End of Life Care:
Syringe Driver
Learning Outcomes
By end of session you should be able to;
• Give a brief account of the clinical
indications for use of the Syringe Driver.
• Identify sites that may be used for infusion
by the Syringe Driver.
• List the equipment necessary.
• Show how to set up, the correct insertion
and monitoring of the syringe driver.
• Identify safe practice and where to get
advice
why might we want to use a
syringe driver?
Indications for the use of the
syringe driver
Patient is unable to take oral medication due to
1. dysphagia
2. altered level of consciousness
3. intractable nausea/vomiting
4. intestinal obstruction
5. oral route not tolerated eg. head/neck
cancer
6. malabsorption
7. rectal route not appropriate
What are the advantages and
disadvantages of using a
syringe driver?
Advantages
1.
2.
3.
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5.
6.
7.
avoids repeated injections
avoids peaks and troughs in blood
levels, provides constant symptom
effective symptom control
can use combination of drugs
saves nursing time giving injections
comfortable for patient, gives mobility
Disadvantages
1. once daily loading may mean lack of
flexibility in dosage
2. sterile abscesses may form at SC site
as a reaction to some drugs
3. irritation leading to erythema or
swelling may interfere with infusion
rate and absorption
4. some patients find them a burden
5. association with dying
Skin site selection
The best sites to use for continuous
subcutaneous infusions are;
• the upper chest wall below the
clavicle
• the upper arm and thigh
• the abdomen
• occasionally the back
Sites to Avoid if Possible
• Lymphoedematous limbs – the subcutaneous
tissues are ‘waterlogged’ with lymph fluid, which
would affect absorption. There would also be
increased risk of leakage or infection.
• Any site over a bony prominence or near a joint.
• The upper abdomen in a patient with an enlarged
liver – there is a risk of puncturing the liver capsule
• The upper chest wall in very cachectic patients –
there is a risk of causing pneumothorax.
• Previous irradiated skin area.
Irritation at Injection Site
Absorption of drugs may be impaired, causing poor
symptom control.
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Ensure needle tip is not too shallow
Try sof-set
Try a different diluent
Change irritant drugs to an alternative (e.g. cyclizine 
haloperidol)
• Give irritant drugs by alternative route (e.g. rectal)
• Add dexamethasone 1mg or hydrocortisone cream to site
• GTN patch over site
Setting up the syringe driver
Equipment
• Prescribed Medication; patient
prescription to include breakthrough
medication
• Syringe Driver; plastic cover; carrying
holster
• 9 volt battery and spare battery
• 1ml or 2.5ml syringe
• 30 ml luer lock syringe
Equipment
• 100cm butterfly infusion set or Mini Med
sofset (106cm = FSB706 / 60cm = FSB708)
• Vygon extension lead if required (FWL057)
• Skin swab, 2% Chlorhexadine Gluconate in
70% Isopropyl Alcohol
• Transparent adhesive dressing
• Diluent
• Blue needle or pink blunt needle (FTR436)
• Drug additive label and syringe driver
monitoring chart
Equipment
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Plastic Apron
Non Sterile gloves (local policy)
Ruler
Sharps bin
Adjustment tool from Graseby
manufacturer (08454 226800 phone for pack of 5)
Test Battery
• Insert the battery into the pump
• This should set off an alarm which
sounds for approx 10 seconds
• If this does not happen – replace the
battery
• Battery will last for approx 50 infusions
Test the Syringe Driver
Before placing the syringe in the driver
• Press the start button for 10 seconds
• Keep the start button depressed during
this time as this tests the syringe driver
safety circuits
• Pressing for less time will start the
syringe driver but will not test the
circuits
Drawing up drugs and priming
line
• Check expiry date of medication and diluents
• Draw up prescribed drug using blue needle
or 18g pink blunt needle
• Add diluent until it measures 48mm (not mls)
• most drugs should be reconstituted with
water for injection, seek advice if unsure
Drug Stability and Incompatibility
Check compatibility of drugs with Drug
Information, telephone:
GRH-08454 226108 or CGH- 08454 223030
Community Specialist Palliative Care Team
01452-371022
Hospital Specialist Palliative Care Team
08454 223447 or 08454 225179
Out of hours advice line bleep 07659 119458
Drawing up and priming line
• Use label with drug; dosage; patients
name; time; nurse signature
• Attach to syringe ensuring that
markings on syringe are still visible
• Connect syringe to giving set and
prime the line
Rate
• Set the rate on the pump to
48mm/24hours
• If the line has been primed, the syringe
will run out in under 24hrs
*See table in your local policy
• Consider giving breakthrough dose of
medication when first setting up syringe
driver
Fitting
• Press white release button and slide to
the right
• Syringe in the grooved furrow
• Ensure wing is against central wall
• Secure with black rubber band
• Move actuator to left until it connects
with the driver. Ensure end of plunger
sits in slot above white release button
Insertion of butterfly infusion
set
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Explain procedure and obtain consent
Wash hands
Non sterile gloves (local policy)
Assist patient to comfortable position
Expose chosen skin site
Clip excess hair if needed
Clean with swab and allow to air dry
Insertion
• Grasp skin firmly either side of site
• Insert needle at 45 degree angle (Sof
Set 90 degree angle)
• Tape the infusion set wings to skin with
transparent dressing coiling the tube
under the dressing
Commencing infusion
• Press start/boost button to begin
infusion - check that the light flashes
• Cover syringe with plastic guard and put
driver in holster or under bedclothes
• Ensure driver not over infusion site
• Document the start of the infusion
Observations and Checks
• Evaluate symptom control on each
contact
• Complete syringe driver observation
chart on set up, 1 hour after and then 4
hourly in hospital or each home visit
• If the site is red or has other problems,
re-site the butterfly using a new
infusion set.
Precipitation
• Precipitation when mixing drugs is a sign of
incompatibility
• Occasionally a mixture that has been used
successfully, will suddenly precipitate in the
middle of an infusion
• It may be related to a reaction occurring in
the subcutaneous tissue, and once it has
happened, it tends to recur in the same
patient.
• Cyclizine is most frequently the problem.
Precipitation, what to do
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Change the site and the whole giving set –
not just the syringe
Consider different diluent
Consider alternative antiemetic/drugs,
some drugs are too irritant for SC use –
diazepam, stemetil, largactil
Keep away from direct sunlight or heat
Separate the drugs being given into two
syringe drivers
Consider once daily SC drugs
Observations and Checks
Syringe Driver:
• Light flashing
• Correct volume of fluid remaining
• Correct rate
• No leakage
• Is protected from light
Injection site:
• Pain, swelling, erythema
Syringe with medication
• Crystallisation
Safety/Hazard
• Indwelling device is a risk, use principles of
asepsis
• If the infusion set becomes disconnected
from the patient discard, recording drug
volumes, and re-site a new syringe and
giving set
• If dropped, immersed in water or
contaminated by fluids:
• Detach driver; shake vigorously if wet
and send to medical physics
• Use another syringe driver
Safety/Hazard
• DO NOT allow the patient to have a
bath or a shower with the syringe driver
in situ as steam and condensation will
affect the mechanism of the driver
• If the patient wishes to have a bath or
shower the syringe driver can be
discontinued for a short period to
enable this
MEDICAL ENGINEERING
• Syringe drivers must be returned to
Medical Engineering for servicing or
repair (Tel: 08454226116).
• If the syringe driver has a serial
number on it preceded by a “G” or an
“E” it must go to Gloucester Royal
Hospital.
• if preceded by “CHD” it must go to
Cheltenham General
Any questions?