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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Syringe Drivers

Subcutaneous drug infusion by portable syringe driver has had a significant impact on palliative care. It allows the continuous delivery of a range of therapies to aid patient comfort, whilst bypassing problems found in terminal illness such as:

  • Dysphagia
  • Inability to take anything orally
  • Weakness

Pain is experienced by 70-90% of patients with advanced cancer.1 Severe pain is experienced by 66% of people with cancer at some point in their illness.2

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.

Drugs are commonly required in palliative care to control:

  • Analgesia - diamorphine injection: dose 5-10mg or one sixth of current 24 hour diamorphine requirement.
    An alternative is sublingual diamorphine 10mg or morphine conc. liquid 20mg/5ml sublingual).
  • Nausea and vomiting - give cyclizine injection 50mg.
    Alternative is buccal prochlorperazine 3mg / rectal prochlorperazine 5mg.
  • Excess secretions - give hyoscine hydrobromide injection 0.4mg or hyoscine transdermal patch 1mg/72hrs (may need 2-3).
  • Agitation/restlessness - midazolam injection 10mg or sublingual lorazepam 1mg/rectal diazepam 10mg.



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.3

Recognising the terminal phase4

Health care professionals may have difficulty in diagnosing dying, but it is prerequisite for providing good care. It can be recognised by the following common features:

  • Day by day deterioration, at a faster rate than previously
  • Patient is drowsy or comatose
  • Bed bound
  • Taking little by mouth
  • Altered breathing pattern
  • Peripherally shut down
  • Patient may declare they are dying

The terminal phase starts approximately 24 hours before death (median value), but may vary from hours to several days.

Setting up the syringe driver

They are used primarily when patients are no longer able to take medicines by mouth. This may be because of persistent nausea, vomiting, dysphagia, weakness or coma. Local palliative care guidelines should always be followed when mixing drugs in a 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.5
  • 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, sub lingual or transdermal. The patient may not want a syringe driver.

Drugs used in the syringe driver6

Drug and Indication Dose Other Comments
Diamorphine (for pain) If pt not receiving oral morphine, 10-20mg per 24 hrs, or total oral dose in mg in last 24 hours divided by 3. Prescribe 1/6 of total 24 hour dose for breakthrough pain.
Increase dose by 1/3 if pain persists.
Hyoscine butylbromide (Buscopan) 60-120mg/24 hrs Anti-spasmodic. Used in bowel spasm or ureteric colic.
Cyclizine (for vomiting) 75-150mg/ 24 hrs. Is stable with diamorphine in concentrations up to 20mg/ml (approximately 200mg 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)

2.5-10mg/24 hrs


10-30mg/24 hrs

  • For vomiting secondary to opiates, uraemia, hyeprcalcaemia and intestinal obstruction. Is non-sedating.
    Rarely need more than 3mg/24 hrs.
  • Used for confusion with evidence of hallucinations. Risk of dyskinesia above 10mg/24hrs
Metoclopramide 30-60mg/24 hrs Vomiting due to gastric stasis or compression.
Levomepromazine 6.25-100mg/24 hrs Second-line anti-emetic. Can be very sedating at higher doses.
Midazolam (for confusion) 20-100mg/24 hrs Confusion without hallucinations. Also used as anti-convulsant.
Hyoscine hydrobromide (scopolamine) (for confusion) 1.6-2.4mg/24 hrs Sedative and anti-spasmodic.
Also anti-emetic.
Hyoscine hydrobromide (for excess respiratory secretions) 1.6-2.4mg/24 hrs Reduces secretions. May give paradoxical agitation in elderly.
Glycopyrrollate (for excess respiratory secretions) 0.6-1.2mg/24 hrs 0.2mg stat dose. 2.5 times potency of hyoscine. No central side-effects.

Drug compatibility7

Generally there are few compatibility problems with common two and three drug combinations containing:

  • Diamorphine
  • Cyclizine
  • Haloperidol
  • Metoclopramide
  • Levomepromazine
  • Hyoscine hydrobromide
  • Midazolam

However there can be problems with:

  • Cyclizine with diamorphine, once diamorphine dose exceeds 200mg/24 hours. It causes precipitation with saline and with diamorphine doses exceeding 200mg/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 SC 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 glycopyrrollate. This problem may be solved by using hyoscine hydrobromide instead of glycopyrrollate. 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:8
    • Site
      • Daily change of site daily
      • Placing a GTN patch over the site of the infusion
    • Needle
      • 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 e.g. cyclizine to haloperidol
      • Irritant drugs could be given by an alternative route e.g. 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.9
      • 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.


Document references
  1. 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.
  2. SIGN (Scottish Intercollegiate Guidelines Network). Control of Pain in Patients with Cancer.; 2000
  3. Liverpool Care Pathway of a Dying Patient (community)
  4. Morita T, Ichiki T, Tsunoda J, et al; A prospective study on the dying process in terminally ill cancer patients.; Am J Hosp Palliat Care. 1998 Jul-Aug;15(4):217-22. [abstract]
  5. Palliative care formulary
  6. North Cumbria Palliative Care. Drugs Used in The Syringe Driver. Last updated June 2006
  7. North Cumbria Palliative Care. Syringe Driver Drug Compatability Chart. Last updated June 2006
  8. Palmer E, Howarth J.; North Cumbria Palliative Care. Syringe Drivers.
  9. 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. [abstract]

Internet and further reading AcknowledgementsEMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 416
Document Version: 2
DocRef: bgp25058
Last Updated: 13 Nov 2007
Review Date: 12 Nov 2008






















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