End of Life Care: Syringe Driver Learning Outcomes By end of

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End of Life CareSyringe Driver
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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

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why might we want to use a syringe driver?
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Indications for the use of the syringe driver

• Patient is unable to take oral medication due to
• dysphagia
• altered level of consciousness
• intractable nausea/vomiting
• intestinal obstruction
• oral route not tolerated eg. head/neck cancer
• malabsorption
• rectal route not appropriate

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What are the advantages and disadvantages of
using a syringe driver?
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Advantages

• 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

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Disadvantages

• once daily loading may mean lack of flexibility
  in dosage
• sterile abscesses may form at SC site as a
  reaction to some drugs
• irritation leading to erythema or swelling may
  interfere with infusion rate and absorption
• some patients find them a burden
• association with dying

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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

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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.

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Irritation at Injection Site

• Absorption of drugs may be impaired, causing poor
  symptom control.
• 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

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• Setting up the syringe driver

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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

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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

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Equipment

• Plastic Apron
• Non Sterile gloves (local policy)
• Ruler
• Sharps bin
• Adjustment tool from Graseby manufacturer (08454
  226800 phone for pack of 5)

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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

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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

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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

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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

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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

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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

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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

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Insertion of butterfly infusion set

• 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

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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

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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

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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.

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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.

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Precipitation, what to do

• 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

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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

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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

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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

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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

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Any questions?