Syringe Driver PW.pptx

Presentation on use of the Syringe driver

1. Syringe Driver Aims of Session To provide an understanding of the Syringe Driver Advantages and Disadvantages When it should be used Medication Regimes

2. What is a Syringe Driver/Pump A portable Battery-operated infusion pump for administering medication. Used to deliver medicines at a predetermined rate via the appropriate parenteral route (e.g. subcutaneous) Suitable for both symptom management and palliative care – not just used at end of life!

3. T34 McKinley Syringe Pump What is a syringe driver?

4. McKinley T34 Syringe Pump in the community will be in a locked box

5. When to use a Syringe Pump Where oral route is not possible or is inappropriate: Dysphagia. Unable to take medicines orally e.g. due to oral cancers. Loss of or altered level of consciousness. means oral route not possible. Intractable nausea and vomiting which has not responded to oral/rectal anti emetics. Intestinal obstruction. Malabsorption. Terminal agitation.

6. Benefits of using a Syringe Pump Oral route is preferred route. Where parenteral administration is necessary, the subcutaneous route should be used where possible in advanced disease because: Intravenous (IV) route is invasive and not necessarily any more effective than Subcutaneous (SC) route. Intramuscular (IM) injections can be painful, particularly in the cachectic patient.

7. Benefits of using a Syringe Pump Drug administered continuously over 24 hours which avoids the “peaks and troughs” of drug delivery and thus maintains consistent control of symptoms. More than one drug can be given at the same time. Medication can be administered if impaired Gastric Intestinal absorption is suspected

8. Benefits of using a Syringe Pump Patient’s well-being - reduced requirement for repeated injections Allows mobility and independence for those not at the end of life Assists with compliance

9. Disadvantages of using a Syringe Pumps Medicine requirements must be anticipated for a 24hour period and may result in loss of flexibility of dosing May require PRN medications at initial set up whilst waiting for medications to reach peak plasma concentration Local reactions such as pain, inflammation or infection can cause discomfort +/- interfere with delivery of medication

10. Disadvantages of using a Syringe Pump Risks associated with additional steps in administration process Patients may view syringe driver as the final step before death Patients may find it obtrusive/disconcerting Initial cost of infusion devices Training of staff, together with need to maintain competency

11. When to start a Syringe Pump in Relation to Symptoms If symptoms are controlled, start the continuous subcutaneous infusion (CSCI) 1–2h before the effect of the medication is due to wear off. This means if a patch is in-situ you should titrate the dose up by leaving the patch on. If symptoms are uncontrolled, set up the CSCI immediately with stat doses of the same drugs.

12. Medicines commonly used in Syringe Pumps Pain – Opioids e.g. Morphine; Diamorphine; Oxycodone (Second line if unable to tolerate side effects of diamorphine or morphine); Alfentanil (Alternative CSCI delivered opioid for patients unable to tolerate morphine/diamorphine e.g. In renal failure.) Anxiety & Agitation - Levomepromazine , Midazolam, Haloperidol Respiratory Secretions - Glycopyrronium , Hyoscine Hydrobromide , Hyoscine Butyl Bromide

13. Medicines commonly used in Syringe Pumps Nausea & Vomiting – Haloperidol, Levomepromazine , Metoclopramide, Cyclizine Anti-spasmodic/intestinal colic – Hyoscine Butyl bromide Breathlessness – Opioids e.g. Morphine, Diamorphine, Midazolam

14. Diluents used in Syringe Pumps Water for Injection is widely used as the first-line diluent – less chance of incompatibility. 0.9% saline should be considered if there is a potential or actual problem with inflammatory reactions at the skin injection site e.g with levomepromazine (but watch out for incompatibilities).

15. Diluents used in Syringe Pumps

16. Doses of medicines used in a Syringe Pump There are no set doses for palliative care – many medicines are used outside of their Marketing Authorisation, and doses may be higher than encountered in non-palliative medicine. Doses should be titrated according to individual need. For pain, breakthrough doses are calculated as 1/6 th of the total 24 hour opioid dose. Dose conversions – will vary depending on source – if unsure refer to local/national guidelines or take advice.

17. Doses of medicines used in a Syringe Pump

18. Doses of medicines used in a Syringe Pump (Refer to local guidelines) All doses are over 24 hours via CSCI PAIN Morphine – if opioid naïve – 5-10mg to start Diamorphine - if opioid naïve – 2.5-5mg to start Oxycodone – if opioid naïve 7.5mg over 24 Alfentanil – used only under specialist advice – 1 st line for renal failure Dose increases normally not more than 30 to 50% of previous dose Use dose conversion tables if changing opioid or same opioid, different route

19. Mixing Medicines and Incompatibilities Common for 2 or 3 medicines to be mixed in a syringe driver. Need to check for ‘compatibility’ – chemical reactions between drugs resulting in altered composition, which may be therapeutically inactive or toxic. Drugs said to be physically compatible if mixing does not result in a physical change, e.g. discoloration, clouding or crystallization. Can be chemically incompatible (i.e. mixing results in loss or degradation of one of the drugs ).

20. Mixing Medicines and Incompatibilities Charts available for drug compatibility – “Palliative Care Formulary” https://about.medicinescomplete.com/ Palliative Care Adult Network Guidelines: http://book.pallcare.info/index.php Common incompatible drugs: Diamorphine & Cyclizine or haloperidol at higher concentrations Levomepromazine and dexamethasone Oxycodone & Cyclizine Diamorphine, Dexamethasone and Levomepromazine

21. Mixing Medicines and Incompatibilities Diluents and incompatibility with drugs: Mixing of medicines leads not only to possible incompatibilities, but also renders the drug mixture unlicensed. Doctors and other independent prescribers (nurse, paramedic and pharmacist) can mix, and direct others to mix, drugs for administration to a particular patient. Supplementary prescribers can mix and direct others to mix when part of a Clinical Management Plan .

22. Where to find information BNF – a bit on dose equivalents and compatibilities. Internet – be careful to use recognised sites – some good ones: NHS Scotland Palliative Care Guidelines www.palliativecareguidelines.scot.nhs.uk Palliative Care Formulary www.palliativedrugs.com https://about.medicinescomplete.com/ Palliative Care Adult Network Guidelines: http://book.pallcare.info/index.php

23. Volumes Factors influencing the volume of the CSCI include the infusion device being used, the total volume of the drugs, the maximum rate of delivery, the intended infusion time. Greater dilution reduces : risk of incompatibility impact of priming an extension set (less drug in the ‘dead space’) injection site skin reactions from the drug. Make up to a standard volume 20ml syringe – 17ml 30ml syringe – 22ml 50ml syringe – 34ml (the maximum volume/24h that infusion device can deliver.

24. Labelling All syringes containing medicines must be labeled immediately following preparation:

25. Labelling labels must not be attached to the part of the syringe barrel which is under the barrel clamp arm (as this may change its external diameter and affect syringe recognition) Incorrect Correct

26. Questions