16.16 Syringe drivers

See here for end of life symptom control via a syringe driver for patients dying of COVID-19

If subcutaneous pain relief is required, contact the palliative care team for advice. Do not start new patients on diamorphine hydrochloride 5mg or 10mg injection. National stock shortage. Review patients currently receiving diamorphine 5mg and 10mg injection. For more information, see the Medicines Optimisation Post Live article

Most patients can take oral medication until the last day or two of life.

Good symptom control is essential. For all patients, ensure pre-emptive prescribing for the commonest symptoms seen at this time. If symptoms are continuous e.g. pain/nausea, the most effective method of administration is by continuous subcutaneous infusion in a syringe driver, but if people are asymptomatic, they can die peaceful deaths without their use.

A syringe driver is indicated when oral medication becomes a burden or is not possible because of:

  • Severe nausea and vomiting
  • Swallowing difficulties
  • Advanced weakness
  • Unconscious, so unable to take oral medication
  • Intestinal obstruction
  • Malabsorption of drugs from alimentary tract
  • To reduce tablet load as they get weaker

Any patient with a syringe driver must have their medication and drug dosages reviewed at least once a day.

Advantages

  • Constant level of analgesia
  • Patient comfort (no need for regular SC injection or cannula changes)
  • Does not limit mobility - highly portable in over the shoulder bags
  • Improves control of nausea and vomiting
  • Improves symptom control where there are problems with absorption of medications e.g. bowel obstruction, ileus or severe constipation.

Disadvantages

  • May be seen as the only solution for difficult symptom management
  • Patient need for frequent reassessment can be forgotten
  • Local skin irritation may occur with certain agents and can interfere with infusion rate and absorption

General principles

The equivalent “as required" dose of drugs should also be prescribed SC when required for breakthrough symptoms.

If frequent breakthroughs needed and/or symptoms not settling, seek advice from your local specialist palliative care services

A bolus, SC dose of medication will be needed if the patient is symptomatic when starting the infusion since the syringe driver will take 2-4 hours to reach an optimal level

When mixing 2 or more drugs in a syringe driver, check compatibilities with the Trust pharmacy department or Palliative Care Team and ensure that diluent is compatible with the drugs.

If more than 3 drugs are needed in a syringe driver, discuss the situation with your Palliative Care Team

Cyclizine is the drug which seems to "precipitate" most commonly in the syringe driver and causes problems with poor absorption and site reactions.

With combinations of 2 or 3 drugs in one syringe, a larger volume of diluent may be needed (e.g. in a 20mL or 30mL syringe)

If any problems or concerns - seek advice from the local specialist palliative care team.

Pain – opioid naive

Contact the palliative care team for advice. Do not start new patients on diamorphine hydrochloride 5mg or 10mg injection. National stock shortage. Review patients currently receiving diamorphine 5mg and 10mg injection. For more information, see the Medicines Optimisation Post Live article

Pain – taking regular opioids

Contact the palliative care team for advice. Do not start new patients on diamorphine hydrochloride 5mg or 10mg injection. National stock shortage. Review patients currently receiving diamorphine 5mg and 10mg injection. For more information, see the Medicines Optimisation Post Live article

Breathlessness

Also refer to 16.9 Breathlessness in palliative care

Breathlessness is Present

The patient can still swallow:
  • Single dose of morphine sulphate liquid 2.5mg – 10mg, and when required (if the patient is not already on an opioid).
  • Consider adding lorazepam 0.5mg – 1mg sub-lingual (off-label use) and 4 hourly when required
The patient can no longer swallow:
  • Contact the palliative care team for advice. Do not start new patients on diamorphine hydrochloride 5mg or 10mg injection. National stock shortage. Review patients currently receiving diamorphine 5mg and 10mg injection. For more information, see the Medicines Optimisation Post Live article

Recurrence of breathlessness:

Consider 24 hourly SC infusion in syringe driver if recurrent symptoms or 2 or more breakthrough doses:

  • Contact the palliative care team for advice. Do not start new patients on diamorphine hydrochloride 5mg or 10mg injection. National stock shortage. Review patients currently receiving diamorphine 5mg and 10mg injection. For more information, see the Medicines Optimisation Post Live article

