in the home environment,
including pharmacological management of symptoms. Use of the SurefuserTM+ can overcome this
limitation.
The SurefuserTM+ is used as a second line infusion device when:
• A NIKI T34TM syringe pump or other battery-operated CSCI pump is not available
• Transferring a person requiring a CSCI between services when it may be difficult to ensure that the
NIKI T34TM is returned
• Health professionals are not available daily to refill a NIKI T34TM syringe pump or other pump that
requires daily refilling
• A disposable device may be advantageous, e.g. in case of infectous diseases.
This practical handbook is part of a learning package that aims to enable health professionals to develop
skills and knowledge and ultimately demonstrate competency in safely setting up the SurefuserTM+
infusion device (hereafter in this document referred to as the SurefuserTM+) and commencing and
monitoring the infusion in a palliative care setting.
The package is relevant to all palliative care clinical settings – community, residential aged care and
hospital.

Components of the learning package

1 A practical handbook for health This handbook contains the essential information
professionals: How to safely set up a you need to know to safely set up a SurefuserTM+,
SurefuserTM+ infusion device, commence commence and monitor the infusion in a palliative
and monitor the infusion in a palliative care care setting.
setting
2 A step-by-step guide: Setting up a This illustrated guide explains how to set up the
SurefuserTM+ infusion device, commencing SurefuserTM+, commence and monitor the infusion
and monitoring the infusion using a step-by-step approach.
3 Short training video: A nurse’s guide to This video illustrates some of the essential elements
using the SurefuserTM+ infusion device in the for ensuring safe delivery of the SurefuserTM+
palliative care setting infusion in a palliative care setting.

4 Competency checklist: How to safely This checklist describes the requirements for
set up a SurefuserTM+ infusion device, ongoing demonstration of competency for safe
commence and monitor the infusion in a and effective use of the SurefuserTM+ to administer
palliative care setting infusions in a palliative care setting.

5
Additional resources
Additional resources to support the use of the SurefuserTM+ are available for:
• Organisations:
•E  xample policy and procedures: Using a SurefuserTM+ infusion device in the palliative care setting
• Families and carers:
• Information sheet for families: SurefuserTM+ infusion device and infusions
•S  urefuserTM+ infusion device and infusions: troubleshooting and monitoring guide for families.

Assumed knowledge
As part of the health professional’s role in caring for a person in a palliative care setting, knowledge is
assumed across the following areas:
• The goals of palliative care
• Common palliative symptoms
• How to assess a person’s symptoms
• Common medicines used in palliative care.
• Use of CSCIs in palliative care https://www.caresearch.com.au/caresearch/tabid/3426/Default.aspx

Competency
To demonstrate competency in the safe use of the SurefuserTM+, a health professional, using the
competency checklist, needs to demonstrate competency to their organisation’s nominated infusion
device assessor (competent health professional).

Further information
The manufacturers of the SurefuserTM+ have more detailed information, if required.
Step-by-step guide for filling and operating a SurefuserTM+.1
http://www.niproaustralia.com.au/products/infusion-care#gallery-details-infusion-care-surefuser

For further or related information, it is the responsibility of the clinician to contact their service manager.

6
About the SurefuserTM+
The SurefuserTM+ is a type of continuous subcutaneous infusion device, that has
some significant differences to other types of infusion devices, including:
• The SurefuserTM+ is a single-use elastomeric infusion device available in a variety
of flow rates and sizes
• A health professional fills the SurefuserTM+ with medicine(s) prescribed by a
doctor or nurse practitioner, rather than filling a syringe that is inserted into a
device powered by a battery or electricity
• The SurefuserTM+ is not battery or electronically powered. The elastomeric
‘balloon’ inside the infusion device constantly pushes medicine
through the tubing as it deflates, and continues until the
balloon is empty or device is disconnected
• The SurefuserTM+ is often used in the community to deliver
intravenous antibiotics or chemotherapy medicine.

