Syringe drivers

What is a syringe driver?

A syringe driver is a small, battery-operated, portable infusion pump. It administers a continuous subcutaneous infusion pump over 24 hours. It can ensure that symptom management is maintained in patients with advanced illness. Medications are drawn into syringes and then attached to the pump, which is set to move the plunger of the syringe forward at an accurately controlled rate.

What are the benefits of a syringe driver?

There are several benefits, including…

• Constant drug concentration

• Usually reloaded once in 24 hours

• No repeated injections

• Does not limit mobility

• Permits better control of nausea and vomiting

• Control of severe symptoms with a combination of drugs in a single infusion

What are the indications for using a syringe driver?

There are several indications for using a syringe driver, including...

• Persistent nausea and/or vomiting

• Difficulty in swallowing

• mouth/throat/oesophageal lesions

• intestinal obstruction

• poor absorption of oral medication

• unconscious and semi-conscious patients

• profound weakness when patients are unable to swallow medication

What should you discuss with family when using a syringe driver?

• any experience or knowledge about syringe drivers

• The stage of the illness and the reason for use of the syringe driver

• Any fears or anxieties about the syringe driver or the drugs to be used

• Explanation that the syringe driver allows symptoms to be managed but does not speed up the dying process

• Advance care planning

• Care of the syringe driver

• What to do and who to ask for help if the syringe driver is not working properly or if symptoms are not controlled

• the possible need to have extra breakthrough doses of medication in addition to the syringe driver to control symptoms

When is an infusion site irritation reaction likely to occur?

If the site of infusion is older than 72 hours then a reaction is more likely to occur

What medications increase the risk of an infusion site reaction?

• Cyclizine

• Levomepromazine

• High doses of diamorphine

How do you prevent infusion site reactions?

• Change the site every 2-3 days before the reaction occurs

• Reduce the concentration of the drug

• Change the drug you are using or use an alternative route - some drugs more irritant than others

• Mixing drugs with 0.9% saline (if compatible)

• Using a non-metal cannula

• Applying hydrocortisone 1% cream to the site around the needle and covering with occlusive dressing

How do you give breakthrough doses with syringe drivers?

• breakthrough pain can be treated with additional subcutaneous doses of the opioid being used (usually morphine)

• If possible, doses should be given through a side port in the syringe driver cannula line to minimise patient distress

• Breakthrough doses are given 2-4 hours prn

• Use 1/6th of the 24-hour doses in the driver!! (not 1/10th in palliative)

How to use opioids in syringe drivers when patient already has opioid patch?

• If the patient has an opioid patch, then leave it on

• The syringe driver is used to top up dose and is titrated as necessary

• The prn dose of opioid should be calculated from the dose of opioid in the syringe driver and the equivalent given by the patch

What are anticipatory medicines?

• ‘Just in case’ or anticipatory medicines are a small supply of medications for you to keep at home, ‘just in case’ you need them at short notice

• Anticipatory prescribing is beneficial for several reasons:

  • Ensure there is a supply of drugs in the patient’s home

  • Ensure they have the apparatus needed to administer them

  • Ensure both are available to an attending clinician for use where appropriate

  • These drugs belong to the patient and have the same legal status as other prescribed controlled drugs

Name the drugs you would expect to see on an anticipatory Rx to treat the following:

• Pain

• Sickness

• Drying chest secretions or treating abdominal cramps

• Restlessness and distress

• Breathlessness

• Opioids - morphine, oxycodone

• Haloperidol, Levomepromazine

• Hyoscine butylbromide - Buscopan

• Midozolam, Levopromezine, haloperidol

• Morphine, oxycodone, midazolam

Morphine dosing requirements for syringe drivers?

• Morphine - ½ total daily dose of oral morphine

• If patient is opioid naive then 10-20mg starting dose

How is diamorphine dosed in syringe drivers?

1/3 total daily oral morphine = diamorphine dose for syringe driver

5-15mg starting dose if opioid naive - increase dose as needed by 30% increments

What antiemetics do we use in syringe drivers? name 4

• Metoclopramide

• Haloperidol

• Cyclizine

• Levomepromazine

What sedative medications are used in syringe drivers? What are they used for?

• Haloperidol

• Levopromazine

• Midozalam

Used for restlessness and agitation, myoclonic jerking, anticonvulsant, terminal agitation and delirium

What anticholinergics do we use in syringe drivers and what are they used for?

• Glycopyrronium

• hyoscine hydrobromide

• hyoscine butylbromide

Used for hypersecretions and colic like symptoms or in intestinal obstruction

Why do we use hyoscine butylbromide more so than hyoscine hydrobromide?

• hyoscine hydrobromide enters the BBB and therefore is associated with more side effects, one of which is sedation. We want to avoid over-sedating palliative care patients due to them being too sedated to engage with family and therefore we would avoid drugs crossing the BBB. Hyoscine butylbromide is less lipophillic so does not readily cross the BBB so used more frequently