If symptoms persist contact the specialist palliative care team

To convert from other strong opioids, see "A guide to equivalent doses for opioid drugs" or contact specialist palliative care team

Nausea and vomiting

Present

  1. Single dose
    1. Levomepromazine 6.25mg SC and 6 hourly when required, or
    2. Haloperidol 1mg - 2.5mg SC and 8 hourly when required, or
    3. Cyclizine 50mg SC and 8 hourly when required
  2. If 2 or more doses given in 24 hours/recurrent symptoms, start SC syringe driver 24 hourly, depending on what the patient has been having orally:
    1. Metoclopramide 30mg, or
    2. Cyclizine 100mg - 150mg (use water for injection)
    3. And/or Haloperidol 3mg - 5mg
  3. If 2 or more doses in 24 hours / recurrent symptoms, stop above and give:
    1. Levomepromazine 6.25mg - 12.5mg SC 24 hourly in syringe driver

It is sometimes necessary to miss step 2 and go straight to step 3.

Absent

Prescribe:

  • Levomepromazine 6.25mg SC 6 hourly when required, or
  • Haloperidol 1mg - 2.5mg SC 8 hourly when required, or
  • Cyclizine 50mg SC 8 hourly when required

If symptoms persist contact the local specialist palliative care team

Terminal restlessness and agitation

Present

  1. 1. Single dose
    1. Midazolam 2.5mg - 10mg SC every 30 minutes until patient settles.
    2. If more than 40mg given contact the local specialist palliative care team for advice
    3. Consider adding levomepromazine 12.5mg - 25mg SC or haloperidol 5mg SC
  2. 2. If 2 or more doses in 24 hours or recurrent symptoms, consider using a syringe driver SC 24 hourly:
    1. Midazolam 20mg - 30mg. In exceptional circumstances, doses of up to 100mg of midazolam may be required
    2. Consider adding levomepromazine 12.5mg - 50mg or haloperidol 10mg - 20mg

Absent

  • Prescribe: Midazolam 2.5mg – 5mg SC when required

For acute confusional states, consider olanzapine where the patient is able to swallow or haloperidol s/c 1mg – 3mg where the patient is unable to swallow.

Consider short acting and least restrictive options to control distress

Consider and exclude or treat urinary retention, uncontrolled pain

If symptoms persist contact the local specialist palliative care team

Respiratory tract secretions

  • Re-positioning of patient often helps
  • Reassurance of family is often helpful, e.g. "the rattly noise is like a floppy snore because their muscles are so weak"
  • If unconscious, patient unaware and not distressed by this situation
  • Drug treatment may be ineffective

Present

Single dose hyoscine hydrobromide 400 microgram SC and 4 hourly when required.

If successful after 1 or 2 doses start hyoscine hydrobromide 1.2mg SC 24 hourly in syringe driver.

If further breakthroughs needed - increase to hyoscine hydrobromide 2.4mg SC 24 hourly in syringe driver

Absent

Prescribe hyoscine hydrobromide 400microgram SC 4 hourly when required

If symptoms persist contact the local specialist palliative care team

Renally impaired end of life patients

Sometimes, patients who are dying have renal impairment as part of multiple organ dysfunction during the dying process. A low eGFR can result in problems with retaining opioids and their by-products. This can cause opioid toxicity causing agitation and distress.

They may need either a lower dose of standard medications prescribed or “renal friendly" drugs.

Signs of opioid toxicity to look for are:
  • “Plucking" of the fingers in the air
  • Myoclonic jerks
  • Hallucinations
  • Drowsiness with a slow respiratory rate

These can be difficult signs to spot and sometimes those who are in the final few hours of life exhibit these signs in a phase of the dying process sometimes known as “terminal agitation".

If patients are known to the Renal Team with Chronic Kidney Disease stage 4 or 5 and an eGFR less than 30, then it is likely that toxic levels of opioids and by-products may build up unless “renal friendly" drugs are used.

If a patient has opted for conservative treatment or is withdrawing from Haemo- or Peritoneal Dialysis, then SC fentanyl or alfentanil should be used in preference to other injectable opioids.

Talk to senior team members, the renal team or the specialist palliative care team to get advice about when it might be appropriate to use “renal friendly" drugs.

Have an extremely low threshold for contacting the renal team or the specialist palliative care team for patients with eGFR less than 30.

 

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