Inclusions with the SurefuserTM+

(Pictured here is the SurefuserTM+ 100mL 2-day infusion)

Lightweight
carry pouch
Blue occlusive cap
Purple occlusive cap

SurefuserTM+ and infusion line

Parts of the Surefuser™+

Casing Balloon reservoir

holds the solution

Robert
clamp
Medicine(s) +
diluent = solution

Flow controller
Infusion line
Filter Connector

7
Choosing the correct size of SurefuserTM+ in the palliative care setting
SurefusersTM+ are available in different sizes.
These resources have been developed based around using the 1-day, 2-day or 3-day-sized SurefusersTM+.
The flow controllers are colour-coded for easy identification of the size of the device and the infusion flow
rate:
Surefuser™+ Total volume Infusion Flow controller colour
of solution flow rate and length
SurefuserTM+ 50mL 1-day
50mL 2.1mL/hour for
*CH2 Order code: #2014300
24 hours
Box of 10
Surefuser™+ 100mL 2-day
100mL 2.1mL/hour for
*CH2 Order code: #2129959
48 hours
Box of 10
Surefuser™+ 100mL 3-day
1.4mL/hour for
*CH2 Order: #2027709 100mL
72 hours
Box of 10
*Clifford Hallam Healthcare (CH2) Pty Ltd - Australian order codes for SurefuserTM+.

These different sizes of SurefuserTM+ ensure:

• an infusion flow rate that allows the subcutaneous cannula insertion site to remain in optimal
condition to absorb medicines
• CSCIs can be continued over weekends or at times where daily visits by health professionals are not
practicable.

Managing the SurefuserTM+

The SurefuserTM+ delivers medicine through a system including:
• A subcutaneous cannula, placed in the
subcutaneous tissue and held in place by a
clear, waterproof dressing
• The subcutaneous cannula is connected to
the device via a Luer Lock connector and a
sterile length of tubing called an infusion
line. The SurefuserTM+ infusion line has a flow
controller, filter and Robert clamp attached.
• The infusion line is attached to the device
where the balloon reservoir contains
a solution of medicine(s) and diluent as
prescribed by a doctor or nurse practitioner
•
The balloon reservoir is held within the
device by a protective casing. As the balloon
deflates, it delivers the solution through the
infusion line and into the person.

8
Securing the flow controller and subcutaneous cannula
Attach the flow controller to the person’s skin with a clear waterproof dressing such as TegadermTM. This
helps regulate the temperature of the solution being infused to be close to skin temperature (32°C),
which is optimal to maintain the prescribed infusion flow rate.
It is important to secure both the subcutaneous cannula and the flow controller separately on a person’s
skin, while minimising any kinking of the tubing.
It is recommended that the subcutaneous cannula is inserted
such that the Y-arm is positioned at the top of the transparent
dressing (as shown in the image at the right).
The infusion tubing and flow controller can then be secured to the
person’s skin above the subcutaneous insertion site. The infusion
tubing is less likely to kink if attached in this way.
See below for examples of correct and incorrect placement of the
subcutaneous cannula insertion site and infusion tubing.

A correct subcutaneous cannula insertion An incorrect subcutaneous cannula insertion

site and infusion tube placement, to ensure site and infusion tube placement, where
no kinking in the tube. kinking is likely to occur.

The lightweight carry pouch

One carry pouch is included in each box of SurefusersTM+.
The carry pouch is lightweight and
breathable. The SurefuserTM+ may slip out if
it is not tightly secured in the pouch.
The string should be tightly tied. Alternatively
a bulldog clip or tape can be placed at
the top of the pouch to help secure the
SurefuserTM+.
The device may also be worn around the
person’s neck if this is comfortable and if
this allows the casing to be level with the
subcutaneous cannula insertion site. This
may prevent the device falling or rolling off the bed.

For more information, watch the training video:

A nurse’s guide to using the SurefuserTM+ in the palliative care setting.2

9
Strategies for safe use

The SurefuserTM+ has no alerts or alarm. It has a silent operation

• Regular monitoring is the only way to detect any issues with the device or the infusion. Carers
and family will require education and support to monitor the SurefuserTM+ correctly
• Attach the flow controller to the person’s skin with a clear waterproof dressing such as TegadermTM.
This helps regulate the temperature of the solution being infused to be close to skin temperature
(32°C), which is optimal to maintain the prescribed infusion flow rate.
• Avoid where possible, temperature extremes in the person’s care environment by providing an
air-conditioner/fan in hot weather or using heating in cold weather.
• Ensure any pre-prepared SurefuserTM+, stored in a fridge prior to use, is at room temperature
before connecting it to the patient.
• Do not hang the SurefuserTM+ casing above or below the person’s subcutaneous cannula insertion
site as this will affect the infusion flow rate.
• Keep the SurefuserTM+ dry. It is water resistant, but not waterproof.
• Do not mix more than three medicines in an infusion device, unless on the advice of a palliative
medicine specialist.5

