End of Life Care:Syringe Driver

Learning OutcomesBy end of session you should be able to;• Give a brief account of the clinical

indications for use of the Syringe Driver.• Identify sites that may be used for infusion

by the Syringe Driver.• List the equipment necessary.• Show how to set up, the correct insertion

and monitoring of the syringe driver.• Identify safe practice and where to get

advice

why might we want to use a syringe driver?

Indications for the use of the syringe driver

Patient is unable to take oral medication due to1. dysphagia2. altered level of consciousness3. intractable nausea/vomiting4. intestinal obstruction5. oral route not tolerated eg. head/neck

cancer6. malabsorption7. rectal route not appropriate

What are the advantages and disadvantages of using a

syringe driver?

Advantages

1. avoids repeated injections2. avoids peaks and troughs in blood 3. levels, provides constant symptom4. effective symptom control 5. can use combination of drugs6. saves nursing time giving injections7. comfortable for patient, gives mobility

Disadvantages1. once daily loading may mean lack of

flexibility in dosage2. sterile abscesses may form at SC site

as a reaction to some drugs3. irritation leading to erythema or

swelling may interfere with infusion rate and absorption

4. some patients find them a burden5. association with dying

Skin site selection

The best sites to use for continuous subcutaneous infusions are;

• the upper chest wall below the clavicle• the upper arm and thigh• the abdomen• occasionally the back

Sites to Avoid if Possible• Lymphoedematous limbs – the subcutaneous

tissues are ‘waterlogged’ with lymph fluid, which would affect absorption. There would also be increased risk of leakage or infection.

• Any site over a bony prominence or near a joint.• The upper abdomen in a patient with an enlarged

liver – there is a risk of puncturing the liver capsule• The upper chest wall in very cachectic patients –

there is a risk of causing pneumothorax.• Previous irradiated skin area.

Irritation at Injection SiteAbsorption of drugs may be impaired, causing poor

symptom control.

• Ensure needle tip is not too shallow• Try sof-set• Try a different diluent• Change irritant drugs to an alternative (e.g. cyclizine

haloperidol)• Give irritant drugs by alternative route (e.g. rectal)• Add dexamethasone 1mg or hydrocortisone cream to site• GTN patch over site

Setting up the syringe driver

Equipment

• Prescribed Medication; patient prescription to include breakthrough medication

• Syringe Driver; plastic cover; carrying holster

• 9 volt battery and spare battery• 1ml or 2.5ml syringe• 30 ml luer lock syringe

Equipment• 100cm butterfly infusion set or Mini Med

sofset (106cm = FSB706 / 60cm = FSB708)• Vygon extension lead if required (FWL057)• Skin swab, 2% Chlorhexadine Gluconate in

70% Isopropyl Alcohol• Transparent adhesive dressing• Diluent • Blue needle or pink blunt needle (FTR436)• Drug additive label and syringe driver

monitoring chart

Equipment• Plastic Apron• Non Sterile gloves (local policy)• Ruler• Sharps bin• Adjustment tool from Graseby

manufacturer (08454 226800 phone for pack of 5)

Test Battery• Insert the battery into the pump• This should set off an alarm which

sounds for approx 10 seconds• If this does not happen – replace the

battery• Battery will last for approx 50 infusions

Test the Syringe DriverBefore placing the syringe in the driver• Press the start button for 10 seconds • Keep the start button depressed during

this time as this tests the syringe driver safety circuits

• Pressing for less time will start the syringe driver but will not test the circuits

Drawing up drugs and priming line

• Check expiry date of medication and diluents• Draw up prescribed drug using blue needle

or 18g pink blunt needle• Add diluent until it measures 48mm (not mls)• most drugs should be reconstituted with

water for injection, seek advice if unsure

Drug Stability and Incompatibility

Check compatibility of drugs with Drug Information, telephone:

GRH-08454 226108 or CGH- 08454 223030 Community Specialist Palliative Care Team

01452-371022 Hospital Specialist Palliative Care Team 08454 223447 or 08454 225179 Out of hours advice line bleep 07659 119458

Drawing up and priming line

• Use label with drug; dosage; patients name; time; nurse signature

• Attach to syringe ensuring that markings on syringe are still visible

• Connect syringe to giving set and prime the line

Rate• Set the rate on the pump to

48mm/24hours• If the line has been primed, the syringe

will run out in under 24hrs *See table in your local policy• Consider giving breakthrough dose of

medication when first setting up syringe driver

Fitting• Press white release button and slide to

the right• Syringe in the grooved furrow• Ensure wing is against central wall• Secure with black rubber band • Move actuator to left until it connects

with the driver. Ensure end of plunger sits in slot above white release button

Insertion of butterfly infusion set

• Explain procedure and obtain consent• Wash hands• Non sterile gloves (local policy)• Assist patient to comfortable position• Expose chosen skin site• Clip excess hair if needed• Clean with swab and allow to air dry

Insertion• Grasp skin firmly either side of site• Insert needle at 45 degree angle (Sof

Set 90 degree angle)• Tape the infusion set wings to skin with

transparent dressing coiling the tube under the dressing

Commencing infusion

• Press start/boost button to begin infusion - check that the light flashes

• Cover syringe with plastic guard and put driver in holster or under bedclothes

• Ensure driver not over infusion site• Document the start of the infusion

Observations and Checks

• Evaluate symptom control on each contact

• Complete syringe driver observation chart on set up, 1 hour after and then 4 hourly in hospital or each home visit

• If the site is red or has other problems, re-site the butterfly using a new

infusion set.

Precipitation• Precipitation when mixing drugs is a sign of

incompatibility• Occasionally a mixture that has been used

successfully, will suddenly precipitate in the middle of an infusion

• It may be related to a reaction occurring in the subcutaneous tissue, and once it has happened, it tends to recur in the same patient.

• Cyclizine is most frequently the problem.

Precipitation, what to do• Change the site and the whole giving set –

not just the syringe• Consider different diluent • Consider alternative antiemetic/drugs, some

drugs are too irritant for SC use – diazepam, stemetil, largactil

• Keep away from direct sunlight or heat• Separate the drugs being given into two

syringe drivers • Consider once daily SC drugs

Observations and Checks

Syringe Driver:• Light flashing• Correct volume of fluid remaining• Correct rate• No leakage• Is protected from lightInjection site:• Pain, swelling, erythemaSyringe with medication• Crystallisation

Safety/Hazard• Indwelling device is a risk, use principles of

asepsis• If the infusion set becomes disconnected

from the patient discard, recording drug volumes, and re-site a new syringe and giving set

• If dropped, immersed in water or contaminated by fluids:

• Detach driver; shake vigorously if wet and send to medical physics • Use another syringe driver

Safety/Hazard• DO NOT allow the patient to have a

bath or a shower with the syringe driver in situ as steam and condensation will affect the mechanism of the driver

• If the patient wishes to have a bath or shower the syringe driver can be discontinued for a short period to enable this

MEDICAL ENGINEERING• Syringe drivers must be returned to

Medical Engineering for servicing or repair (Tel: 08454226116).

• If the syringe driver has a serial number on it preceded by a “G” or an “E” it must go to Gloucester Royal Hospital.

• if preceded by “CHD” it must go to Cheltenham General

Any questions?