Download Administration of Drugs via the CME Medical T34 Syringe Driver

Standard Operating Procedure (SOP)
Administration of Drugs via the CME Medical T34
Syringe Driver
DOCUMENT CONTROL:
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible
committee/individual:
Date issued:
Review date:
Target Audience
2
Clinical Effectiveness Committee
5 November 2013
Community Practice Educator
Medicines Management Committee
25 February 2014
November 2016
Community Nursing Staff
1.
Aim
This Standard Operating Procedure (SOP) represents current recommended good
practice and will ensure the proper action to take regarding the setting up and
management of the CME Medical T34 Syringe driver by clinical staff in the
Community setting.
2.
Scope
All registered nurses using the CME T34 Syringe Driver must be personally
competent and accountable in the use and operation of the device by attending
bespoke training. Evidence of training will be recorded on each staff member’s
training record. Mandatory annual updates will be provided.
3.
Link to overarching policy and/or procedure
This SOP is to be used in conjunction with the RDaSH Policy Safe and Secure
Handling of Medicines.
4.
Procedure
4.1 General Information
The McKinley T34 Syringe Driver is being introduced across Rotherham Doncaster
and South Humber NHS Foundation Trust (RDaSH) in line with the requirements of
the National Patient Safety Alert entitled ‘Safer Ambulatory Syringe Drivers’
(NPSA/2010/RRR019) (2010) and will replace the previously used Micrel MP101
pumps throughout the Trust.
4.2 Safety
The McKinley T34 is a small battery operated machine, designed to give a
continuous subcutaneous infusion in millilitres (ml) per hour over a given period. This
method of symptom control, used predominantly in palliative and terminal care
provides relief of multiple symptoms e.g. pain, nausea and agitation via a single
route. The safe use of the syringe driver requires comprehensive knowledge in order
to maintain patient safety.
Caution: If a patient is discharged home with a different make of syringe driver, this
should be changed to a McKinley T34 device as soon as possible.
Lock boxes will fit syringes up to 30ml and should always be used with the CME
Medical T34. Lock boxes reduce the risk of accidental or intentional interference with
the syringe driver and protect from damage caused by normal daily use or drops
within the range of one metre.
Page 2 of 27
4.3 Cleansing, Decontamination and Maintenance
All staff must follow standard infection prevention and control precautions including
hand hygiene, aseptic technique, use of personal protective equipment,
decontamination of reusable medical devices, sharps management and disposal of
healthcare waste.
The device must be decontaminated between patients, daily when in use and as and
when it becomes dirty or contaminated.
Always turn the syringe driver off before cleaning.
After patient use decontaminate the unit using lint free cloth such as Tuffi 5.
Also clean actuator screw thread and guiding rods to remove debris or other
particles.
Do not clean the syringe pump with chemicals such as xylene, acetone, or similar
solvents. These chemicals can cause damage to components and labels.
Do not soak or immerse any part of the syringe driver in any solution. Immersing the
pump in liquid will cause damage to components and this will void the guarantee.
It is recommended that Tuffi 5 wipes are also used to decontaminate the lock box.
All Syringe Drivers will require routine annual maintenance and service as a
minimum or when syringe driver warning is indicated on individual syringe drivers.
Key Health Solutions will provide maintenance work. Devices due for maintenance
can be returned to the Community Support Manager who will then forward the
devices onto Key Health Solutions. A declaration of decontamination status for will
need completing and attaching to the device prior to sending it for repair or service.
4.4 Storage.
It is essential that all syringe drivers are accounted for at all times.
All District Nursing Teams are required to keep an up to date list of the exact location
of the Syringe Drivers. (See appendix 1)
Syringe Drivers will be stored at District Nursing Team bases. They will be stored in
lockable cases and each device will have its’ own case. It will be the responsibility of
the nurse who last used the device to clean the syringe driver and lock box adhering
to the Standard Infection Prevention and Control Precautions Policy.
The case will be refilled ready for further use and stored in a safe place within the
base point. There will be 1 case for each device and these cases will be stored at
each base point in the Community.
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4.5 Equipment Required
1. Syringe driver McKinley T34 and Lock Box. Ensure within maintenance date.
Obtain a new syringe driver if out of date.
2. 9-volt alkaline battery Duracell Procell. The average battery life is 3-5 days
depending on usage e.g. key presses or backlight use.
3. Winged infusion set Saf-T-Intima24Gx0.75 FSP318Yellow.
4. Administration set CME McKinley Micro set 100-172S (Anti-siphon valve and
female luer lock. Length approx. 100cm, priming volume approx. 0.5ml).
5. BD Plastipak luer lock syringe 20ml or 30ml. N.B. luer lock syringes must
always be used to ensure secure connection of the infusion set. The pump is
calibrated to luer lock and failure to use may result in under or over infusion
due to variation in syringe dimensions.
6. Combi-stopper to cap the syringe or administration set
7. Transparent adhesive dressing
8. Drugs and diluent prescribed
9. Needle (to draw up drug)
10. Drug additive label
11. Patient’s Syringe Driver Prescription and Observation Chart or Care of the
Dying IPOC document.
12. Sharps receptacle
13. Disposable carrying pouch (only if patient is mobile)
14. Instruction procedure manual and equipment, as documented on syringe
driver check list.