Managing monitoring requirements

IMPORTANT: The infusion flow rate is affected by changes in ambient temperature, viscosity of the
solution and gravity. The SurefuserTM+ can run 10-15% faster when the room temperature is very
warm or very cold.7 This may result in the device completing the infusion up to a few hours earlier or
later than expected (particularly with 2-day and 3-day infusions).
The health care team should take steps to ensure the person’s symptoms are well managed if the
delivery of medicine finishes earlier or later than expected, including:
• Informing the family/carers of this variability and helping them plan what they should do to
manage any symptoms that may occur, e.g. by using the caring@home package for carers
• Ensuring the person has anticipatory medicines prescribed and available for breakthrough
symptoms
• Educating the family/carers and ensuring they are confident to monitor symptoms and give
anticipatory medicines if required.

Monitoring labels
The exact amount of solution infused by the SurefuserTM+ can sometimes be
difficult to determine, particularly with the longer 100mL 2- and 3-day infusions.
Monitoring labels have been developed as a part of this package to assist
families, carers and health professionals to:
• maintain the recommended regular four-hourly checks of the SurefuserTM+
and the subcutaneous cannula insertion site
• ensure the blue monitoring line is progressing at the correct infusion flow
rate, and not running too fast or too slow.
The image (right) shows an example of a 100mL 2-day SurefuserTM+ monitoring
label.

10
 The labels can be attached to the SurefuserTM+ casing, ensuring that the graduated markings and the
subcutaneous medicine label are not covered. The label colours correspond with the colour of the flow
controller on the matching SurefuserTM+.
• The health professional should fill in the times and dates that the family and carers should check the
SurefuserTM+ and the subcutaneous cannula insertion site.
• The family or carers should mark where the blue infusion line is at each four-hourly check during the
day to ensure the infusion flow rate is not too fast or too slow.
• Family or carers should refer to the SurefuserTM+ infusion device troubleshooting and monitoring guide
for families or contact their health care team with any concerns.

SurefuserTM+ 50mL 1-day monitoring label

SurefuserTM+ 100mL 2-day monitoring label

SurefuserTM+ 100mL 3-day monitoring label

Monitoring the infusion over time

SurefuserTM+ infusion rates can be more variable that powered
CSCI devices. The small variations in the infusion flow rate are
unlikely to cause any clinically significant issues, though all
people under care should have their symptoms monitored and
reviewed regularly to ensure they are comfortable.
• The SurefuserTM+ operates silently. Regular monitoring is
the only way to detect any issues with the device and the
infusion. Therefore, monitoring every four hours during
the day is recommended.
• The SurefuserTM+ has graduated markings printed on the
casing that are numbered in 10mL increments. The location
of the blue infusion line on the graduated markings roughly
corresponds to 10 x millilitres remaining to be infused.
The infusion on the left has approximately
• The family or carers should note the movement of the 50mL remaining to infuse.
blue infusion line every four hours (during the day) on the
monitoring label as shown.

11
In the hospital or residential aged care facility setting must be documented every four (4) hours

• A 50mL 1-day infusion is recommended Device Check Volume

Sign Comments
(Y/N) Left (mL)
• The usual four-hourly checks are the same as for other powered
CSCI devices.
• Both the Medicine Administration Record (MAR) and the
Statewide Subcutaneous Medicine Infusion Chart can be used
to record the routine checks3.
• Graduated markings on the SurefuserTM+ casing are numbered
in 10mL increments. These are approximations only but can be used on the Medicine Infusion Chart.
Heath professionals should record approximately what volume is left, based on where the blue
infusion line is in the Volume Left (mL) column.

