Nursing Practice
6 - 7 JULY 2015, BIRMINGHAM
Review
Medicines management
Syringe pumps are a vital tool for administering medicine, especially in palliative care.
However, nurses must have training before using them to ensure patient safety
Safe practice in syringe
pump management
In this article...
 easons for using a syringe pump
R
Advantages and disadvantages of syringe pumps
Principles of patient care
Author Juliette Mukoreka and Isatta Sisay
are clinical nurse specialists in palliative
care at Trinity Hospice, London.
Abstract Mukoreka J, Sisay I (2015) Safe
practice in syringe pump management.
Nursing Times; 111; 14: 19-21
Syringe pumps offer an alternative route
for delivering medicine when the oral route
cannot be used. This is particularly
important for patients receiving palliative
care, for whom a continuous infusion of
medication can improve symptom control.
This article explains how to administer
drugs safely using these devices.
S
yringe pumps are used as part of
palliative care to administer
medicines subcutaneously to
patients who are unable to
manage or tolerate oral medication.
Ambulatory syringe pumps are portable
battery-operated devices for delivering
medication by continuous subcutaneous
infusion (CSCI) over a given time period
(usually 24 hours). They are useful when
small volumes of drugs need to be infused
at a slow rate (Dougherty and Lister, 2011),
and their compact design enables patients
to move around and maintain independ-
ence (Costello et al, 2008). The pumps are
simple to operate, but training is essential.
Patients, carers and health profes-
sionals often wrongly associated syringe
pumps with imminent death (Graham and
Clarke, 2005), but the devices may be used
at any time in the care pathway to control
symptoms where drugs cannot be admin-
istered orally, such as in patients with
intractable nausea and vomiting (Costello,
2008; Dickman et al, 2005) – box 1 on page
20 lists indications for their use. It is there-
Alamy
fore important when starting a pump to
Keywords: Medicines administration/
Syringe pumps/Safety
CONGRESS
●This article has been double-blind
peer reviewed
5 key
points
1 Ambulatory
syringe pumps
deliver medication
by continuous
subcutaneous
offer patients and their families reassur- infusion over a
ance and explain the need for the syringe given time period
pump (Costello, 2008).
Continuous subcutaneous infusion
maintains a constant serum level of medi-
2 Their compact
design enables
patients to move
cines (Barnes et al, 2009), which achieves around and
better symptom control than intermittent maintain
dosing. It also reduces the need to use less independence
popular routes of administration such as
rectal or intravenous (Morgan and Evans,
2004). Box 2 on page 21 lists the advantages
3 Although the
pumps are
relatively simple to
and disadvantages of CSCI. operate, training is
essential
Selecting syringe pumps
4 Patients and
Several models of syringe pump are avail- relatives often
able. The most commonly used in the UK associate syringe
until recently were the Smiths Medical pumps with
(formerly Sims Graseby) MS16A and MS26 imminent death
(Costello et al, 2008). Although the flow
rate in both devices is determined by how
far the syringe moves in millimetres (mm),
5 It is important
to explain the
purpose of syringe
there are critical differences between the pumps to patients
two. The MS16A is calibrated in mm/hr
while the MS26 is calibrated in mm/24hrs,
and errors – some fatal – have been
reported when confusion has arisen
during their use. As a result, the National
Patient Safety Agency (2010) published a
rapid response report advising all health-
care organisations using ambulatory
syringe pumps to change to devices with
the following features:
» Rate settings in millilitres (ml)
per hour;
» Mechanism to stop infusion if syringe
is not properly and securely fitted;
» Alarms that activate if syringe is
removed before the infusion is stopped;
» Provision of internal log memory to
record pump activity.
Standardisation of a single syringe There are critical differences between the
pump model, centralised purchase and two most commonly used syringe pumps
www.nursingtimes.net / Vol 111 No 14 / Nursing Times 01.04.15 19
 Nursing Practice
Review
storage of equipment, scheduled regular
maintenance and appropriate training in
the use of syringe pumps across a locality
has been suggested as effective means
of error reduction (Dickman et al, 2005;
NPSA, 2004). In our locality the
CME McKinley T34 syringe pump was pro-
cured because it met the requirements
listed above and has additional safety fea-
tures; for example, the infusion rate
cannot be altered once the device is
infusing, and the device has a syringe size
detector (NPSA, 2008).
There are other syringe pumps in use,
including Eden Medical’s MP Daily, and
Cardinal Health AD. These also offer all the
safety features expected from current infu-
sion pumps. However, this article focuses
on the McKinley device as it is used widely
across the NHS.
Using syringe pumps
All staff must receive training before using
a syringe pump, and be familiar with local
policies and procedures. It is important to
discuss the procedure with the patient and
follow local medicines administration pol-
icies at all times including checking drugs,
compatibility and the patient’s identity.
