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Syringe Drivers

Key Messages

  • A person with palliative care needs who has difficulties ingesting or digesting medications may receive them subcutaneously (under the skin) using a syringe driver. [1-7]
  • A syringe driver is a small, portable, power-driven device used to administer a continuous 24-hour dose of medication. [1-4,6,7]
  • Patients and carers can find a syringe driver convenient as it removes the need for repeated doses of medication and makes it more likely that a consistent dose is maintained. [1-3]
  • Syringe drivers sometimes have a negative significance for patients and, in this case, careful explanation, discussion, and additional support may be required. [1-4]
  • For older people at end-of-life, syringe drivers can be effective in managing common symptoms such as nausea, vomiting, pain, dyspnoea (difficulty breathing) and excessive secretions. [6,7]
  • Health professionals need to be competent in setting up and using syringe drivers and care needs to be taken with contraindications, drug incompatibilities and conversion rates. [1-4]

 

No Evidence Synthesis

due to the sparcity of the published evidence

Background

An important element of palliative care is the prevention and relief of suffering from physical, psychosocial and spiritual problems. [1,2,5,8,9] Common symptoms at the end of life include fatigue, pain, nausea, vomiting, dyspnoea (difficulty breathing), noisy breathing, agitation and delirium. [1,2,4-7] These can be managed with pharmacological and non-pharmacological means. [2,6,7] Respecting the severity of symptom(s), medication is given by the most reliable route, the preferred route being orally i.e. by mouth. A person may be unable to take medication orally because of dysphagia (difficulty swallowing), weakness, dry mouth the inability to tolerate oral medication or malabsorption of oral medication. [1-7] In these instances, the subcutaneous (under the skin) route is preferred option for effective symptom control. [1,2,4-7] Continuous subcutaneous drug administration can be achieved by using a syringe driver. [1-7]
 

Evidence Summary

Subcutaneous infusion devices (syringe drivers) are commonly used to give comfort in palliative care to treat distressing symptoms when other routes are inappropriate or ineffective. [1-4,6,7,9] These devices are power-driven devices that can deliver a range of medications at a controlled rate, providing symptom control via continuous subcutaneous infusion of drugs. Most commonly, the medication is delivered over a period of 24 hours [1-4,6,7] and the device can remain in place for an indefinite period. [1,2,4] How frequently the site is changed will be determined by how well it is tolerated by the patient and the local healthcare service policy. [2]

For a palliative care patient, the subcutaneous route is preferred to other parenteral routes (e.g. intravenous, intramuscular and suppositories) because it is less invasive and has less risk of causing infection. [2] Patients and carers can find a syringe driver convenient as it removes the need for repeated doses of oral medication or injections. [1-3] Usually the syringe is filled once per day. [2,3] Detailed information about commonly used medications, incompatibilities, contraindications, equipment and techniques are available in numerous resources. [1,2,4-7]

The decision to commence a subcutaneous infusion should be made after careful review by the treating doctor(s). [1] The decision should be personalised, clearly documented collaborative - including the patient, family and/or carer. [1] Evidence indicates that these devices are reliable, well accepted by patients and carers and can allow mobile patients to continue with their daily activities. [1,2,4] However, some people may perceive these devices as signalling a poor prognosis and they may be fearful of how to manage the device, to monitor the insertion site and to respond to an alarm. [1,2,4] Health professionals can help the experience of patients and carers with a syringe driver to be positive by providing good anticipatory care, a clear explanation of the benefits, and guidance and practical tips to maximise comfort and safety. [1,2,4]