In the community setting

• 1-day, 2-day or 3-day SurefusersTM+ can be used depending on clinical need
• A level of vigilance and care is required by family or carers in the home environment to ensure the
SurefuserTM+ is operating correctly
• The role of the health professional is to provide education and support to develop a monitoring plan
that the family and carers can achievably manage.
It is recommended that family and carers check the SurefuserTM+ and the subcutaneous cannula
infusion site:
• Every four hours during the day
• Before going to bed at night
• First thing in the morning
• Mark the movement of the blue infusion line on the monitoring label (every four hours during the
day).
Family and carers should check that:
• The person they are caring for is comfortable and their symptoms are managed as well as possible
• There are no temperature extremes in the care environment. Provide care in a room with an air-
conditioner or fans in hot weather or heating in cold weather
• The SurefuserTM+:
• blue infusion line has moved down the scale towards zero. This indicates that the balloon is
deflating as it delivers medicine to the person
• is intact with no solution leakage
• Robert clamp on the infusion line is open or bypassed
• infusion tubing is not tangled, kinked or squashed and is securely connected to the subcutaneous
cannula
• solution remains clear without discolouration, fogging or crystallisation
• flow controller is firmly attached to the person’s skin with a clear waterproof dressing
• is stored in the lightweight carry pouch and kept on top of bedding/blankets
• casing is not hanging above or below the person’s subcutaneous cannula insertion site
• does not get wet. It is not waterproof. If the device gets wet, dry it immediately with a clean towel.

12
Educating the person and their family/carers
Using the principles of adult education, the person and their family/
carers need to know:
• Why an infusion device is used
• How the SurefuserTM+ operates
• How to care for the device and the subcutaneous cannula insertion
site
• That the SurefuserTM+ infusion flow rate may vary depending on
changes in ambient temperature, viscosity of the solution and
gravity
• How to note the movement of the blue infusion line on the
monitoring label (every four hours during the day)
• How to seek assistance from the health care team if they are
concerned about the person they are caring for or the operation of
the SurefuserTM+.
The health care team should provide education and information that is tailored to the individual/s and
their circumstances and provide to them the following documentation:
• I nformation sheet for families: SurefuserTM+ infusion device and infusions
• S urefuserTM+ infusion device and infusions: troubleshooting and monitoring guide for families
• Any relevant information according to your local policy and procedures.

Medicine orders and documentation for a SurefuserTM+

Documentation will vary according to clinical setting and local policy and procedures.
In the Queensland digital hospital setting:
• Medicine orders for use in a SurefuserTM+ should be ordered in the Medication Administration Record
(MAR) as per, Metro South Health | Digital Hospital Quick Reference Guide – Medication: Order
Subcutaneous Infusion Pump (Surefuser) or by following the local Hospital and Health Service Quick
Reference Guide.
In non-digital hospitals, residential aged care facilities or community settings:
• Medicine orders for a 1-day SurefuserTM+ can be ordered on the Queensland Health Palliative Care
Subcutaneous Medicine Infusion Device Chart (Queensland Health internal only)3 or the form your
service usually uses for a CSCI
• For 2- and 3-day SurefuserTM+ infusions, it is recommended to use a specific, once-only form Coming
Soon.
Medicine is to be ordered to infuse over a specific period, dependant on the clinical situation and
staff availability to prepare and commence a subsequent infusion.

13
 Medicine Compatibility

IMPORTANT:
• Medicines used together in a CSCI device should be checked for compatibility. There is limited
data on compatibility and stability of CSCI medicine combinations lasting longer than 24 hours.
Clinical judgement and specialist palliative care advice may be required.4
• Do not mix more than three medicines in an infusion device, unless on the advice of a palliative
medicine specialist.5
• Check the solution in the balloon reservoir and infusion line regularly for discolouration, fogging or
crystallisation. Stop the infusion and discard the contents if this happens and contact prescriber
• Sterile 0.9% sodium chloride is the first choice of diluent in Australia. If in doubt, check with a
pharmacist or an evidence-based syringe pump compatibility guide.6

It is recommended you choose from the following options:

Surefuser™+ Volume Rate Suggested use

• Transfer between services
• Inpatient settings where no powered CSCI pump (e.g. NIKI
Surefuser™+ 50mL 2.1mL per hour T34TM syringe pump) is available
1-day over 24 hours • In the community where the prescriber would like the
family to connect a pre-prepared, 1-day Surefuser™+ each
day to minimise variation of rates of delivery.

Surefuser™+ 2.1mL per hour • In the community, where a nurse visits on alternate days.
2-day 100mL over 48 hours

Surefuser™+ 1.4mL per hour •

In the community, where a nurse is not available on
3-day 100mL over 72 hours weekends.

