Essential Syringe Driver

Training for T 34

Elaine Bird

St Luke’s Hospice

Aim

• For all practitioners to be accountable for their

individual competence and capability when

caring for a resident with a T34 Syringe Driver.

Objectives • Discuss NMC core standards of conduct and practice

• Discuss standards for medications

• Understand clinical rationale for commencing and discontinuing a T34 syringe driver in palliative care

• Understand the importance of clear individualised care plan, incorporating open honest communication & continual holistic assessment.

• Discuss common medications and guidelines for recommended dose administration

• Demonstrate the correct procedure for setting up and continual monitoring of the T34 syringe driver.

NMC Code for professional

standards of practice & behaviour

• Prioritise people

• Practice effectively

• Preserve safety

• Promote professionalism & trust

Standards for practice of

administration of medicine

You must know

• The identity of the patient & any allergies

• Understand the therapeutic use of medications, its usual dosage, side effects, precautions and contra indications.

• The prescription label is clear and unambiguous.

• The expiry date of the medicine to be administered

Medicine Standards Continued

• You are responsible for the initial and continued assessment of the patient

• You must be fully aware of the individual care plan

• In the event of an error you must take action to prevent harm, report ASAP to the prescriber and document your actions

Clinical reasons for commencing a

T34 Syringe Driver in Palliative and

End of Life Care

• Dysphagia

• Pain control

• Relief of nausea & vomiting

• Control of restlessness or agitation

• Relief of anxiety

• Control of convulsions

• Control of excessive bronchial secretions

Individual Care plan

• Discuss what should be incorporated in an

individual care plan and how/where to

document

Advantages of using Continuous

Subcutaneous Infusion (CSCI)

• No peaks or troughs in plasma drug

levels

Plasma

drug

level

Time

4 Hourly injections CSCI

Toxicity

Therapeutic level

Disadvantages of using CSCI

• When the syringe is changed the symptoms

for the next 24 hours need to be anticipated

• If symptoms change, top up injections may

be required

• Machine inefficiency

• Battery failure

• Local skin reactions

Infusion sites

• Lateral aspect of upper arms

• Anterior aspect of thighs

• Anterior of chest wall

• Anterior abdominal wall

• Scapula region especially if restless

Sites to avoid

• Areas of lymphoedema

• Radiotherapy sites

• Bony prominences or near a joint

Recommended labelling of the

Syringe

Labels must be applied to the syringe

• Patient’s name

• NHS Number (D O B if not available)

• Date and time syringe Driver recharged

• Drugs And Doses

• Initial volume of fluid in syringe

Using the T34 Syringe Driver • The T 34 in Sheffield is programmed to use a

30ml Luer-Lok BD syringe ONLY

• Check service expiry date

• The standard delivery of medication in Sheffield

is programmed for 24hours

• Two registered nurses required to set up the

syringe driver

• Familiarise yourself with the Policy & Procedure

• Complete the T34 competency form

Maintenance and Cleaning

• Must have an annual service

• After each use, thoroughly clean with 70% alcohol wipes – including battery holder and cover

• A declaration of decontamination form must be sent back with the syringe driver after use

• Any syringe driver involved in a medication incident must be quarantined immediately and sent to BME

After a Patient Dies

If RGN is competent with verifying expected death the syringe driver can be stopped removed and drugs disposed of in line with company’s policy and procedure

If a doctor is required to verify death the syringe driver can be stopped but MUST be left in place until death has been officially verified.

Recommended Drugs, no more than 3 different

medications and ensure compatibility

• Diamorphine

• Morphine

• Oxycodone

• Midazolam

• Haloperidol

• Metoclopramide (Maxolon)

• Levomepromazine (Nozinan)

• Hyocine Butylbromide (Buscopan)

Starting Dose If opiate naïve- Best practice is to administer PRN S/c

injections for 24 hours

If taking oral opiates calculate the 24 hr dose administered

Divide by 2 to convert oral morphine to S/C Morphine

Divide by 3 to convert from oral morphine to S/C Diamorphine

Example

Oromorph 5mg qds = 20mg in 24 hours

20mg ÷ 2 = 10mg S/C Morphine in 24 hours

20mg ÷ 3 = 6.6mg S/C Diamorphine in 24 hours

MST 30mg bd = 60mg in 24 hours

60mg ÷ 2 = 30mg S/C Morphine in 24 hours

60mg ÷ 3 = 20mg S/C Diamorphine in 24 hours

Actual dose prescribed would depend on

symptoms experienced by the patient

Oxycodone

Divide by 2 to convert oral oxycodone

to S/C oxycodone

• Oxycodone 5mg qds = 20mg in 24 hours

• 20mg ÷ 2 = 10mg S/C Oxycodone in 24 hours

• Oxycodone 20mg bd = 40mg in 24 hours

• 40mg ÷ 2 = 20mg S/C Oxycodone in 24 hours

Guidelines for PRN opiate

medications

Guidelines for Prn Medications is to divide the 24 hour dose of an opiate medication by 6

For example

MST 20mg bd = 40mg morphine in 24 hours

40mg ÷ 6 = 6.6mg prn oromorph

Syringe Drivers exactly the same

10mg diamorphine over 24 hours

10mg ÷ 6 = 1.6mg

PRN medication

Actual dose prescribed would depend on

symptoms experienced by the patient

If sliding scale dose of prn oromorphine,

morphine, diamorphine or oxycodone has

been prescribed increase frequency of

medication before increasing the dose

Dame Cicely Saunders.

• You matter because you are you. You

matter to the last moment of your life

and we will do all we can, not only to

help you die peacefully, but to live until

you die’

References

• NMC The code (2015)

• Sheffield Palliative Care Formulary 3rd Ed

• http://www.intranet.sheffieldccg.nhs.uk/Do

wnloads/Medicines%20Management/pres

cribing%20guidelines/Palliative%20Care%

20Sheffield%20Palliative%20Care%20For

mulary.pdf