The syringe driver

The syringe driver

The following guidelines acknowledge that subtle changes in clinical practice may occur between hospital, hospice and community practice and endeavour to promote safe and consistent methods of practice, based on collaborative experience around the West Midlands Region.

At the time of writing it is recognised that many palliative care teams will be phasing out the use of Graseby syringe drivers in accordance with NPSA Alert Dec 20101. However we acknowledge that Graseby syringe drivers are still currently in use in some areas of the West Midlands while the changeover to the new syringe drivers takes place. Therefore for this reason information about both Graseby and McKinley syringe drivers is included in this chapter.

The syringe driver is a small portable battery-driven infusion pump, used to deliver medication subcutaneously as a continuous infusion usually over 24 hours. It can be used when other routes (e.g. oral, buccal, rectal, transdermal) are unsuitable.

 

INDICATIONS FOR STARTING A SYRINGE DRIVER

 

The syringe driver may be indicated in the following situations:

•  persistent nausea or vomiting

•  difficulty swallowing

•  poor alimentary absorption

•  intestinal obstruction

•  profound weakness / cachexia

•  comatose or moribund patient

•  administration of drugs that cannot be given by non-parenteral routes

 

 Three of the commonest syringe drivers are:-

Graseby® MS 16 (Blue) delivers at a rate of mm/hour
Graseby
® MS 26 (Green) delivers at a rate of mm/day
McKinley
® T34 set up according to volume of fluid

 

CARE OF THE SYRINGE DRIVER

If doses of drugs need to be changed then change the syringe. Change the syringe and the infusion line. It is best not to alter the rate.

Check the syringe driver and infusion regularly for:

•  irritation at the injection site, change site or ask advice

•  crystallisation of drug (seek specialist advice)

•  light flashing  (if not check the battery)

•  secure connections or kinked tubing

•  leakage

•  correct volume remaining

 

CHOICE OF INFUSION SITES

Sites of choice include:

•  anterior chest wall

•  lateral upper arms

•  anterior abdominal wall

•  anterior outer thigh

•  area over scapula (in confused or disorientated patient)

Avoid areas of inflammation, oedema, broken skin, bony prominences, recently irradiated areas, sites of tumour, sites of infection, skin folds or lymphoedema.

 

Below see Compatibility Chart in Appendix

 

 

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•  Since the syringe bore varies with different manufacturers

and syringe volumes, it is the length of the infusion fluid that is important, not the volume in the syringe

•  Staff should only use this equipment if trained to do so

 

SETTING UP A GRASEBY® SYRINGE DRIVER

You will need:

•  Syringe driver

•  9v Battery

•  Luer-lok syringe (usually 10ml but 20ml or 30ml may be used)

•  Infusion or (giving) set (chose the smallest volume)

•  Fine gauge needle (23G or 25G butterfly)

•  Clear adhesive film dressing

•  Diluent (usually water for injection)

•  Medication as prescribed

•  Label to be attached to the syringe

•  Holster for ambulatory patients

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 COMMENCING THE GRASEBY® INFUSION

 •  Insert fine gauge butterfly with long tubing into the skin of the anterior chest wall (or other convenient subcutaneous site) at an angle of 45 degrees to the skin

•  Start the syringe driver by pressing the start/boost button

•  Light will flash every 2025 seconds on MS26

•  Protect the mixture from light by using a holster or covering

•  A separate subcutaneous dose of analgesic, anti-emetic, antisecretory or anxiolytic may be required when setting up the syringe driver. Do not use the boost button for this

•  Any unused solution should be discarded

•  As required subcutaneous doses of drugs should be prescribed separately in anticipation of breakthrough symptoms.

DO NOT:-

•  Change the rate setting on the syringe driver

•  Add medication to an existing syringe

•  Use the boost button

 

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SETTING UP A MCKINLEY® SYRINGE DRIVER

You will need:

•  McKinley®  T34 syringe driver

•  9v alkaline/lithium battery – PP3 recommended

•  20ml or 30ml BD Plastipak®  Luer-lok syringe

•  If a large volume of medication is required then a 50ml syringe is also an option (this will not fit in the lockable case device); it may not be possible for syringes to be filled to capacity

i.e. 34-44ml can be delivered from a 50ml syringe and 24ml can be delivered from a 30ml syringe

•  Infusion (or giving) set

•  22 G cannula

•  Clear adhesive film dressing

•  Diluent (usually water for injection)

•  Medication as prescribed

•  Label to be attached to syringe

•  Holster for ambulatory patients

 

PREPARING THE MCKINLEY® SYRINGE DRIVER INFUSION

With McKinley®  T34 the final volume in the syringe will determine the rate of infusion (ml/hr)

•  Dissolve powdered drugs with sterile water for injection if necessary (sterile water for injections may not be needed if other drugs can act as the diluent)

•  Draw up drugs into syringe and dilute to volume required with sterile water for injection

•  Rock the syringe to ensure mixing of the contents.