15. Signing in and out sheet completed with the syringe driver serial number date,
time, patient name and address (see appendix 2)
16. Battery will be removed when device not in use. Syringe driver to be stored in
cases provided by Trust.
A reciprocal agreement is in place between RDaSH and Doncaster and Bassetlaw
Hospital NHS Foundation Trust (DBHFT) for the safe return of syringe drivers to their
respective bases.
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The syringe driver must be returned to base after use. If the patient is admitted to
hospital, then it is the responsibility of the nurse who is allocated to the visit to ensure
that they retrieve the syringe driver. The responsible nurse will contact the
Community Support Manager via e-mail using the relevant form. (See appendix 2)
An agreement is in place with Doncaster Royal Infirmary (DRI) for devices that turn
up with patients that have been admitted to hospital. These devices will be returned
to the medical devices unit at DRI. The medical devices unit will then return the
device to the Community Support Manager. If devices from DRI are sent home with
patients in the community, these will be returned by the Community Support Manager
to the medical devices unit at DRI.
Transferred out of RDaSH
The registered nurse must:
•
•
•
•
Record the details and serial number of the syringe driver on the district nurse
referral form or on the transfer letter if the patient is discharged to a care
home, other hospital or hospice
Place a copy of the form in the patient’s notes
Request that care home, hospital or hospice return the syringe driver to
Medical Technical Services
Inform Medical Technical Services of the transfer
Caution: If a patient is discharged home from a neighbouring hospital (other than
Doncaster Royal Infirmary) with a different make of syringe driver, this should be
changed over to the McKinley T34 and the other syringe driver returned to the
hospital in question as soon as possible.
4.6 Administration Procedure
It is good practice for two staff members, one of which must be qualified, to
undertake the procedure; however, in community settings where there may not be
another health professional available, the patient’s relative may act as a second
signatory to check relevant aspects of the procedure. E.g. Stock levels.
Indications for the use of a syringe driver
The inability of the patient to swallow or absorb oral drugs because of:
Intestinal Obstruction
Persistent Vomiting
Dysphagia
Mouth Throat or Oesophageal Tumour
Altered Level of Consciousness
Malabsorption
Profound Weakness
Page 5 of 27
Advantages
Plasma drug levels are maintained preventing peaks and troughs
Effective symptom control without repeated injections
Control of multiple symptoms with a combination of drugs
Mobility and independence maintained for some patients
Disadvantages/Risks
Medication errors relating to drug or dose
Inflammation or infection may occur at skin site
Drug/patient and drug/diluent incompatibility
Standard Operating Procedure for the Administration of Drugs via a
4.6 Involving the patient and family
Communication and consultation with the patient and family is essential. Before
starting a subcutaneous infusion, the reasons for using this method of administration
should be explained to the patient and family. Informed consent for administration
should be obtained, in accordance with the Mental Capacity Act 2005 Policy. The
discussion is then to be recorded in the nursing care plan. Attention should be paid to
both the physical and psychological aspects involved in accepting a new way of
receiving medication. Some patients feel that this method of drug delivery is a last
resort that their activities will be restricted and that death may be imminent. It is
necessary to listen to and answer the patient’s questions, acknowledge their concerns
and then give explanations and reassurance as appropriate. The patient and family
will be informed that the syringe driver device is on loan to them and must be returned
as delivered after use. A signature will be required from the patient or family after
discussion. (See appendix 5)
The explanation should include the following:
The reasons for using a syringe driver
How the syringe driver works
The siting procedure and site care
How the dose of medication can be adjusted to manage symptoms
Encouragement to describe symptoms
Page 6 of 27
4.7 McKinley T34 Feature Recognition
Barrel clamp arm…. secures syringe and detects brand and size
Collar sensor……… detects correct loading of syringe collar
Plunger sensor…… detects correct loading of the syringe plunger
Actuator…………… drives the syringe plunger to deliver the syringe contents
Info key……………. (a) shows infusion summary, protocol parameters, battery level
(b) when pump is paused, access the main menu
(c) activates/deactivates keypad lock
UP arrow key……... (a) scrolls between options
(b) increases infusion parameters
Down arrow key….. (a) scrolls between options
(b) decreases infusion parameters during programming/titration
Yes/Start…………... Confirms selection and starts infusion
No/Stop……………. (a) stops infusion
(b)takes the user back a step during programming
FF (Forward) ….…. (a) moves actuator forward when no syringe in place and
barrel clamp arm is down
(b) accesses purge function (if enabled)
Back (Reverse)…... moves actuator backward when no syringe is in place
and barrel clamp arm is down
On/Off key…………Switches the pump on and off
Infusion LED light…A green indicator lights:
(a) during system self-test
(b) intermittently to indicate infusion delivery
A red indicator light:
(a) continuously to indicate an alarm state
(b) when pump paused/on stand-by mode
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4.8 Procedure for setting up the syringe driver
A registered nurse must calculate the volume of drug that needs to be drawn up from
the concentration of the preparation to be used and the prescribed dose.
When preparing medicines and disposing of waste materials, the registered nurse
must adhere to the following guidance:Safe and Secure Handling of Medicines Policy
SOP for Controlled Drugs
Standard Infection Prevention and Control Precautions Policy
Sharps Policy – Safe Use and Disposal of Sharps and Management of
Contamination Injuries
Hand Hygiene policy
NMC Standards of Medicines Management
The Medicines Act (1986)
Waste Policy
A registered nurse must ensure:•
•
•
The prescription has been completed correctly, perform the calculation and
check the medication.
