The Syringe Driver Competency Programme A learning programme endorsed by Hospice New Zealand

What is a syringe driver? A battery powered pump that administers drugs subcutaneously over a predetermined period of time. A syringe containing medication is attached to the pump which pushes the plunger forward at an accurately controlled rate.

Syringe Driver used in New Zealand – Niki T34 A small, lightweight and robust battery powered ambulatory syringe driver that complies with all current applicable safety standards.

Reasons for using a syringe driver A syringe driver should be considered as a means of providing improved symptom control via subcutaneous infusion of medications when the person has: Unrelieved pain Persistent nausea and/or vomiting Dysphagia Gastro-intestinal obstruction Poor absorption of oral medication Weakness/alteration of consciousness

Nursing responsibilities Consider and discuss: Legal Responsibilities Professional Responsibilities Responsibilities in relation to the syringe driver

Nursing responsibilities Understand indications for a Subcutaneous Infusion Understand purpose and action of all medications administered Recognise adverse effects Assess subcutaneous sites/device Documentation Education

Addressing patient and family concerns What experience has the patient and family had with syringe drivers? What are their beliefs about morphine? Do they understand what is happening? What are their fears and anxieties?

Medications commonly used in a syringe driver Opioids: - morphine sulphate (most commonly used) - oxycodone - methadone - fentanyl Anticholinergics: - hyoscine butylbromide (buscopan) Antiemetics: - metoclopramide - cyclizine - haloperidol - levomepromazine Anxiolytics/sedatives: - midazolam

Drugs that should NOT be used subcutaneously Diazepam Prochlorperazine Chlorpromazine

Prescribed medications for a syringe driver Chart medications required per 24 hours e.g. Morphine 20mg Haloperidol 2mg Midazolam 10mg Subcut over 24 hours

Prescribed medications for a syringe driver Familiarise yourself with the documents used in your area for prescribing subcutaneous infusions and PRN (as required) medications. PRN medications must ALWAYS be prescribed for breakthrough symptoms.

Converting oral morphine to subcutaneous morphine Calculate the total daily dose equivalent of oral morphine the patient has had from all routes (oral + SC,?IV,?IM) in the past 24 hours Divide that dose by 2 to get the subcutaneous 24 hour dose e.g. Total daily dose of oral Morphine is 60mg Give 30mg via continuous subcutaneous infusion over 24hrs Subcutaneous infusion must be prescribed on a medicine chart or infusion chart

Immediate symptom management When commencing a subcutaneous infusion consider an immediate release dose of analgesic and/or other medication Remember it will take up to four hours for medications to reach therapeutic concentrations

Managing breakthrough pain If the patient has breakthrough pain the prn dose must be the equivalent of the four-hourly dose Anything less will be ineffective Breakthrough dose = divide the 24 hour dose by 6 e.g. 30mg morphine in syringe driver over 24 hours 5mg subcutaneous prn or 10mg orally prn to manage breakthrough pain

Drug calculation Formula: Dose required x Volume Dose in stock 1 OR What you want x Volume What you’ve got 1

Practice calculation Person is charted: Morphine 15 mg Haloperidol 1.5 mg via syringe driver over 24 hours In stock: Morphine Sulphate 10mg/1ml, 30mg/ml Haloperidol 5mg/ml Calculate the volume of the prescribed medications and diluent for a 20 or 30 ml syringe

Preparation Check the prescription has been completed correctly and is legible Check the compatibility of the prescribed medications using the Palliative Care Handbook Gather equipment

Gather Equipment There may be variations to some of the equipment brands.

Types of Subcutaneous Devices 25G Winged infusion set BD Saf-t-intima 22G or 24G – Needleless system BD Nexiva

Setting up Hand hygiene Draw up medications accurately as prescribed Fill syringe to suggested standard volume with diluent Label the syringe clearly with completed Medication added label (see example below). Ensure this label is flat when attached to the syringe, so it does not interfere with the barrel clamp arm of the Niki T34.

Setting up Position the label so the medications listed can be viewed as well as the graduations on the syringe for checking purposes. Attach the syringe to the extension tubing and manually prime. Apply the clamp.