Disposing of the SurefuserTM+

The SurefuserTM+ is a disposable, single-use-only product that
must be discarded immediately after use.
• I npatient facilities – If no solution is left in the device at
the time of the infusion being ceased, it can be discarded
in the rubbish bin. If any residual solution is present, the
device must be returned to the Pharmacy Department to
be discarded.
• I n the community – Dispose of any remaining solution in
the SurefuserTM+ by cutting the infusion tubing close to the
base of the device and emptying the solution onto some paper towel or newspaper. The device and
paper towel can then be disposed of in the person’s household rubbish bin. Ensure the work surface
is cleaned, and hands are washed afterwards.

14
Troubleshooting
Health professionals can use the following table to troubleshoot common issues with the SurefuserTM+.
Family/carers should contact their health care team if they have any concerns about the person they are
caring for or the operation of the SurefuserTM+.

Issue Check possible cause Action

Robert clamp closed • Open clamp
• Bypass tubing through the clamp and close it
(this ensures the clamp cannot be accidentally
NO FLOW

closed, cutting off the infusion)

Infusion line kinked • Unkink/straighten infusion line

Air bubbles in filter • Tap the filter and flow controller with your finger
to remove air bubbles
Subcutaneous cannula insertion site is non- • Flush cannula
operational • Re-site if blocked or use secondary subcutaneous
cannula site
Discoloured/foggy/crystallised medicine in • Discontinue use of the device and discard it
SurefuserTM+ balloon reservoir or infusion line • Review medicines with prescriber
SurefuserTM+ casing is positioned lower than • Reposition the SurefuserTM+ casing to roughly
the subcutaneous cannula insertion site the same level as the person’s subcutaneous
cannula insertion site
SLOW FLOW

Ambient temperature is cold • Consider warming the room

• Place a blanket on the person
• Consider positioning the flow controller to a
warmer part of the body, e.g. abdomen
Person’s skin is cool to the touch or they have • Place a blanket on the person
peripherally shut down • Ensure the flow regulator is in direct contact
with the person’s skin
• Consider positioning the flow controller to a
warmer part of the body, e.g. abdomen
Discoloured/foggy/crystallised medicine in • Discontinue use of the device and discard it
SurefuserTM+ balloon reservoir or infusion line • Review medicines with the prescriber

SurefuserTM+ casing is positioned higher than • Reposition SurefuserTM+ casing to roughly

FAST FLOW

the subcutaneous cannula insertion site the same level as the subcutaneous cannula
insertion site

Person’s skin is hot to touch or they have a • Remove blankets or clothing

fever • Use a damp sponge on the person
• Move the flow controller to a cooler part of the
body, e.g. arm
Ambient temperature is hot • Cool the room with an air conditioner or fan
• Ensure SurefuserTM+ remains on top of the
bedding

15
References
 ipro Australia Pty Ltd. Step-by-step guide for filling and operating a SurefuserTM+. Available from: http://www.
1. N
niproaustralia.com.au/medicenter_gallery/infusion-care-surefuser#more-information (Accessed on 10 June,
2021)
 epean Blue Mountains Local Health District. Surefuser – A nurse’s guide to using the SurefuserTM + infusion device
2. N
in the palliative care setting. 2020. Available from: https://vimeo.com/403504780 (Accessed on 10 June 2021)
 ueensland Health. Queensland Health Palliative Care Subcutaneous Medicine Infusion Device Chart. 2020.
3. Q
(Queensland Health internal document only)
4. S afer Care Victoria. Syringe driver compatibility guidance document. February 2021. Available from: https://www.
bettersafercare.vic.gov.au/sites/default/files/2021-02/GUIDANCE_Syringe%20driver%20compatability%20
FINAL_0.pdf (Accessed 10 June 2021)
 ickman, A, Schneider, J. The syringe driver: continuous subcutaneous infusions in palliative care. 4th Edition.
5. D
Oxford: Oxford University Press; 2016
6. F lowers C, McLeod F. Diluent choice for subcutaneous infusion: a survey of the literature and Australian practice.
International Journal of Palliative Nursing 2005;11(2):54-60.
7. Maes, H. SurefuserTM+ Conditions affecting flow rate. Nipro Medical Europe White Paper, July 2020.

16
 PallConsult
Support for clinicians
delivering end-of-life care

A step-by-step guide – Setting up the SurefuserTM+ infusion

device, commencing and monitoring the infusion
This guide assumes a subcutaneous cannula has already been inserted into the person.