Confirm the previous opioid dose, formulation and frequency.
Ensure the medication prescribed and the doses are clinically appropriate
based on the patient’s previous requirements (NPSA, 2008).
The diluent will be prescribed on the patient’s Syringe Driver Prescription (Syringe
Driver Pro-Forma).
Sterile water for injection
Advantages
• Recommended because of its use in reconstituting lyophilized (freeze-dried)
diamorphine (the parenteral strong opioid of choice in the UK)
• More supporting compatibility data
• Reduces the risk of precipitation with cyclizine lactate
Disadvantages
• Large volumes are hypotonic and can cause infusion site pain
Sterile 0.9% Sodium chloride
Advantages
• Recommended with certain drugs e.g. octreotide
• Less infusion site pain and fewer skin reactions
Disadvantages
• Incompatible with cyclizine
• Increases likelihood of precipitation when more than one drug is used
Page 8 of 27
There is a potential for interaction between drugs in a syringe driver. The
compatibility of the drugs and the diluent to be drawn up must be checked prior to
mixing. The Palliative Care Formulary (Twycross et al, 2011), The Syringe Driver,
Continuous subcutaneous infusions in palliative care (Dickman A and Schneider J,
2011) suggest suitable combinations of drugs. If there are any concerns regarding
compatibility please contact the Specialist Palliative Care Team or Pharmacy. Out of
hours, please contact the on call Consultant in Palliative Medicine or on call
Pharmacist. Please refer to Compatibility and stability tables for a subcutaneous
infusion in a McKinley T34 Syringe Pump (Appendix 3).
In Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) a
combination of no more than 3 dugs should be prescribed on the prescription form or
drawn up into a syringe. If more than 3 drugs are required, 2 prescription forms and 2
syringe drivers will be needed. Please seek advice from the Specialist Palliative Care
Team.
N.B. Ampules containing a liquid solution may contain an amount in excess of the
volume stated on the label. Therefore, measure the volume of liquid as it is drawn up
to ensure accuracy of the dose.
•
•
•
•
•
•
Select the appropriate syringe size 20ml or 30ml
Draw up the prescribed medication
Add the diluent up to the required volume
Complete the label, including:
- Patient name and NHS number
- Medicine name and dose
- Batch numbers
- Diluent used
- Route of infusion
- Date and time prepared
- Initials of the registered nurses preparing the syringe
Attach the label to the syringe ensuring that it is flat and not folded. Leave the
scale visible so that it can still be read.
Skin Site Selection for Subcutaneous Infusions
Following completion of the procedure record keeping principles will be used to
record correctly the prescribed medication, dose, dilutant and site of the syringe
driver alongside the amount of prescribed medication remaining. (See appendix
3). Note when using Appendix 3:This is not an exhaustive list of compatible combinations. When setting up a syringe
driver you should consult the list, if the prescribed combination is not on the list you
should risk assess the situation.
Contact St Johns Hospice to determine the suitability for the combination, as they
have access to a more extensive list.
Consider the administration history for that patient – has the combination been
administered without incident prior to this instance.
Page 9 of 27
Contact the prescriber and consider their personal experience or advice they have
taken, in prescribing the combination. Additionally – this list is up review in Sept
2013 – so will need to be updated accordingly.
The CME Medical T34 ambulatory syringe pump is calibrated to operate with BD
Plastipak Luer lock syringe brands and sizes. It is programmed to recognise both the
brand and the size of syringe being used (commonly 20ml. and 30ml).It will be
defaulted using a Prime and Load (Lock – on) Programme of a 24 hour delivery
system.
Fill volume
Medication and diluents should always be drawn up to the following volumes
20ml syringe draw up to 17ml
30ml syringe draw up to 22ml
N.B The 50ml BD Plastipak luer lock syringe is the largest syringe that will fit the
McKinley T34. It allows drugs to be drawn up to approximately 34ml volume for BD
Plastipak syringes. This may reduce the need for a second syringe driver when
giving larger volumes of drugs.
50ml syringes will not fit into the lock box and are not recommended for
routine use.
If a 50ml syringe is thought to be required, please contact the Advanced users
within your team.
Where possible involve the patient in the choice of a suitable site. Areas suitable for
subcutaneous infusion include those with a good depth of subcutaneous fat, towards
the trunk of the body, particularly if the patient’s peripheral circulation is
compromised.
Page 10 of 27
Acceptable sites
Sites to avoid
Oedematous areas, including areas affected by lymphoedema or ascites. (poor
absorption, increased risk of infection)
Sites over bony prominences (discomfort and poor absorption)
Joints or skin folds (discomfort and movement may displace cannula)
Previously irradiated skin (may have poor perfusion - affects drug absorption)
Upper abdomen in a patient with an enlarged liver (risk of puncturing the liver
capsule)
Upper chest wall in a very cachectic patient (risk of pneumothorax)
Infected, broken, inflamed or bruised skin
Sites of tumour
Inserting BD Saf-T- Intima Venflon
Please note PPE and hand hygiene principles should be adhered to for all
procedures.
