Subcutaneous (s/c) drug infusion by portable syringe driver has had a significant impact on pain management. It allows the continuous delivery of a range of therapies to aid patient comfort. It is most frequently used in palliative care (particularly cancer care), bypassing problems such as:
- Inability to take medication orally
- Sublingual administration is not always easy if the mouth is dry, co-ordination is poor or cognitive function is impaired.
- Rectal administration can be a challenge for carers both physically and emotionally.
- A syringe driver is only an alternative method of administering medication. It does not produce more effective analgesia than the oral route unless the patient cannot use oral medication, or has serious compliance problems. It should not be routinely used as a "medical last rite" if there is no specific indication for medication.
Common indications, and medications given via in syringe drivers:
- Analgesia - diamorphine injection: dose 5-10 mg or one sixth of current 24 hour diamorphine requirement.
An alternative is sublingual diamorphine 10 mg or morphine concentrated liquid 20 mg/5 ml sublingual).
- Nausea and vomiting - give cyclizine injection 50 mg. Alternative is buccal prochlorperazine 3 mg / rectal prochlorperazine 5 mg.
- Excess secretions - give hyoscine hydrobromide injection 0.4 mg or hyoscine transdermal patch 1 mg/72 hrs (may need 2-3).
- Agitation/restlessness - midazolam injection 10 mg or sublingual lorazepam 1 mg/rectal diazepam 10 mg.
Although GPs provide the majority of palliative care services in the UK, there are often problems with symptom control and communication. Many feel clinical training is inadequate. The Liverpool Care Pathway for the Dying Patient provides a national framework for caring for patients in the terminal phase of their illness.
Setting up the syringe driver
- A syringe driver takes 3-4 hours to establish a steady state drug level in plasma. If the patient is in pain, vomiting or very agitated give a stat s/c injection of appropriate medication while setting the syringe driver up.
- Only use drugs that are known to be effective via the subcutaneous route. Diazepam, chlorpromazine and prochlorperazine are too irritant to be given subcutaneously.
- Check drug compatibility before mixing. If you are unable to discuss advice concerning drug combinations with either the palliative care team or the hospital drug information service, information can also be found at the palliative drugs web site.
- Always use water for injection to dilute the drugs. Saline may be used if there are problems with site irritation. Saline should not be used with cyclizine as it can cause precipitation.
- Calculate the total dose of drug required in 24 hours and then divide volume of solution by 24, to give a rate per hour.
- Never use solutions that have precipitated or discoloured.
- Always consider alternative routes, such as buccal, rectal, sublingual or transdermal. The patient may not want a syringe driver.
Drugs used in the syringe driver
|Drug and Indication||Dose||Other Comments|
|Diamorphine (for pain)||If pt not receiving oral morphine, 10-20 mg per 24 hrs, or total oral dose in mg in last 24 hours divided by 3.||Prescribe one sixth of total 24 hour dose for breakthrough pain.
Increase dose by one third if pain persists.
|Hyoscine butylbromide (Buscopan®)||60-120 mg/24 hrs||Anti-spasmodic.
Used in bowel spasm or ureteric colic.
|Cyclizine (for vomiting)||75-150 mg/ 24 hrs. Is stable with diamorphine in concentrations up to 20 mg/ml (approximately 200 mg dose per 24 hrs)||Used in vomiting associated with intestinal obstruction, raised intracranial pressure or hepatomegaly.
May cause drowiness and anticholinergic side-effects.
|Haloperidol (for vomiting)
Haloperidol (for terminal agitation/confusion)
|2.5-10 mg/24 hrs
10-30 mg/24 hrs
|Metoclopramide||30-60 mg/24 hrs||Vomiting due to gastric stasis or compression.|
|Levomepromazine||6.25-100 mg/24 hrs||Second-line anti-emetic.
Can be very sedating at higher doses.
|Midazolam (for confusion)||20-100 mg/24 hrs||Confusion without hallucinations.
Also used as anti-convulsant.
|Hyoscine hydrobromide (scopolamine) (for confusion)||1.6-2.4 mg/24 hrs||Sedative and anti-spasmodic.
|Hyoscine hydrobromide (for excess respiratory secretions)||1.6-2.4 mg/24 hrs||Reduces secretions.
