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Syringe driver in palliative care

Small portable battery operated device that administers medicine subcutaneously over a selected time period , usually over 24 hrs

 

Used often in palliative care The syringe may have a single drug or a combination of drugs administered at a constant rate Used when the patient is unable to take medications orally due to 
○ persistent nausea and vomiting
○ dysphagia / difficulty in swallowing due to profound weakness / low energy levels
○ bowel obstruction or malabsorption
○ inadequate symptom control via tablets for e.g due to poor absorption
○ reduced level of consciousness – in last days of life
○ intractable pain
○ obstructive oral / neck / oesophageal lesions
○ severe stomatitis 
○ repeated subcutaneous dose administration is inappropriate

 

provides an alternative route when using oral route becomes unmanageable permits good symptom control – steady levels of plasma drug concentration drugs usually are more bioavailable by injection than orally ie the dose of the drug given via a syringe pump is likely to lower than previously given orally better control of nausea and vomiting allows control of multiple symptoms with a combination of drugs avoid necessity for repeated injections S/C route is more comfortable in comparison to IM ( particularly in cachectic patient ) less invasive than IV does not restrict mobility and independence syringe only needs changing once a day unless prescription changes technically simple to set up and use

 

dosage – requirement has to be anticipated after setting up it may take up to 4 hrs for the medications to reach a concentration that provides adequate pain relief – ie PRN medications would be required initially exacerbation of symptoms may require additional PRN injections to supplement the infusion 
( this can also be done via a separate SC line ) not all medications would be compatible with syringe driver irritation or erythema and swelling at the cannula site may interfere with the rate & absorption training is necessary for safe and effective use machine inefficiency battery failure the patient / relatives may perceive this as a final step before death and find its use disconcerting and intrusive

 

lack of consent / permission from the patient and / or family /carers as proxy other viable route of administration is available intended drugs to be used are contraindicated / allergies

 

Indications and consent – obtain consent – if the patient is unable to consent gain consent from relatives / next of kin / carers explain to the patient / carer
○ reason for using this method
○ what does it involve – ie how the device works
○ advantages and disadvantages site selection – discuss with patient their preferences for selection taking into account disabilities & physical needs
○ avoid areas of broken skin , inflammation , skin folds , oedema , lymphoedema , ascites, close proximity to joints , areas with tumors or previously irradiated areas
○ use an area with good depth of subcutaneous fat
○ avoid upper arm in bed-bound patients – who need turning over
○ avoid bony areas in cachetic patients ( abdomen may be more sui
○ suitable areas include the upper chest , upper arm , anterior abdomen , anterior aspect of thighs reassure that syringe driver does not always mean that death is imminent reiterate that the syringe driver allows for effective symptom management associated with the process of dying but does not speed up the process of dying discuss any fears or anxieties about the syringe driver including the medicines used as opiates ensure that relatives have the telephone numbers – whom and how to contact if they feel that SD is not functioning properly

 

Prescribing and compataibility – the doctor is responsible for prescribing the medication to be infused and the registered nurse is responsible for administering , the set up , monitoring and reloading the driver every 24 hrs always check for allergies discontinue medications which are not essential prescribe each component , specify the diluent and ensure compatibility 2 to 3 drugs are generally administered via the same driver -drug compatibility should be checked for all combinations pH is a good indicator of drug compatability
○ most drugs used are acidic
○ drugs as dexamethasone , dilcofenac , ketorolac & phenobarbital are alkaline
hence a combination of acidic / alkaline drugs would be incompatible & require seperate infusions
○ in general increasing the number of medicines in the solution increases the risk of problems with combinations
○ physical incompatibility may manifest as changes in the solution as discoloration , clouding or precipitation water is the recommended diluent in UK – less chance of precipitation , compatible with most medications
○ note that levomepromazine , ondansetron , octreotide , methadone, ketorolac , ketamine or furosemide – should be diluted with normal saline
○ there is no definitive evidence to indicate how much diluent should be used but as a general rule a more dilute solution reduces the risk of drug imcompatibility and minimizes site irritation instructions do not need the rate of infusion but the duration -the driver would detect the syringe size , the volume of the medication and set the rate to deliver the infusion over the required period it is common practice to use a 20 mL syringe and 30 mL for large infusions diamorphine is the opioid of choice in syringe drivers – very soluble , allowing large doses to given in smaller volumes it should also be noted that S/C infusion of many drugs use in palliative care in the UK is outside the product licence