• Clean the site with soap and water if the skin is dirty otherwise there is no need to
swab the skin
•
Apply the clamp to the line
•
Grasp the “pebbled” side of the wings of the cannula, pinching the wings firmly
together. This “locks” the needle and prevents it from retracting during insertion
•
Ensure that the needle is point down and bevel uppermost, to guide the cannula
through the tissues. This prevents kinking of the cannula
Page 11 of 27
•
If the needle is not already orientated with the point down open the wings and
gently twist the white shield until the needle is correctly positioned
•
Insert the cannula subcutaneously at an angle of less than 45 degrees, lowering the
initial angle of the cannula to a level more parallel to the skin (caution on the chest
wall) and advance to the hilt of the cannula
•
Open the wings (pebbled side down) flat against the skin
•
Apply transparent adhesive dressing over the insertion site and the cannula wings
•
Apply firm finger- tip pressure over the wings of the cannula (avoiding the centre
where the needle retracts) simultaneously grasp the pebbled end of the
coloured/white cylinder shield and pull in a straight continuous motion until the
needle has fully with drawn into the cylinder and pops off
•
Gently remove cylinder from the cannula port, if it has not released spontaneously,
exposing the adapter with the rubber bung
•
Place the needle shield in the sharps bin
•
Change the site every 7 days or as necessary depending on the condition of the
skin
N.B.The Saf-T-Intima cannot be primed when using the McKinley T34. When
setting up the syringe driver the primed extension line is connected directly to
the un-primed Saf-T-Intima
The registered nurse must prepare the syringe and confirm the patient’s identity as
on prescription
•
•
•
•
•
•
•
•
•
•
•
Check the battery life by pressing the INFO Key twice ***
Prepare syringe and contents and cap the syringe.
Press STOP
Press and hold INFO key to deactivate keypad lock
If the infusion complete alarm has activated, press YES to confirm end of
infusion
Switch syringe driver OFF
Clamp Saf-T-Intima
Raise the barrel clamp arm
Remove old syringe
Follow instructions on page 18 Power on and pre-loading
When “Start infusion?” screen displays, connect the infusion line to the
syringe, release the clamp on the Saf-t- Intima and press YES
*** For community use the battery will need changing when the device registers at
40% battery life left.
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Bolus dose of medication
If the patient has uncontrolled symptoms prior to setting up the McKinley T34, it may be
necessary to give a bolus dose of medication.
A separate Saf-T- Intima 24Gx0.75 FSP318 Yellow should be inserted for the purpose of
giving bolus doses. A Swan Lock needle free device should be attached to the Saf-TIntima port.
Temporary interruption to the infusion
This is not normal practice in a community setting and should only be used in
exceptional circumstances e.g. showering or bathing.
N.B. Stopping the infusion will delay the end time of the infusion
Stopping the Infusion
• Press STOP – unlock the keypad and turn the syringe driver OFF.
• Clamp the Saf-T- Intima
• Disconnect the syringe driver. DO NOT REMOVE THE SYRINGE FROM THE
PUMP
• Cap the Saf-T-Intima and infusion line to minimize cross infection.
• Record time and reason why infusion stopped on Syringe Driver Observation
Chart
Resuming the Infusion
• Check that the prescription, syringe label and patient details are correct
• Reconnect the line to the syringe on the pump maintaining asepsis
• Press and hold ON button
• The screen will request confirmation of size and brand of syringe
• Press YES to confirm
• The screen will display “Press YES to Resume” “NO for New Syringe”
• Press YES to resume
• The screen will display remaining volume/ duration/ rate of infusion
• Ensure information is correct as prescribed
• Press YES to confirm
• Unclamp Saf-T-Intima
• Screen will display “Start Infusion?”
• Press YES to start infusion
• Press and hold INFO key to lock the keypad
• Replace the Lock Box
• Record on the Syringe Driver Observation chart the time the infusion was
recommenced
N.B. If “NO for New Syringe” is pressed the remaining infusion will be reset to deliver
over the next 24hrs at a different rate, and the infusion will be incorrect.
If “NO for New Syringe” has been pressed in error. Discard the remainder of the
syringe contents, prepare, and set up a new syringe.
Page 13 of 27
N.B. In a community setting the following procedure should not be applicable
as staff will check the battery status before commencing each 24 hour regime.
Changing the battery during an infusion
•
•
•
•
•
•
•
•
•
When near the end of the battery alert sounds, it indicates that the battery
should be changed within the next half hour
Press STOP and apply clamp to Saf-T-Intima
Insert new battery
Restart the syringe driver
Reconfirm syringe size and brand
Press YES to resume
Reconfirm volume and duration and rate of infusion
Press YES to recommence the infusion
Lock the keypad
Following completion of the procedure all patient records will be updated and
signed by the registered nurse. (For paper documentation see appendix 2).
Records will also include those accessed on System One.
What to do if there is an occlusion in the extension line
•
•
•
•
•
•
Check that the Saf-t-Intima is not clamped
Check the extension line and Saf-t-Intima for any kinking – straighten if kinked
Check the syringe, extension line and Saf-t-Intima for any signs of
crystallization of the solution.
If crystallization detected – prepare and fit new syringe, extension line and
change Saf-t-Intima site
If no physical reason for the occlusion is detected – resite the Saf-t-Intima
If occlusion is still present – change the site, extension line and syringe
N.B. During an occlusion the pump’s Post Occlusion Reduction System will
reverse the operation of the motor and drive the actuator backwards,
otherwise the pressure build up could cause a surge of fluid into the patient
on release of the occlusion. When the pump is resumed/restarted following
the backward movement of the actuator, time will be added to the time
remaining to protect the original calculated rate.