May give paradoxical agitation in elderly.
|Glycopyrrollate (for excess respiratory secretions)||0.6-1.2 mg/24 hrs||0.2 mg stat dose.
2.5 times potency of hyoscine.
No central side-effects.
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Generally there are few compatibility problems with common two and three drug combinations containing:
- Hyoscine hydrobromide
However there can be problems with:
- Cyclizine with diamorphine, once diamorphine dose exceeds 200 mg/24 hours. It causes precipitation with saline and with diamorphine doses exceeding 200 mg/24 hours. This can be solved by using water as diluent. At higher diamorphine doses, either put cyclizine in a second syringe driver or use levomepromazine as a single daily s/c injection instead.
- Hyoscine butyl bromide (Buscopan®) is occasionally incompatible with cyclizine. Levomepromazine could be given as a single daily injection in place of cyclizine.
- Ketorolac has many incompatibilities. The main ones are with haloperidol, midazolam and cyclizine. Using a separate syringe driver is recommended.
- Dexamethasone has common/unpredictable precipitation. It also inactivates glycopyrrolate. This problem may be solved by using hyoscine hydrobromide instead of glycopyrrolate. Alternatively, dexamethasone could be given as a separate once daily injection.
Problems with syringe drivers
- Mechanical problems
- Reactions at the infusion site can be controlled by considering:
- Daily change of site
- Placing a GTN patch over the site of the infusion
- Needle should be bevel down
- Placing the needle I/M, rather than s/c
- A small teflon cannula may be less irritating than a butterfly needle
- Contents of infusion
- Irritant drugs concentration may be too strong.
- Can irritant drugs be substituted for non-irritant eg cyclizine to haloperidol.
- Irritant drugs could be given by an alternative route eg PR or IM (levomepromazine can be given as a single daily injection).
- Saline can be used for dilution instead of water (except for cyclizine).
- Hyaluronidase (1500 units) can be added to the infusion.
- Dexamethasone can be added to the infusion, in a dose appropriate to the patients clinical condition. (To add dexamethasone the diamorphine should be made up with as much water as volume calculation allows. Other additions are then made. Dexamethasone is then drawn slowly into the syringe which is inverted a few times to mix).
- Difficulties with mixing drugs within the syringe
- Errors in over infusion
- Fatalities have occurred.
- If infusion running too quickly or slowly check rate calculation; if infusion running too slowly check start button, battery, syringe driver is in good working order, cannula for blockages and injection site for inflammation.
Further reading & references
- Supportive and palliative care, NICE (2004)
- Palliative care - nausea and vomiting, Clinical Knowledge Summaries (2007)
- Safer management of controlled drugs: early action, Dept of Health (February 2007)
- Gold Standards Framework for England; A programme for community palliative care; A standard of excellence for carers
- Palliative care - dyspnoea, Clinical Knowledge Summaries (2007)
- Palliative care - oral problems, Clinical Knowledge Summaries (2007)
- Palliative care - cough, Clinical Knowledge Summaries (2007)
- Palliative cancer care - secretions, Clinical Knowledge Summaries (2007)
- Foley, K.M.(2004) Acute and Chronic cancer pain syndromes. In Doyle, D., Hanks, G., Cherny, N. and Calman,K. (Eds.) Oxford Textbook of Palliative Medicine. 3rd edn. pp 298-316. Oxford. Oxford University Press.
- Control of pain in adults with cancer, Scottish Intercollegiate Guidelines Network - SIGN (November 2008)
- Liverpool Care Pathway for the Dying Patient (LCP), The Marie Curie Palliative Care Institute, Liverpool
- Palliative care formulary
- North Cumbria Palliative Care. Drugs Used in The Syringe Driver. Last updated June 2006
- North Cumbria Palliative Care. Syringe Driver Drug Compatability Chart. Last updated June 2006
- Palmer E, Howarth J; North Cumbria Palliative Care. Syringe Drivers.
- Wilson V; Guidelines for use of the MS26 daily rate syringe driver in the community. Br J Community Nurs. 2000 Apr;5(4):162-8.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 18/03/2011||Document ID: 416 Version: 6||© EMIS|
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