In general, avoid combining more than three medicines in one syringe occasionally more than one syringe driver is required. The Palliative Care Handbook, Guidelines for clinical management and symptom control. Pain control Diamorphine hydrochloride is the preferred opioid since its high solubility permits a large dose to be given in a small volume see under Mixing and Compatibility, below. They provide continuous subcutaneous administration of medicines to enable effective symptom control when medicines given by other routes are inappropriate or no longer effective. Medicines are drawn up into a syringe that is then attached to the driver, which is set to move the plunger of the syringe forward at an accurately controlled rate. Patients with neuropathic pain may benefit from a trial of a tricyclic antidepressant.

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Once their pain is controlled, patients started on 4-hourly immediate-release morphine can be transferred to the same total hour calcluate of morphine given as the modified-release preparation for hourly or hourly administration.

Many residential aged care facilities have syringe drivers on site and staff trained in their use. The table shows approximate equivalent doses of morphine and diamorphine hydrochloride. They provide continuous subcutaneous administration of medicines to enable effective symptom control when medicines given by other routes are inappropriate or no longer effective.

Transdermal route Transdermal preparations of fentanyl and buprenorphine are available, they are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose. The equivalent subcutaneous dose of diamorphine hydrochloride is about one-third of the oral dose of morphine.

A number of factors influence the longevity of the insertion site. Precipitation may occur as a result of a reaction between medicines in a syringe. Instructions are also available online from many hospices.

When and how to use a syringe driver in palliative care

Symptom control Several recommendations in this section involve unlicensed indications or routes. The lockable, battery operated, Niki T34 syringe driver is the current device available in New Zealand for the continuous subcutaneous administration of medicines in a community setting. Octreotidewhich stimulates water and electrolyte absorption and inhibits water secretion in the small bowel, can be used by subcutaneous infusion to reduce intestinal secretions and to reduce vomiting due to bowel obstruction.


During the titration phase the initial dose is based on the previous medication used, the severity of the pain, and other factors such as presence of renal impairment, increasing age, or frailty.

A syringe driver is useful when the oral route of administration is not possible and repeated subcutaneous doses are inappropriate, ineffective or impractical. In severe chronic cholestasis, absorption calcupate vitamin K may be impaired; either parenteral or water-soluble oral vitamin K see phytomenadione and menadiol sodium phosphate should be considered.

These antimuscarinics are generally given every 4 hours when required, but hourly use is occasionally necessary, particularly in excessive respiratory secretions. A luer-lock syringe should always be used to avoid any risk of disconnection. Gastro-intestinal pain The pain of bowel colic may be reduced by loperamide hydrochloride.

Medicine requirements must be anticipated for a 24 hour period and can result in a loss of flexibility in dosing Medicines given by other routes including “as needed” subcutaneous injections may be required to manage the patients symptoms for the initial four hours of the syringe driver infusion while the medicines reach a plasma concentration that provides effective symptom control An increase in the patients symptoms may require additional injections for relief Local reactions such as pain, inflammation or infection can cause discomfort and interfere with the delivery and absorption of the medicines Patients may see the use of a syringe sydinge as a final step before death and find its use disconcerting and obtrusive The patients symptoms and syrigne of the infusion must still be reassessed regularly.

A suitable laxative should be prescribed routinely. If syrijge fails, metoclopramide hydrochloride by mouth or by subcutaneous or intramuscular injection can be added; if this also fails, baclofenor nifedipineor chlorpromazine hydrochloride can be tried. Guidelines for health professionals in the community on the use of syringe drivers for adults in palliative care.


Levomepromazine has a sedative effect. Pain management with opioids Oral route Treatment with morphine is given by mouth as immediate-release or modified-release preparations.

The first syringe of a new prescription will lose some of the solution when the line is primed, therefore the infusion will not run for a full 24 hours. Palliative care is an approach that improves the quality of life of patients and their families facing life-threatening illness, through the prevention and relief syring suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.

BPJ When and how to use a syringe driver in palliative care

Nausea and vomiting Haloperidol and levomepromazine can both be given as a subcutaneous infusion but sedation can limit the dose of levomepromazine. Ketamine is sometimes used under specialist supervision for neuropathic pain that responds poorly to opioid analgesics.

Restlessness and confusion may require treatment with an antipsychotic, e. The individual medicines to go in the syringe can be prescribed on a xalculate prescription for a community pharmacy. Ministry of Health MOH.

Immediate-release morphine can be given for breakthrough pain. If problems arise with an infusion site the patient may have localised discomfort, or there may be reduced absorption of the medicine and a loss of syringw control. Normal saline is also compatible with most medicines with some exceptions, e.

Hyoscine hydrobromide effectively reduces respiratory secretions and bowel colic and is sedative but occasionally causes paradoxical agitation.