Page 14 of 27
Procedure for releasing a trapped foreign object from the actuator
(See appendix 4)
WARNING: IF A FOREIGN OBJECT IS TRAPPED IN FRONT OF OR BEHIND THE
ACTUATOR DURING PRE-LOADING (AUTOMATIC ACTUATOR MOVEMENT) OR
WHEN MANUALLY ADJUSTING THE ACTUATOR, THE USER SHOULD:
•
•
•
•
•
•
Ignore screen prompts as the prompt that may display will be in relation to
alarm activation and NOT the trapped object
Turn the syringe driver OFF
Raise the barrel clamp arm and turn it to the left or right to keep it in the raised
position
Turn the syringe driver ON
Turn and lower the barrel clamp arm
Use the FF key (or BACK key) to move the actuator in order to release the
object
4.9 Contacting the Palliative care team for advice
Out of hours advice – Monday – Friday after 18:00hrs, weekends and bank
holidays contact the on call Consultant in Palliative Medicine via DRI
switchboard.
4.10 Incident Reporting
Systems are in place within Rotherham Doncaster and South Humber NHS
Foundation Trust to report and manage incidents, near misses and serious untoward
incidents involving syringe pumps. Staff should be familiar with the reporting process
and the Incident Reporting Policy.
Page 15 of 27
Acknowledgements
McKinley T34 Ambulatory Syringe Pump Operations Manual (2011)
Illustrations courtesy of CME McKinley Medical
CME McKinley UK Ltd
Kincraig Business Park
Kincraig Road
Blackpool
FY2 0PJ
Tel: 01253 894646
www.cme-mckinley.co.uk
5.
Links to Associated Documents
Aseptic technique and Aseptic Non Touch Technique Policy
Lifecycle of Clinical & Corporate Records Policy
Medical Devices Policy
The Medicines Act (1986)
Mental Capacity Act 2005 Policy
Incident Reporting Policy
Policy for Consent to Examination and Treatment.
SOP for Controlled Drugs
Standard Infection Prevention and Control Precautions Policy
Sharps Policy – Safe Use and Disposal of Sharps and Management of
Contamination Injuries
Hand Hygiene Policy
NMC Standards of Medicines Management
Waste Policy
Page 16 of 27
6.
References and Literature review
British Medical Association and the Royal Pharmacological Society of Great Britain.
(2013) British National Formulary No 64 London. BMA and RPSGB.
Dickman A and Schneider J (2011) The Syringe Driver. Continuous subcutaneous
infusions in palliative care 3rd edition, Oxford University Press, Oxford
Perdue, C. (2004) The syringe driver – an aid to delivering symptom control. Nursing
Times, 100, 13. pp32-35.
Medicines Act 1986. HMSO: London
Mental Capacity Act (2005) DOH: London
Mitten, T. (2001) Subcutaneous drug infusions: a review of problems and solutions.
International Journal of Palliative Nursing, 7,2. pp.75-85.
National Patient Safety Agency (2008) Reducing dosing errors with Opioid Medicines
Rapid Response Report 05
National Patient Safety Agency (2010) Safer ambulatory syringe drivers Rapid
Response Report 019
NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and
midwives, Nursing and Midwifery council, London
NMC (2008) Standards for medicines management, Nursing and Midwifery Council,
London
Twycross, R and Wilcock A (2011) (eds) Palliative Care Formulary4th edition,
Nottingham, palliativedrugs.com Ltd.
Wilson J. (2001) Infection Control in Clinical Practice. BailliereTindall. London pp138
7.
Appendices
Appendix 1. Syringe Driver base information
Appendix 2. Subcutaneous syringe driver instruction and observation chart for
McKinley T34 and continuation sheet
Appendix 3. McKinley Syringe pump compatability tables
Appendix 4. Procedure for releasing a trapped object from the actuator
Appendix 5. Form for the patient regarding loan of syringe driver
Page 17 of 27
Appendix 1
SYRINGE DRIVE BASE INFORMATION
SYRINGE DRIVER
IDENTIFICATION CODE
CLUSTER AREA
IN USE/NOT IN USE nb. IF IN
USE PLEASE REFER TO THE
RECORD SHEET
STAFF SIGNATURE
Appendix 2
SUBCUTANEOUS SYRINGE DRIVER INSTRUCTION AND OBSERVATION CHART FOR MCKINLEY T34
PRESCRIPTION DETAILS [for completion by the prescriber] – a separate form must be completed for each syringe driver
a
DRUG
DOSE
DILUENT PHARMACY
ALLERGY
STATUS
Please
circle
Date
1.
Route
Duration
of flow
SC
2.
Please circle
12 hours
24 hours
3.
Water for
injection
or
Normal
Saline
4.
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any
necessary treatment changes or need for review. If, as the prescriber, you wish to review the patient on a particular date, please stipulate below -
Review date: ………………………..
Prescriber name: ………………………………………… Signature: ………………………………………………… Practice: ……………………………………………..
PATIENT DETAILS
[Affix label if available]
NHS Number: ………………………………………………..
Surname: ………………………………………………………
Forename(s): …………………………………………………
Address: ………………………………………………………..
……………………………………………………….
