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

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.

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
Hyoscine.
 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”
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.