Preparing the syringe
Manufacturers recommend the size of
syringe that should be used with their
devices. Pumps are calibrated in ml per
hour, and it is important to establish what
final volume is required in the syringe, then
choose a syringe size. The prescribed medi-
cation should be drawn up first and then
diluent added to the appropriate volume.
Medications, diluents and compatibility
Drugs in syringe pumps are generally pre-
pared with a diluent – commonly water for
Box 1. Indications for
using a syringe pump
A syringe pump is indicated for
patients who:
● Are unable to take medications orally
as a result of persistent nausea,
vomiting, dysphagia, severe weakness
or unconsciousness;
● Are unable to absorb oral
medications;
● Are unwilling or unable to take
medicines by mouth;
● Have a malignant bowel obstruction
where surgery is inappropriate;
● Have head and neck lesions or
surgery.
Source: Dougherty and Lister, 2011
20 Nursing Times 01.04.15 / Vol 111 No 14 / www.nursingtimes.net
injections, or sodium chloride 0.9%
(Flowers and McLeod, 2005). This dilutes
the medicine to minimise site reactions
and enables it to be given over a set period.
The diluent used should be compatible
with the medicine. Information on suit-
able diluents can be obtained from
www.palliativedrugs.com, manufacturers’
literature, local clinical information or
a pharmacist.
If a patient needs more than one medi-
cine for symptom control, the medicines
need to be compatible with the diluent and
with each other. If compatibility is an issue,
two syringe pumps may be required.
Diamorphine can be given by subcuta-
neous infusion in strengths of up to 250mg/
ml. Up to strength of 40mg/ml, both water
for injections or sodium chloride 0.9% are
suitable diluents, but above this strength
only water for injections is used to avoid
precipitation (Barnes et al, 2009).
Examples of common medicines that
can be mixed with diamorphine or mor-
phine in palliative and end-of-life care
include: cyclizine, dexamethasone, halop-
eridol, hyoscine butylbromide, levome-
promazine, metoclopramide, midazolam
(British Medical Association and Royal
Pharmaceutical Society for Great Britain,
2014). A drug additive label should be com-
pleted according to local policy and
attached to the syringe to identify:
» The drugs added;
» The diluent;
» Time and date the infusion started;
» Patient’s name;
» Name and signature of the person
starting the infusion.
When drugs are drawn up the fluid in
the syringe should be inspected for any
discoloration or precipitate which may
indicate incompatibility (Dougherty and
Lister, 2011).
Setting up an infusion
The battery power should be checked
before starting the infusion; the average
battery life is approximately three to four
days, depending on use. If the remaining
battery power is less than 40% at the start
of the infusion it is advisable to discard the
battery and install a new one.
Fine-bore lines with a small priming
volume (less than 1ml and preferably
less than 0.3ml) are recommended. When
a new infusion line is used it should
be primed with contents from the
syringe until the fluid just shows at the
needle tip. If a new line is required part way
through an infusion, for example due to
due to site irritation, it will require
priming, which means that the syringe
FIG 1. Acceptable
insertion sites
Anterior Anterior
aspect of chest wall
upper arms
Anterior
abdominal Anterior
wall aspects of
the thighs
pump will not run for the full 24 hours.
When an infusion line is already in situ
and resiting is not required, the line can be
disconnected from the previous syringe.
» The used syringe should be removed
from the pump with the line attached;
» The new syringe is then loaded into the
pump;
» The line can then be disconnected from
the old syringe and attached to the
number pump;
» The infusion programme should then
be set according to manufacturers’
instructions.
To avoid an inadvertent bolus dose, the
syringe must be attached to the pump
before connecting to the line.
The pump should be started according
to the prescription and manufacturers’
instructions, and the infusion monitored
regularly to ensure it is running and to
detect complications.
Choosing a site
A 23g butterfly needle or Sof-Set needle is
normally used for subcutaneous infusions.
The insertion site depends on the patient’s
needs (Fig 1). For ambulatory patients the
chest and abdomen are usually the pre-
ferred injection sites; movement of the
arm may cause problems such as bruising
if it is used as the injection site. For
agitated and distressed patients,
placement around the scapula reduces the
likelihood of accidental removal of the
 Nursing
Times.net
cannula. The thigh may also be used. Sites
to be avoided include:
» Oedematous areas
» Bony prominences;
» Irradiated sites;
» Areas where there is tissue damage
such as broken skin or cutaneous
tumour sites (Twycross and Wilcock,
2007).
It has been suggested that the site
should be rotated every three days to mini-
mise the risk of site reactions (Dickman et
al, 2005). However, Twycross and Wilcock
(2007) suggest that, with non-irritant
medicines, the site may remain satisfac-
tory for seven days or more, so local poli-
cies should be followed. The infusion
needle should be secured with a trans-
parent dressing so that it can be observed
for signs of inflammation. Patients should
be encouraged to report any redness, pain,
swelling or irritation at the site.