DOB: ……………………..
a. Pharmacy: Only complete if this form is used on a ward.
NOT required for community use.
DAILY SET UP
MONITORING PROGRESS
ADMINISTRATION & OBSERVATION DETAILS [for completion by administering clinician]
WARD OR BASEPOINT NAME
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary
treatment changes or need for review.
ADMINISTRATION1
Day and Date
OBSERVATIONS2
Time [HH:MM]
6
Start time of infusion:
Site appearance :
17ml infusion in 20ml syringe
Syringe size used
Syringe/line contents clear3 - OK to continue? [Y/N]
22ml infusion in 30ml syringe
20ml or 30ml
Infusion rate setting – as at set up? [Y/N]
Syringe Driver serial No.:
Battery Status [%]:
Infusion time remaining [HH:MM]
Infusion rate [ml/hr]:
Volume still to be infused (vtbi) [ml]
Site used5:
Site Appearance6:
Is the VTBI correct for time remaining [Y/N]
Drawn up by:
Checked by:
Volume infused [ml]
Details of any problems & actions taken:
Battery status [%]4
Is the key pad locked? [Y/N]
Observer’s initials
If syringe contents discarded:
Volume discarded:
Date & time:
Discharged by:
Checked:
1.
2.
3.
To be completed each time syringe driver is loaded
WARD - Completed 30 minutes after loading and then every 4 hours
COMMUNITY – Complete at set up, at each subsequent visit and at syringe change
If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact
prescriber. Refer to policy for guidance on checking compatibility
4. Change battery when less than 10% (ward ) or 40% (community)
5. Document insertion site of winged infusion
6. Appearance: Use code below
NP (no problem) P (pain)
I (inflammation)
SW (swelling)
B (bleeding) H (hardening)
Page 1
SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET
DAILY SET UP
MONITORING PROGRESS
ADMINISTRATION & OBSERVATION DETAILS
WARD OR BASEPOINT NAME
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary
treatment changes or need for review.
ADMINISTRATION1
Day and Date
OBSERVATIONS2
Time [HH:MM]
Start time of infusion:
Site appearance6 :
17ml infusion in 20ml syringe
Syringe size used
Syringe/line contents clear3- OK to continue? [Y/N]
22ml infusion in 30ml syringe
20ml or 30ml
Infusion rate setting – as at set up? [Y/N]
Syringe Driver serial No.:
Battery Status [%]:
Infusion time remaining [HH:MM]
Infusion rate [ml/hr]:
Volume still to be infused (vtbi) [ml]
5
6
Site used :
Site Appearance :
Is the VTBI correct for time remaining [Y/N]
Drawn up by:
Checked by:
Volume infused [ml]
Details of any problems & actions taken:
Battery status [%]4
Is the key pad locked? [Y/N]
If syringe contents discarded: Volume discarded:
Observer’s initials
Date & time:
Discharged by:
Checked:
DAILY SET UP
MONITORING PROGRESS
ADMINISTRATION & OBSERVATION DETAILS
WARD OR BASEPOINT NAME
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary
treatment changes or need for review.
ADMINISTRATION1
Day and Date
OBSERVATIONS2
Time [HH:MM]
6
Start time of infusion:
Site appearance :
17ml infusion in 20ml syringe
Syringe size used
Syringe/line contents clear3 - OK to continue? [Y/N]
22ml infusion in 30ml syringe
20ml or 30ml
Infusion rate setting – as at set up? [Y/N]
Syringe Driver serial No.:
Battery Status [%]:
Infusion time remaining [HH:MM]
Infusion rate [ml/hr]:
Volume still to be infused (vtbi) [ml]
Site used5:
Site Appearance6:
Is the VTBI correct for time remaining [Y/N]
Drawn up by:
Checked by:
Volume infused [ml]
Details of any problems & actions taken:
Battery status [%]5
Is the key pad locked? [Y/N]
If syringe contents discarded: Volume discarded:
Observer’s initials
Date & time:
Discharged by:
Checked:
1.
2.
3.
To be completed each time syringe driver is loaded
WARD - Completed 30 minutes after loading and then every 4 hours
COMMUNITY – Complete at set up, at each subsequent visit and at syringe change
If contents of syringe look cloudy, precipitation has occurred. STOP infusing and
contact prescriber. Refer to policy for guidance on checking compatibility
4. Change batter when less than 10% (ward ) or 40% (community)
5. Document insertion site of winged infusion
6. Appearance: use code below
NP (no problem) P (pain)
I (inflammation)
SW (swelling)
B (bleeding)
H (hardening)
Page ……..
SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET
DAILY SET UP
MONITORING PROGRESS
ADMINISTRATION & OBSERVATION DETAILS
WARD OR BASEPOINT NAME
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary
treatment changes or need for review.
ADMINISTRATION1
Day and Date
OBSERVATIONS2
Time [HH:MM]
Start time of infusion:
Site appearance6 :
17ml infusion in 20ml syringe
Syringe size used
Syringe/line contents clear3- OK to continue? [Y/N]
22ml infusion in 30ml syringe
20ml or 30ml
Infusion rate setting – as at set up? [Y/N]
Syringe Driver serial No.:
Battery Status [%]:
Infusion time remaining [HH:MM]
Infusion rate [ml/hr]:
Volume still to be infused (vtbi) [ml]
5
6
Site used :
Site Appearance :
Is the VTBI correct for time remaining [Y/N]
Drawn up by:
Checked by:
Volume infused [ml]
Details of any problems & actions taken:
Battery status [%]4
Is the key pad locked? [Y/N]
If syringe contents discarded: Volume discarded:
Observer’s initials
Date & time:
Discharged by:
Checked:
DAILY SET UP
MONITORING PROGRESS
ADMINISTRATION & OBSERVATION DETAILS
WARD OR BASEPOINT NAME
The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary
treatment changes or need for review.