Gather the equipment required

• SurefuserTM+ infusion device
• Medicine(s) as per medicine order
• 50mLs or 100mLs sodium chloride 0.9% (depending on
length of infusion)
• Alcohol swabs
• 50mL Luer Lock syringe(s)
• 3mL Luer Lock syringe(s) for drawing up medicine(s)
• Drawing-up needle(s)
• Clear waterproof dressing
• Subcutaneous medicine label
• Infusion monitoring label (not shown in the image)
• Lightweight carry pouch
• Non-sterile kidney dish
• Sharps container

Complete the subcutaneous medicine label for the SurefuserTM+

Complete the following required details on the

subcutaneous medicine label and set it aside:
• Person’s name
• ID number
• Date of birth
• Medicine(s) added
• Units + mLs of medicine(s) added
• Diluent added
• Date prepared
• Time prepared
• Initials of the health professional who prepared the medicine(s)
• Initials of the health professional who checked the medicine(s)

Fill the SurefuserTM+ (This guide shows the process for filling a 100mL 2-day SurefuserTM+)

1. W
 ash your hands and don Personal Protective Equipment (PPE) as per
local policy and procedures

17
 a b
2. a. Attach a drawing-up needle to a 3mL Luer
Lock syringe, open the medicine(s) and
draw up the dose that has been ordered
b. Pull back the syringe plunger slightly on
a 50mL syringe and add the drawn-up
medicines from the 3mL syringe into it
–
Discard the 3mL syringe and drawing
up needle

a b
3. a. Attach a drawing-up needle to the 50mL
syringe, open the diluent and draw up
volume required to fill the syringe to 50mL
b. 
Open a second 50mL syringe, attach a
drawing-up needle and draw up 50mL of
diluent. Filling the SurefuserTM+ with both
syringes makes a total of 100mL of solution
If using a 50mL 1-day SurefuserTM+, you will
*
only need to fill one 50mL Luer Lock syringe c d
with solution
c. 
Remove the drawing up needle(s) and
discard in the sharps container
d. Place the filled syringe(s) in the kidney dish

a b
4. a. Unwrap the SurefuserTM+ from its packaging
b. The SurefuserTM+ package includes:
• The SurefuserTM+ and infusion tubing
• A purple occlusive cap
• A blue occlusive cap
• A lightweight carry pouch

a b
5. a. Close the Robert clamp on the infusion line
(it will snap closed)
• Make sure the tubing is caught between
the two pieces of the clamp as shown
b. Unscrew and discard the blue filling port
cap
c. Screw the Luer Lock syringe into the filling
port until it is firmly attached c

18
 a b
6. a. Support the SurefuserTM+ with one
hand, while placing the other hand
around the syringe barrel
b. Place the syringe plunger against a
non-slip work surface and apply firm
downward pressure to the syringe

– The solution
will begin to
fill the balloon
reservoir

a b
7. a. 
Keep applying firm downward
pressure to the syringe until it is
empty, then disconnect it
b. Screw on the second filled syringe
and repeat the process with firm
downward pressure until it is empty,
and the balloon reservoir is filled. The
blue infusion line should sit at the top
of the graduated markings Fill until the
blue infusion
*If filling a 50mL 1-day SurefuserTM+, you line reaches
will only require one filled 50mL syringe the top of the
graduated
markings

a b
8. a. Check the port section for leaks and
make sure that there is no damage in
the balloon reservoir
b. Unscrew the syringe from the filling
port
c. Open the purple occlusive cap packet
and screw the cap onto the filling
port c d
d. Attach the subcutaneous medicine
label, taking care not to cover the
graduated markings on the device
e. Attach the infusion monitoring
label, taking care not to cover the
graduated markings on the device
f. Discard the syringes in the rubbish e
bin (not pictured)

19
Prime the SurefuserTM+
1.  Remove the white cap on the end of the infusion line and discard it
• This will allow the solution to flow through the line and prime it,
once the Robert clamp is released

a b
2. a. 
Hold the Surefuser™+ infusion line
filter in an upright position
• The filter arrow should point upwards
b. Open the Robert clamp
• The solution will automatically
flow slowly through the line

The filter arrow should point upwards

a b
3. a. If the solution flows from the filter to
the flow controller and there are no
air bubbles in front of the filter, the
filter can be released and placed on
the work surface
b. If the solution does not flow, tap the
filter firmly with your finger to expel
any air

a b c
4. a. 
Priming is complete when all air
bubbles have been bled from the
infusion line and a drop of fluid is
seen at the infusion line connector
b. Close the Robert clamp, making sure
that the infusion line is in the middle
of the clamp
c. Open the blue occlusive cap packet
and screw the cap onto the end of the
infusion line

The SurefuserTM+ is now ready to be connected to the person.