Selecting a site Site selection is dependant upon the patient’s skin turgor and comfort. Consider the patient's mobility, skin condition, ease of access and mental state. Inadequate or poorly selected site selection can lead to poor medication absorption and ineffective therapeutic effect.

Sites to avoid Any area that restricts body and limb movement (i.e. skin folds, joints) Breast tissue Areas of obvious bruising, swelling, infection, redness, limbs at risk of lymphoedema, oedema and/ or hardened, broken skin Irradiated skin areas Areas where there is minimal subcutaneous tissue (i.e. thin patients outer arms/subclavicular area)

Site choice Upper anterior chest - site of choice Anterior upper arms. (Avoid upper arm in bedbound patients) Anterior upper thigh Upper back is suitable for restless or confused patients

Insertion site Universal precautions – follow local policies and protocols Wash and dry hands Swab site with cleansing swab and leave to dry Prime the subcutaneous device with diluent as per local guidelines Insert the subcutaneous device as shown and secure with a transparent dressing (e.g. tegaderm)

Local policy Make sure you are familiar with all local policies and documentation for cannula insertion and syringe driver use Complete all documentation

Insertion Grasp the wings of the device between finger and thumb, pinching firmly Ensure the bevel of the device faces upwards

Insertion of the device Using thumb and index finger gently pinch the skin around selected site to identify the subcutaneous tissue. Insert the full length of the catheter and needle through the skin at a 30 degree angle.

Insertion site

Infusion devices

Loading the syringe Before turning the pump on ensure a syringe is not loaded and the barrel clamp arm is down

Loading the syringe Press the ON/OFF key to power the pump up. The display will indicate PRE-LOADING and the actuator will start to move

Loading the syringe Wait until the actuator stops moving and the LOAD SYRINGE flashing screen appears

Loading the syringe Battery test When setting up the syringe driver always check that there is enough charge in the battery to cover the infusion being set-up as follows: Press the INFO key Select BATTERY LEVEL from the menu and press YES to confirm Verify sufficient battery charge is available to complete the infusion (approx 30% battery level is required to complete a 24 hour infusion). If not, change the battery. The Battery Level screen will return to the Load Syringe Screen after a few seconds.

Loading the syringe 5. Load the syringe

Loading the syringe The pump will display the size and brand of the syringe detected.

Loading the syringe 18.0 ml 24:00 0.75 ml/h The pump will display an infusion summary screen 18.0 ml 24:00 0.75 ml/h

Loading the syringe Check that all of the information on the summary screen is correct and matches the patient’s prescription

Loading the syringe Release clamp (if present)

Loading the syringe 0.75 ml/h Infusion starts & a green LED light on the keypad will flash 0.75 ml/h

Loading the syringe Monitor whilst infusing Start a 4 hourly checklist

Observations Assess symptom management four hourly, or more frequently if symptoms are not well controlled, in inpatient units – refer to local policy A minimum of daily assessment in the community Check insertion site for leakage, irritation, inflammation, infection and needle displacement Check syringe and infusion set for precipitation or crystallisation Check syringe driver screen for rate, VTBI, TVI, time and battery remaining Complete documentation

Alarms and alerts Alerts – an alarm will sound intermittently, the infusion will continue, a message appears on the display screen indicating the cause. This message then alternates with the normal “Infusion running” screen. Alarms – an alarm will sound continuously, the infusion will stop, the LED turns to red, and a message appears on display screen indicating the cause.

Trouble shooting The syringe will not start The correct instructions were not followed The syringe driver is faulty Battery is absent/flat Follow manufacturers instructions for use Remove and send for service Replace battery The infusion is fast (running more than an hour ahead of expected time) Wrong rate set Wrong syringe brand Syringe driver is faulty Start again Correct error and start again Remove from use, send for service

Trouble shooting The infusion is slow (running more than an hour behind of expected time) Wrong rate set Wrong syringe brand or size, or inserted incorrectly, pump stopped and restarted, battery restarted, battery empty, crystalisation/kinking of tubing, site problem (inflamed, lumpy, painful), faulty syringe driver Correct error Check event log Check battery Resite Remove and send for service The syringe driver has stopped before emptying the syringe Alarm state has occurred (audible alarm activated) Battery exhausted As per pump alarm table Replace battery – note the infusion needs to be stopped and the pump turned off before removing the battery