Subcutaneous (SC) drug infusion Syringe Driver. Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets. See also: End of Life Care written for patients. Subcutaneous (SC) 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: Dysphagia. Inability to take medication orally. Weakness. Pain is experienced by most patients with advanced cancer. Severe pain is experienced by 6. 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.
Other common indications for using a syringe driver in palliative care include the treatment of nausea and vomiting, excessive respiratory secretions, and agitation or restlessness. Although GPs provide the majority of palliative care services in the UK, there are often problems with symptom control and communication. See separate Palliative Care, Looking after People with Cancer and End of Life Care articles.
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.
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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 SC injection of appropriate medication while setting up the syringe driver. Only use drugs that are known to be effective via the SC route. Diazepam, chlorpromazine and prochlorperazine are too irritant to be given SC. 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 website.
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 2. Never use solutions that have precipitated or become discoloured. Always consider alternative routes, such as buccal, rectal, sublingual or transdermal.
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The patient may not want a syringe driver. Drugs used in the syringe driver. Drug and Indication. Dose. Other Comments.
Diamorphine (for pain)If the patient is not receiving oral morphine, 1. Prescribe one sixth of total 2. Increase dose by one third if pain persists. Hyoscine butylbromide (Buscopan. Used in bowel spasm or ureteric colic. Cyclizine (for vomiting)7.
Is stable with diamorphine in concentrations up to 2. Used in vomiting associated with intestinal obstruction, raised intracranial pressure or hepatomegaly. May cause drowsiness and anticholinergic side- effects.
Haloperidol (for vomiting)Haloperidol (for terminal agitation/confusion)2. For vomiting secondary to opiates, uraemia, hypercalcaemia and intestinal obstruction. Rarely need more than 3 mg/2. Used for confusion with evidence of hallucinations. Risk of dyskinesia above 1. Metoclopramide. 30- 6. Vomiting due to gastric stasis or compression.
Levomepromazine. 6. Second- line anti- emetic. Can be very sedating at higher doses. Midazolam (for confusion)2. Confusion without hallucinations. Also used as anticonvulsant.
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Hyoscine hydrobromide (scopolamine) (for confusion)1. Sedative and antispasmodic. Also anti- emetic. Hyoscine hydrobromide (for excess respiratory secretions)1. Reduces secretions.
May give paradoxical agitation in the elderly. Glycopyrrolate (for excess respiratory secretions)0. No central side- effects. Drug compatibility.
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 2. It causes precipitation with saline and with diamorphine doses exceeding 2. 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. 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. Human errors. 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 is running too quickly or slowly, check rate calculation; if infusion is running too slowly, check start button, battery, syringe driver is in good working order, cannula for blockages and injection site for inflammation.
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