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

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

McKinley T34 Syringe Pump

Graseby Syringe Driver MS16

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.

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.

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

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

Morphine Sulphate Opioid of choice. Most commonly used. Controlled drug. Preparations – 10, 15, 30, 60 100mg/ml vials.

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

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.

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.

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.

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

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.

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.

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.

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.

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

Sedatives Midazolam Haloperidol (Serenace) Methotrimeprazine (Nozinan) Clonazepam

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

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.

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

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.

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

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.

Other Drugs occasionally used Octreotide Phenobarbitone Ketamine Methadone Dexamethasone

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.

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

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

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.

“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

The “Box” Not necessarily permanent

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

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