•  Label the syringe clearly with the:-

•  patient’s name

•  infusion contents and doses

•  date and time

•  initials of persons preparing and checking

•  Prime the infusion line and cannula

•  Insert the cannula subcutaneously into the patient in an appropriately identified area for administration

•  Secure with clear film adhesive

 

PREPARING THE MCKINLEY® SYRINGE DRIVER

•  Install the battery in the syringe  driver  (a battery of 100% has a

3-4 day life only)

•  Ensure barrel clamp arm is down

•  Press and hold the ON/OFF key until “pump identification” screen appears

•  Screen will indicate “Pre-Loading” and then syringe sensor detection screen will appear

•  Press INFO key several times to check battery power (and discard if e.g. <40% according to local policy), then press YES to confirm

 

PreLoading

Use NO to Interrupt

 

FITTING SYRINGE INTO MCKINLEY® SYRINGE DRIVER

•  Check patient’s name is correct with the patient’s ID label (e.g. wrist banda label)

•  Check drugs are correct with the prescription chart

•  Lift and turn barrel arm

•  Seat the filled syringe collar and plunger so the back of the collar sits in the central rest, the collar should be vertical and the scale on the barrel should face forward and be easily read

•  Lower the barrel clamp arm (syringe graphic will stop flashing when syringe correctly seated)

•  Syringe brand and size will be displayed

20ml BD Plastipak

Select↑↓ , Press YES

•  Confirm the syringe size and brand match screen message. Press YES to confirm

COMMENCING THE MCKINLEY® SYRINGE DRIVER INFUSION

•  After confirming the syringe the display will show the deliverable volume, duration and rate of the infusion e.g.

Volume                                        20.3ml
Duration                                     24.00
Rate                                             0.85ml/hr
Confirm,         Press YES

 

•  Check the line is connected to the syringe driver and press YES

•  Press YES to confirm or ON/OFF to return to syringe options

•  Pump screen will prompt – Start Infusion?

•  Check the line is connected to the syringe driver and press YES

•  When the syringe driver is running the screen will display e.g.

 

Time Remaining           23:59

       Rate                                 0.66ml/h

<<< Pump Delivering             

 

•  Green LED light will flash every 32 seconds

•  A breakthrough dose of analgesia may be needed as it will take 4 to 6 hours for therapeutic blood plasma levels to be reached using the syringe driver for the first time or for dose increments

•  To lock the keypad: press and hold down the INFO key (screen shows a progress bar moving from left to right) until the bar has moved completely to the right and a beep is heard to confirm lock has been activated. (When keypad is locked the buttons NO/STOP; YES/START; INFO are still active)

•  To unlock the keypad: repeat this procedure, the bar will run from right to left and a beep is heard to confirm the keypad is unlocked

•  A lockbox is available for the McKinley®  syringe driver – see photo below (this lockbox will not take a syringe larger than 30ml although the McKinley®  syringe driver will take a 50ml syringe)

 


As mentioned below 2nd paragraph,  for Compatibility Chart see  Appendix
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NB Compatibility chart mentioned above can be found in appendix 1

 

Notes

Although subcutaneous administration of these drugs is common and accepted good practice in palliative care, the use of this route lies outside the product license for most of these preparations.

 

Acknowledgements

Sharon Hollyoak, Macmillan Specialist Palliative Care Nurse, University Hospital Coventry.

 

References

1. NPSA Alert December 2010; NPSA/2010/RRR019.

2. Twycross R, Wilcock A (Eds). Palliative Care Formulary: Fourth

Edition. Palliativedrugs.com Ltd 2011: chap 20, pp665-680.

3. Dickman A. Drugs in Palliative Care. Oxford University Press

2010: chap 2.

4. University Hospitals of Coventry and Warwickshire NHS Trust

McKinley T34 Syringe Pump Guidelines 2011 (Draft).

 

NB: Click on Tables below to enlarge

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