ADMINISTRATION1
Day and Date
OBSERVATIONS2
Time [HH:MM]
6
Start time of infusion:
Site appearance :
17ml infusion in 20ml syringe
Syringe size used
Syringe/line contents clear3 - OK to continue? [Y/N]
22ml infusion in 30ml syringe
20ml or 30ml
Infusion rate setting – as at set up? [Y/N]
Syringe Driver serial No.:
Battery Status [%]:
Infusion time remaining [HH:MM]
Infusion rate [ml/hr]:
Volume still to be infused (vtbi) [ml]
Site used5:
Site Appearance6:
Is the VTBI correct for time remaining [Y/N]
Drawn up by:
Checked by:
Volume infused [ml]
Details of any problems & actions taken:
Battery status [%]5
Is the key pad locked? [Y/N]
If syringe contents discarded: Volume discarded:
Observer’s initials
Date & time:
Discharged by:
Checked:
4.
5.
6.
To be completed each time syringe driver is loaded
WARD - Completed 30 minutes after loading and then every 4 hours
COMMUNITY – Complete at set up, at each subsequent visit and at syringe
change
If contents of syringe look cloudy, precipitation has occurred. STOP infusing and
contact prescriber. Refer to policy for guidance on checking compatibility
4. Change batter when less than 10% (ward ) or 40% (community)
5. Document insertion site of winged infusion
6. Appearance: use code below
NP (no problem) P (pain)
I (inflammation)
SW (swelling)
B (bleeding)
H (hardening)
Page ……..
Appendix 3
Compatibility and stability tables for a subcutaneous infusion in a McKinley T34 Syringe
Pump
Table 1: Subcutaneous Morphine Infusion
Diluent: Water for injections
•
The figures in these tables are not clinical doses to prescribe. Most patients do not
need such large amounts of medication.
•
•
Refer to the relevant guidelines to obtain the usual dose range for each of the medications.
Use the minimum effective dose and titrate according to response.
Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed.
•
Drug Combination
Concentrations of two drug combinations that are physically
stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Morphine Sulphate
Cyclizine
300mg
150mg
380mg
150mg
Morphine Sulphate
Glycopyrronium bromide
300mg
1200 micrograms
380mg
1200 micrograms
Morphine Sulphate
Haloperidol
400mg
10mg
500mg
10mg
Morphine Sulphate
Hyoscine butylbromide
300mg
120mg
380mg
120mg
Morphine Sulphate Hyoscine
hydrobromide
450mg
1200 micrograms
580mg
1200 micrograms
Morphine Sulphate
Levomepromazine
300mg
100mg
380mg
100mg
Morphine Sulphate
Metoclopramide
120mg
60mg
150mg
70mg
Morphine Sulphate
Midazolam
300mg
30mg
380mg
35mg
Morphine Sulphate
Octreotide
400mg
400 micrograms
500mg
500 micrograms
Drug Combination
Concentrations of three drug combinations that are physically
stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Morphine Sulphate
Cyclizine
Haloperidol
40mg
100mg
2mg
50mg
100mg
3mg
Morphine Sulphate
Haloperidol
Midazolam
100mg
5mg
20mg
130mg
6mg
25mg
Morphine Sulphate Hyoscine
butylbromide
Midazolam
50mg
40mg
60mg
60mg
50mg
75mg
Morphine Sulphate
Metoclopramide
Midazolam
50mg
30mg
7mg
60mg
40mg
10mg
Morphine Sulphate
Midazolam
Levomepromazine
180mg
10mg
5mg
230mg
12mg
5mg
73
Table 2: Subcutaneous Diamorphine infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections
•
The figures in these tables are not clinical doses to prescribe. Most patients do not
need such large amounts of medication.
•
•
Refer to the relevant guidelines to obtain the usual dose range for each of the medications.
Use the minimum effective dose and titrate according to response.
Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed.
•
Drug Combination
Concentrations of two drug combinations that are
physically stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Diamorphine
Cyclizine
340mg
150mg
440mg
150mg
Diamorphine
Glycopyrronium bromide
425mg
1200 micrograms
550mg
1200 micrograms
Diamorphine
Haloperidol
800mg
10mg
1000mg
10mg
Diamorphine
Hyoscine butylbromide
1000mg
120mg
1000mg
120mg
Diamorphine
Hyoscine hydrobromide
1000mg
1200 micrograms
1000mg
1200 micrograms
Diamorphine
Levomepromazine
850mg
100mg
1000mg
100mg
Diamorphine
Metoclopramide
1000mg
85mg
1000mg
110mg
Diamorphine
Midazolam
560mg
80mg
720mg
80mg
Diamorphine
Octreotide
425mg
900 micrograms
550mg
900 micrograms
Drug Combination
Concentrations of three drug combinations that are
physically stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Diamorphine
Cyclizine
Haloperidol
340mg
150mg
10mg
440mg
150mg
10mg
Diamorphine
Haloperidol
Midazolam
800mg
7mg
65mg
1000mg
10mg
80mg
Diamorphine
Hyoscine butylbromide
Midazolam
120mg
80mg
20mg
150mg
100mg
25mg
Diamorphine
Levomepromazine
Metoclopramide
850mg
100mg
50mg
1000mg
100mg
60mg
Diamorphine
Levomepromazine
Midazolam
850mg
50mg
30mg
1000mg
60mg
40mg
74
Table 3: Subcutaneous Oxycodone infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections
•
The figures in these tables are not clinical doses to prescribe. Most patients do not
need such large amounts of medication.
