Syringe drivers

Question 1

What does CSCI stand for?

Answer 1

continuous subcutaneous infusion

Question 2

Why use syringe drivers?

Answer 2

to deliver a medication for a persistent symptom that needs persistent management
when oral route is unavailable

Question 3

What symptoms can be managed with a syringe driver at the end of life?

Answer 3

pain
agitation
secretions
nausea + vomiting
breathlessness

Question 4

What is anticipatory prescribing?

Answer 4

on PRN section
for all patients deemed to be end of life
something for all possible symptoms patient might experience so can be given quickly if needed
must be prescribed SC

Question 5

Why is there more than one prescription box on a syringe driver prescription sheet if you can put 4 drugs in a syringe?

Answer 5

compatibility - not all drugs can be mixed
more than 4 drugs needed sometimes
easier to review/change doses
volume

Question 6

Where are syringe driver cannulae normally sited?

Answer 6

centrally on torso - extremities shut down at end of life

Question 7

What diluent can be used for syringe drivers?

Answer 7

normal saline or water for injection (some drugs can only be one or the other)

Question 8

What is the rate for a syringe driver on the prescription chart?

Answer 8

over 24 hours

Question 9

Why are syringe drivers giving medicines SC not IV?

Answer 9

not IV as can be hard to get veins at end of life as peripheries shut down

Question 10

What is the volume on a syringe driver prescription?

Answer 10

17ml (for 20ml syringe)
or 22ml (for 30ml syringe)

Question 11

Management of secretions at end of life

Answer 11

drugs
suction
position change
no intervention but talk to family

Question 12

What drugs can be used to manage secretions at the end of life?

Answer 12

anticholinergics:
- hyoscine butylbromide (buscopan)
- hyoscine hydrobromide
- glycopyrrhonium

Question 13

Why is hyoscine butylbromide preferred to hyoscine hydrobromide?

Answer 13

butylbromide does not cross BBB - so fewer side effects

hydrobromide can be sedating

Question 14

What anti-emetics are commonly used at end of life?

Answer 14

metoclopramide
cyclizine
haloperidol
levomepromazine

(ondansetron has poor compatibility with other drugs and doesn’t dissolve as well - generally avoid but used in parkinsons patients)

Question 15

What can cause agitation at end of life?

Answer 15

overwhelming other symptom (eg. pain)
reversible causes
delirium
anxiety/fear

Question 16

What drugs can be used for delirium at end of life?

Answer 16

anti-psychotics:
haloperidol
levomepromazine

Question 17

What drugs can be used for anxiety/fear at end of life?

Answer 17

benzodiazepines:
midazolam
lorazepam

Question 18

What drugs can be used for breathlessness at the end of life?

Answer 18

opiates (morphine)
benzodiazepines (midazolam)

Question 19

Why is levomepromazine not really used outside of palliative care?

Answer 19

works on most of receptors in vomiting pathway
therefore many side effects (mainly sedation + postural hypotension)

Question 20

What opioids are used in palliative care?

Answer 20

morphine (not good in renal failure)
diamorphine
oxycodone
alfentanil (good when eGFR<30 but short half life)
fentanil

Question 21

What dose of morphine should be started in a syringe driver if a patient is opiate naive?

Answer 21

start at low dose
5-10mg morphine in syringe driver

Question 22

What would oral morphine 30mg BD dose be for a syringe driver?

Answer 22

oral morphine –> SC morphine = /2

60mg morphine in 24h PO = 30mg morphine in 24h SC

prescribe 30mg SC morphine

Question 23

Why is a lower dose of SC opiates needed compared to PO?

Answer 23

SC has higher bioavailablity so more is absorbed and little is metabolised before action

Question 24

When putting opioids in a syringe driver, what should be crossed off the regular prescriptions?

Answer 24

any pre-existing opioids
(Do not cross off PRN)

Question 25

What should you look for on a patient when calculating their total analgesic dose?

Answer 25

any patches

Question 26

What dose of analgesia should be put in a syringe driver if patient had been on opioids leading up to this?

Answer 26

total daily dose
add up regular dose + taken PRNs in last 24h

Question 27

How is analgesia PRN dose calculated for palliative care?

Answer 27

calculate total 24h dose (total regular + taken PRNs in last 24h)
divide by 6
(works for morphine + oxycodone)
(divide by 6 as doses usually last around 4h, so 6 in 24h)

Question 28

What does high dose metoclopramide increase the risk of?

Answer 28

extra-pyramidal side effects + risk of colic

Question 29

What anti-emetics are good for brain mets?

Answer 29

cyclizine
dexamethasone

Question 30

What is the dose conversion for anti-emetics from PO to SC?

Answer 30

PO and SC doses the same