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

2. 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.

3. 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.

4. 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

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

6. 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

7. 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?

8. 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

9. Drugs that should NOT be used subcutaneously
Diazepam
Prochlorperazine
Chlorpromazine

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

11. 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.

12. 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

13. 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

14. 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

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

16. 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

17. 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

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

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

20. 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.

21. 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.

22. 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.

23. 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)

24. 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

25. 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)

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

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

28. 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.

29. Insertion site

30. Infusion devices

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

32. 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

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

34. 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.

35. Loading the syringe
5. Load the syringe

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

37. 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

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

39. Loading the syringe
Release clamp (if present)

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

41. Loading the syringe
Monitor whilst infusing
Start a 4 hourly checklist

42. 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

43. 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.

44. 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

45. 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