•
•
Refer to the relevant guidelines to obtain the usual dose range for each of the medications.
Use the minimum effective dose and titrate according to response.
Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed.
•
• If the 10mg/ml preparation of oxycodone injection is used, and the 24 hour dose of
oxycodone exceeds 60mg, an alternative opioid may be needed for breakthough pain.
Drug Combination
Concentrations of two drug combinations that are physically
stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Oxycodone
Cyclizine
Do not mix - Incompatible
Do not mix - Incompatible
Oxycodone
Haloperidol
140mg
10mg
180mg
10mg
Oxycodone
Hyoscine butylbromide
140mg
40mg
180mg
50mg
Oxycodone
Hyoscine hydrobromide
130mg
1200 micrograms
160mg
1200 micrograms
Oxycodone
Levomepromazine
120mg
100mg
150mg
100mg
Oxycodone
Metoclopramide
80mg
40mg
100mg
50mg
Oxycodone
Midazolam
80mg
40mg
100mg
50mg
Oxycodone
Octreotide
80mg
400 micrograms
100mg
500 micrograms
Drug Combination
Concentrations of three drug combinations that are physically
stable for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Oxycodone
Haloperidol
Hyoscine butylbromide
80mg
2mg
100mg
100mg
5mg
120mg
Oxycodone
Haloperidol
Hyoscine hydrobromide
80mg
2mg
1000 micrograms
100mg
5mg
1200 micrograms
Oxycodone
Haloperidol
Midazolam
80mg
2mg
15mg
100mg
5mg
20mg
Oxycodone
Levomepromazine Hyoscine
butylbromide
80mg
20mg
100mg
100mg
25mg
120mg
75
Table 4: Subcutaneous Alfentanil infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections
•
The figures in these tables are not clinical doses to prescribe. Most patients do not
need such large amounts of medication.
•
•
Refer to the relevant guidelines to obtain the usual dose range for each of the medications.
Use the minimum effective dose and titrate according to response.
Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed.
•
Drug Combination
Concentrations of two drug combinations that are physically stable
for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Alfentanil
Cyclizine
4mg
150mg
5mg
150mg
Alfentanil
Glycopyrronium bromide
5mg
1200 micrograms
8mg
1200 micrograms
Alfentanil
Haloperidol
7mg
10mg
10mg
10mg
Alfentanil
Hyoscine butylbromide
5mg
120mg
8mg
120mg
Alfentanil
Hyoscine hydrobromide
7mg
1200 micrograms
10mg
1200 micrograms
Alfentanil
Levomepromazine
7mg
40mg
10mg
50mg
Alfentanil
Metoclopramide
2mg
60mg
3mg
80mg
Alfentanil
Midazolam
3mg
50mg
5mg
60mg
Alfentanil
Octreotide
6mg
800 micrograms
8mg
900 micrograms
Drug Combination
Concentrations of three drug combinations that are physically stable
for 24 hours
17ml in 20ml syringe
22ml in 30ml syringe
Alfentanil
Haloperidol
Midazolam
4mg
5mg
35mg
6mg
5mg
45mg
Alfentanil
Hyoscine butylbromide
Levomepromazine
5mg
120mg
25mg
7mg
120mg
25mg
Alfentanil
Metoclopramide
Midazolam
3mg
35mg
20mg
3mg
45mg
30mg
Alfentanil
Levomepromazine
Midazolam
3mg
80mg
30mg
5mg
100mg
40mg
1.
Dickman A: The syringe driver: continuous subcutaneous infusions in palliative care. 2nd Edition, 2005. OUP.
2.
Palliative care drug information online http://www.palliativedrugs.com/
Appendix 4
77
Appendix 5
You have been loaned a syringe driver by Rotherham Doncaster and South Humber NHS Foundation
Trust.
Make and Model...........................................................................................................
Serial Number...............................................................................................................
This syringe driver will be cleaned, maintained and tested to ensure it is, and remains fit for purpose
by the Nursing team.
We have included an instruction manual for the unit that you have been given.
Please ensure that;
•
•
The driver is kept dry
It is handled with care
Delivered by (Print name)................................................................RDaSH Employee
Instruction given - Date.............................Signature.....................................................
Syringe driver accepted by (print name)...................................................Patient/carer
Date accepted..................................................................
By accepting this machine I agree to the above.
Signature...................................................................................................Patient/carer
Advice available from............................................................
Please contact .............................................................................. for any issues or to return the unit.
The equipment specified remains the property of Rotherham Doncaster and
South Humber NHS Foundation Trust and must be returned to the contact above
in the condition it was received in when no longer required.
78