End of Life Care: Syringe Driver

1. End of Life Care:Syringe Driver

2. 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

3. why might we want to use a syringe driver?

4. 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

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

6. Advantages • avoids repeated injections • avoids peaks and troughs in blood • levels, providesconstant symptom • effective symptom control • can use combination of drugs • saves nursing time giving injections • comfortable for patient, gives mobility

7. 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

8. 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

9. 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.

10. 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

11. Setting up the syringe driver

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. Any questions?