 

Breakthrough pain and review of effectiveness – remember it takes about 4 hrs for medications to achieve a steady state prescribe prn medications for any distressing or uncontrolled symptoms to cover that period the prn medications need to be given via a separate S/C inj or via a S/ C cannula – and not via the syringe driver review the effectiveness of the drugs / PRN medications prescribed atleast daily and consider whether any changes are required ensure that the correct S/C breakthrough doses have been prescribed for e,g for analgesia 1/6 of the total 24 hr dose opioid dose breakthrough dose for e.g the patient is receiving 30 mg of S/C morphine over 24 hrs
the breakthrough dose orally would be 1/6 th ie 5 mg subcutaneously
oral dose would be 10 mg
if the 24 hr dose increases the break through dose also increases & vice versa discontinue prescriptions by clearly CROSSING THROUGH THE WHOLE PRESCRIPTION , with the date discontinued and signature do not alter an existing prescription – ALWAYS REWRITE A NEW syringe driver prescription in a new box it is advised that if the dosage is changed , new drug added the SD should be reloaded if the patient is able to revert from a syringe pump to oral / transdermal medications – convert the drugs sequentially rather than all at once

 

Trouble shooting – Troubleshooting

Experienced nurses would be able to manage most situations , but in case you are asked for advice – you can can consider a logical sequence to identify the problem by asking
 Is the problem with the syringe driver ?

Is it medication precipitation ?

Is it a site reaction ?

An example of SD check chart is shown here from NHS Wales

 

You matter because you are you. You matter to the last moment of your life and we will do all we can , not only to help you die peacefully , but to live until you die“

 Dame Cicely Saunders

 

Cicely Saunders ( 1918 – 2005 ) -founded the first modern hospice and was responsible for establishing the discipline and the culture of palliative care in the UK. She championed the concept of Total pain which included the physical , emotional , social and spiritual dimensions of distress and regarded each person , whether patient or staff as an individual till the end.

REFERENCES

  1. University Hospital of Leicester – Policy for the use of ambulatory T34 syringe driver in adults receiving palliative and / or end of life care in the university hospitals Developing and Approving Clinical and Non Clinical Policies and Guidance Documents (Policy for Policies) (leicestershospitals.nhs.uk)
  2. Oxford Radcliffe Hospitals Clinical protocol for the use of syringe drivers in palliative care patients ( adults ) 44279.indd (palliativedrugs.com)
  3. Greater Manschester Health and Social Care Partnership Palliative Care pain and symptom control guideline for adults Fifth edition Palliative-Care-Pain-and-Symptom-Control-Guidelines.pdf (england.nhs.uk)
  4. Anticipatory prescribing Palliative care drugs Anticipatory drugs and syringe driver chart V2 (palliativedrugs.com)
  5. When and how to use a syringe driver in palliative care BPAC NZ BPJ 48: When and how to use a syringe driver in palliative care (bpac.org.nz)
  6. Syringe pumps Scottish Palliative Care Guidelines Scottish Palliative Care Guidelines – Syringe Pumps
  7. Robinson RChauhan AEngland R, et al 135 The use of opioids in syringe drivers: an audit across 2 specialist palliative care services in the East Midlands Region
  8. Guidelines for syringe driver management in palliative care cpcre_sd_gdlne.pdf (health.qld.gov.au)
  9. St Lukes the Sheffield Hospice Essential Syringe Driver Training for T34 Elaine Bird Slide 1 (sth.nhs.uk)
  10. York Teaching Hospital NHS Foundation Trust Symptom control in the last days of life https://www.yorkhospitals.nhs.uk/seecmsfile/?id=3669
  11. Guidance on the prescribing and use of the Transdermal Fentanyl Patches in the Dying Phase Guidance on the Prescribing and use of Transdermal Fentanyl Patches in the Dying Phase (adults) (uhb.nhs.uk)

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