A syringe driver can be used at home and maintained over extended periods. In community palliative care, a syringe driver is usually managed by a palliative care or nursing service. [2,9] Carers asked to monitor for possible technical problems, adverse effects or requirements for breakthrough medication. [2] Patients and their families may be trained to operate the syringe driver so that the patient can stay in or return to their home community. [2] This may be of particular benefit to living in remote areas. Clear information for patients and carers (spoken, written, demonstrations and questions to check understanding) promotes safety and acceptance of the infusion device. [1-3] Access to 24-hour support and good anticipatory care can be associated with a positive experience. [1] The insertion site must be checked every 4 hours to prevent and identify any site-related complications (redness, tenderness, haematoma, leakage, and swelling). [1-4] There are multiple possible insertion sites available. [1,2] It is important to choose a site where the cannula is safely secured to prevent disconnection (care with agitated or restless clients or residents). [1,2]

There are some limitations and risks specific to the use of these devices such as technical problems (flat battery, kinks in the tubing, empty syringe) and skin reactions at the insertion site. [1-4] Insertion of the cannula may be inappropriate if a patient is very agitated. [5] When using continuous subcutaneous infusions with syringe drivers, two to three compatible drugs can be administered simultaneously. [2] It is important to refer to published information on drug compatibility or to a pharmacist to gauge if medications prescribed are appropriate to mix in a single syringe. Opioid for breakthrough pain may be given by a separate port. [2] Breakthrough medication is extra medication that may be required for symptoms that are not controlled by the medications prescribed for continuous delivery via the subcutaneous infusion device. [4] Depending on the infusion set used, additional intermittent doses of as-needed drug can be given. This is more appropriate than simply using the “boost” facility on the syringe driver, particularly if multiple medicines are in the syringe.

There is a risk of potentially serious medication error if staff members are unfamiliar with the equipment, if different types of pumps or drivers are in use in the same setting, or if staff members use different ways to calculate infusion rates. [3] It is recommended that practitioners maintain their knowledge, practical skills and standardised equipment is available across the facility. [1] Regular maintenance of the device is important i.e. regular battery check and annual service. [1,2,4]
 

Quality Statement

The use of syringe drivers in palliative care is standard practice in Australia [1,4] yet no systematic reviews on this subject were found. Specific to the use of syringe drivers in palliative care, one set of Australian guidelines (2010) was found with a related learning module (2014). [1,4] Two guidelines which refer to the use of syringe drivers in palliative care were retrieved [2,9] as was guidance in relation to the use of syringe drivers in palliative care in residential aged care. [6,7] Other sources were used to give context to this topic. [3,5,8]

 

Page created 08 January 2017

 

  • References

  • About PubMed Search

  1. Centre for Palliative Care Research and Education (CPCRE). Management of Subcutaneous Infusions in Palliative Care: Learning Modules [Internet]. 2013 [updated 2013 Sep 25; cited 2018 Jan 8].​
  2. Therapeutic Guidelines Limited. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Ltd, 2016.
  3. CareSearch. Syringe Drivers [Internet]. 2017 [updated 2017 Apr 20, cited 2018 Jan 8].
  4. Centre for Palliative Care Research and Education (CPCRE). Guidelines for subcutaneous infusion device management in palliative care. 2nd ed. Brisbane; Queensland Health: 2010.
  5. Tait P, Morris B, To T. Core palliative medicines: Meeting the needs of non-complex community patients. Aust Fam Physician. 2014 Jan-Feb;43(1):29-32.
  6. Brisbane South Palliative Care Collaborative. Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents. Brisbane: Queensland Health; 2013.
  7. Brisbane South Palliative Care Collaborative. Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents: A Resource for General Practitioners. Brisbane: Queensland Health; 2015.
  8. World Health Organization (WHO). WHO Definition of Palliative Care. 2018 [cited 2018 Jan 09].
  9. Guidelines and Audit Implementation Network (GAIN). Guidelines for Palliative and End of Life Care in Nursing Homes and Residential Care Homes (1.09MB pdf). Belfast: GAIN; 2013.

Definitions

CareSearch - Guidelines

Searches

(syringe driver*[tiab] OR infusion pump*[tiab] OR "Infusion Pumps"[Mesh] OR "infusions, subcutaneous"[MeSH] OR syringe pump*[tiab] OR subcutaneous infusion*[tiab] OR graseby[tiab])