1. SYRINGE DRIVERS Coranne Rice.
Clinical Nurse Specialist in Palliative Care
Beaumont Hospital.
23rd Sept 2010

2. Definition.
A portable battery operated pump, which delivers a continuous subcutaneous infusion over a specified period of time.
Dickman et al 2005

3. McKinley T34 Syringe Pump

4. Graseby Syringe Driver MS16

5. Aims. Delivers a continuous infusion of drugs via subcutaneous route.
Ensures a stable plasma level of drugs.
Eliminates the need for repeated injections.
Used when oral medications are no longer appropriate for a number of reasons.

6. Indications For Use Persistent nausea and vomiting
Inability to swallow oral medications.
Severe mucositis
Poor alimentary absorption (intestinal obstruction/ mal-absorption)
Intractable pain not controlled by oral medications
Rectal route not appropriate.

7. Drugs used in Syringe Drivers
Analgesics.
Anti emetics.
Sedatives.
Drying agents.

8. Analgesics Morphine Sulphate. Oxycodone. Hydromorphone. Fentanyl.
Diclofenac.

9. Morphine Sulphate Opioid of choice. Most commonly used.
Controlled drug.
Preparations – 10, 15, 30, mg/ml vials.

10. Oxycodone. Twice as strong as Morphine Sulphate
eg. Morphine Sulphate 60mgs = Oxycodone 30mgs.
Controlled drug.
Used in patients with renal failure.
Caution when mixed with Cyclizine.
Preparation - 10mg/ml vial

11. Hydromorphone Six times stronger than Morphine Sulphate
eg. Morphine Sulphate 60mgs = Hydromorphone 10mgs.
Controlled drug.
Used in patients with renal failure.
Preparation - 20mg/ml vial.

12. Fentanyl Used under the advice of Specialist Palliative Care. Opioid.
Controlled drug.
Used in patients with renal failure
Known for its patch and oral routes.

13. Diclofenac. Difene. Non steroidal anti-inflammatory drug (NSAID).
Total dose in 24hrs -150mgs.
Caution in patients with renal failure and peptic ulcer disease.
Mix with NaCl in a 20ml syringe.
Use a separate syringe driver.

14. Anti Emetics Cyclizine. Metoclopramide. Haloperidol.
Methotrimeprazine.
Ondansetron.

15. Cyclizine
Valoid.
Nausea/Vomiting caused by stimulation of the vomiting centre or vagus nerve eg. raised intracranial pressure, radiotherapy to head/ neck, bowel obstruction and movement.
Preparation - 50mg/ml vial.
Total dose in 24hrs – 150mgs.
Incompatible with Buscopan and used with caution with Oxycodone.

16. Metoclopramide Maxalon.
Nausea/Vomiting caused by drugs, gastric stasis, partial obstruction, constipation.
Preparation - 20mg/2ml vial.
Total dose in 24hrs - 120mgs
Caution when used with Cyclizine.
May crystalize with cyclizine.

17. Haloperidol
Serenace.
Nausea/Vomiting caused by stimulation of the chemoreceptor trigger zone eg. Drugs (especially opioids), intestinal obstruction, hypercalcaemia.
Preparation - 5mg/ml vial.
Can be used for the treatment of Delirium.

18. Methotrimeprazine. Nozinan. Broad acting anti emetic.
Acts on main receptor sites involved in the vomiting pathway
Strong sedative effect.
Preparation – 25mg/ml vial.
Can be used in the treatment of agitation.

19. Ondansetron
Zofran
Nausea/Vomiting caused by chemotherapy and radiotherapy.
Total dose in 24hrs – 32mgs.
Caution - causes constipation.

20. Sedatives Midazolam Haloperidol (Serenace) Methotrimeprazine (Nozinan)
Clonazepam

21. Midazolam. Short acting benzodiazepine
Used in the treatment of agitation, anxiety, seizures, myoclonus
Preparation 10mg/2ml vial
Can use up to 60mgs in 24hrs.

22. Clonazepam Used under the advice of Specialist Palliative Care.
Benzodiazepine.
Used in the treatment of neuropathic pain,
agitation, anxiety, seizures and myoclonus.
Preparation – 1mg/ml vial.

23. Drying Agents Hyoscine Butylbromide (Buscopan)
Glycopyrronium (Robinul)
Hyoscine Hydrobromide (Hyoscine)

24. Hyoscine Butylbromide
Buscopan.
1st drug of choice.
Non sedating.
Doesn’t cross the blood brain barrier.
Incompatible with Cyclizine.
Preparation - 20mg/ml vial.
Maximum dose in 24hrs -120mgs.

25. Glycopyrronium Robinul. Non sedating.
Doesn’t cross the blood brain barrier.
Preparation 200mcg/ml vial.
Maximum dose in 24hrs – 2.4mgs.

26. Hyoscine Hydrobromide
Crosses the blood brain barrier.
Can cause agitation and delirium
Preparation – 400, 600 mcg/ml vials
Maximum dose in 24hrs – 2.4mgs.
Not recommended in Palliative Care.

27. Other Drugs occasionally used
Octreotide
Phenobarbitone
Ketamine
Methadone
Dexamethasone

28. Octreotide Used under the advice of Specialist Palliative Care.
Reduction of intestinal secretions
Used in the treatment of excessive diarrhoea or large volume vomiting.
Preparation 100, 500mcg vials.
Can use up to 2,000mcg in 24hrs.

29. Phenobarbitone Used under the advice of Specialist Palliative Care.
Long acting barbiturate.
Anti epileptic.
Controlled drug
Preparation -200mg/ml vial.
Can use up to 1,200 mgs in 24hrs.
Used in terminal restlessness/agitation
Used in separate syringe driver

30. Drugs never used in Syringe Drivers
Diazepam
Chlorpromazine (Largactil)
Prochlorperazine (Stemetil)

31. Mixing Medications in a Syringe Driver.
Care should be taken when mixing two or more drugs in a syringe driver.
Ensure that the drugs used are compatible with each other.
Ensure that the diluent used is compatible with the drugs used.
At least 2-3 mls of diluent should be added to all syringes.
Observe for crystallisation of drugs in syringe driver.
Change drugs in syringe driver every 24hrs.

33. “Kill Two Birds with the One Stone”
Morphine Sulphate: Pain, Dyspnoea.
Midazolam: Agitation, Dyspnoea.
Haloperidol: Antiemetic, Agitation, Delirium.
Metoclopramide: Antiemetic, Constipation.
Hyoscine Butylbromide: Drying secretions, Crampy abdominal pain.
Methotrimeprazine: Antiemetic, Agitation.
Phenobarbitone: Anti-Epileptic, Agitation

34. The “Box”
Not necessarily permanent

35. Information
The Syringe Driver- Continuous subcutaneous infusions in palliative care.
Policy/Procedure/Guidelines for the safe and appropriate use of the McKinley T34 Syringe Pump.
McKinley T34 Syringe Pump Observation Sheet.
Careplan - Comfort measures for palliative care patients.
Analgesic Conversion Guidelines in Palliative Care.
Drug Combinations as Subcutaneous Infusions (in Syringe Driver) for Palliative Care

36. References
Dickman A. Schneider J. Varga J.(2005) Continuous Subcutaneous Infusions in Palliative Care. 2nded Oxford University Press.