NOTE: The SurefuserTM+ should be connected to the person as soon as possible
and the infusion commenced.

20
Attach the SurefuserTM+ to the person's subcutaneous cannula

1.  Wash your hands again and don PPE as per local policy and procedures.

2. a. Swab the end of the person’s subcutaneous cannula Y-arm with the alcohol swab
b. Remove the blue occlusive cap from the end of the infusion line connector and discard it
c. Screw the infusion line connector onto the Y-arm of the subcutaneous cannula
a b c

a
3. Attach the flow controller (writing side visible) securely to the person’s skin
with a clear waterproof dressing
Ensure the flow
controller is
NOTE: attached with the
a. The flow controller must be attached with writing side visible
the writing side visible. It is most accurate
when firmly attached to the person’s skin.
b
The warmth of the person’s skin assists with a The clear dressings
more accurate infusion flow rate on the subcutaneous
b. It is important to make sure that this new cannula insertion site
and the SurefuserTM+
dressing does not overlap with any existing
flow controller
dressings, for example, the dressing securing
should not overlap,
the subcutaneous cannula
as shown.

Commence the infusion

a b
1. a. 
Open the Robert clamp to start the
infusion
•The solution will now begin to be
delivered to the person
b. Bypass the Robert clamp by pulling the
tubing from the middle of the clamp and
closing the clamp
c d
•This ensures that the Robert clamp
cannot be accidentally closed, stopping
the flow of medicine (e.g if the person
lays on it)
c. Place the SurefuserTM+ in the lightweight
carry pouch provided
• Secure the top of the pouch by tying
the string tightly or with a bulldog clip
or tape, to ensure the SurefuserTM+ doesn’t fall out
d. Store the SurefuserTM+ as advised, with the casing at the same level as the person’s subcutaneous
cannula insertion site

21
Dispose of the SurefuserTM+
a b
1. T his is a disposable, single-use only product
that must be discarded immediately after use:
a. In hospital: If no solution is left in the
SurefuserTM+ at the time of the infusion
being stopped, then it can be discarded in
the rubbish bin. If any solution is present, the
device must be returned to the Pharmacy
Department to be discarded. c
b. In the community: Dispose of any remaining solution in the SurefuserTM+
by:
1. cutting the infusion tubing close to the bottom of the device
2. emptying the solution onto some paper towel/newspaper
3. The SurefuserTM+ and paper towel can then be discarded in a rubbish bin,
the work surface cleaned, and hands washed.

Precautions when using the SurefuserTM+

IMPORTANT:
• The infusion flow rate is affected by changes in ambient temperature. The SurefuserTM+ can deliver
medicine faster when the room temperature is hot and slower if room temperature is cool.
• Ensure the SurefuserTM+ casing is stored at the same level as the person’s subcutaneous cannula
insertion site. It should not hang above or below the insertion site as this will affect the infusion
flow rate.

• Never fill the balloon reservoir beyond the specified amount as the balloon reservoir could rupture
• Do not apply extra pressure to the port when filling as this may cause the port to break and leak
• Do not pull excessively on the infusion line as this may cause leakage and the line may detach from the
device
• Before closing the Robert clamp, verify that the infusion line is in the centre of the clamp. If the Robert
clamp does not clip the infusion line properly, the medicine flow will not be stopped
• During usage, check the condition of the Surefuser™+ and infusion line regularly for leakage or damage
• The SurefuserTM+ is not waterproof. Do not submerge or wet the device
• If required, breakthrough subcutaneous medicines (PRNs) should NOT be administered through the
subcutaneous cannula connected to the SurefuserTM+. It is recommended that a second subcutaneous
cannula be inserted into the person for administration of breakthrough subcutaneous medicines. This
also provides a back-up site if the SurefuserTM+ subcutaneous cannula is accidentally removed or blocked.

22
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