Documentation and monitoring
Dougherty and Lister (2011) suggest that at
a minimum the patient’s condition should
be checked 15 minutes and one hour after
the infusion is started and four-hourly
thereafter (although local policy should be
followed). However, this is not always pos-
sible in primary care or community set-
tings, and it may then be beneficial to
involve the patient and/or relatives in the
monitoring process.
Subcutaneous infusions should be
monitored regularly for precipitation and
discolouration, and to ensure the infusion
is running at the correct rate. Pump func-
tioning is assessed by regular monitoring
of the volume to be infused over the time
remaining and the battery life; any devia-
tions need to be investigated immediately.
Patient monitoring is crucial if symptom
control is to be maintained. Regular
Box 2. Pros and cons of syringe pumps
Advantages
● Increased comfort as repeated
injections are not required
● Control of multiple symptoms with a
combination of drugs
● Round-the-clock comfort because
plasma drug concentrations are
maintained without peaks and troughs,
giving constant therapeutic drug levels
over a 24-hour period
● Mobility maintained because the
device is lightweight and can be worn in
a holster under or over clothes
● Generally needs to be loaded only
once every 24 hours
For more articles on drug calculations, go
to nursingtimes.net/drugcalculations
Box 3. Advice on using syringe pumps
● Know when it is appropriate to use a
syringe pump
● Become familiar with the location and
operation of the device used in your
organisation
● Always use a luer-lock syringe and
giving set
● Be aware of the drugs commonly used
and their dose
● Always explain the rationale for using a
pump to the patient, carers/relatives
observation and questioning, such as “do
you have any pain?”, ensures any neces-
sary breakthrough doses of medicines can
be given and patient comfort maintained.
Symptom charts should be completed
according to the patient’s condition and
local policy.
Any changes that may need to be made
to the medication in the syringe pump
should be anticipated; for example, if a
patient has required regular breakthrough
doses of diamorphine to control pain, the
quantity of the drug in the syringe pump
may need to be increased (Barnes et al,
2009). When the 24-hour dose is changed,
the breakthrough dose should also be
adjusted accordingly.
Discontinuing a pump
To terminate the pump, press the
STOP button and remove the needle/can-
nula as soon as possible. Although the
syringe pump keeps a record of how much
it has delivered, the amount of drugs deliv-
ered and wasted should be documented
on the controlled stock sheet that is part
of the nursing documentation. Waste
should be disposed of in the sharps bin by
a qualified nurse.
Disadvantages
● Staff training
● Possible inflammation and pain at the
infusion site and potential source of
infection
● In emaciated patients or those on
long-term infusions skin-site availability
may become a problem
● Lack of reliable compatibility data for
some mixtures of medications
● Daily visits from district nurses and
other health professionals might be too
intrusive for some patients and family.
Source: www.palliativedrugs.com
www.nursingtimes.net / Vol 111 No 14 / Nursing Times 01.04.15 21
● Ensure you know where you can site
the pump and how to do it
● Ensure you are able to monitor the
pump and the patient’s condition
(according to your local policy)
● Anticipate any need for dose changes.
● Document care of the pump and
ongoing assessment of the patient’s
symptoms with relevant assessment tools
● Know who to contact for assistance
or information
Conclusion
Syringe pumps have an important role in
symptom management. They are often
viewed by patients and families as signal-
ling the end of life, but they offer patients
the opportunity to receive effective
symptom control. It is vital that nurses
using pumps have appropriate training
and supervision to avoid errors. Box 3
offers advice on using the pumps. NT
References
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Great Britain
Costello J et al ( 2008) Benefits and drawbacks of
syringe driver in palliative care. International
Journal of Palliative Nursing; 14; 3, 139-144.
Dickman A et al (2005) The Syringe Driver:
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Care. Oxford: Oxford University Press
Dougherty L, Lister S (2011) Royal Marsden
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Flowers C, Mcleod F (2005) Diluent choice for
subcutaneous infusion: a survey of the literature
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the subcutaneous route in palliative care: the
inventor, the history and the implications. Journal
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palliative care. International Journal of Palliative
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Report. London: NPSA. Bit.ly/
NPSAAmbulatorySyringes
National Patient Safety Agency (2008) Patient
Safety Alert: Promoting safer use of injectable
medicines. Bit.ly/NPSAInjectableMedicines
National Patient Safety Agency (2004) Improving
Infusion Device Safety. London: NPSA. Bit.ly/
NPSAInfusionSafety
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For more on this topic go online...
Using subcutaneous fluids in
end-of-life care
Bit.ly/NTSCFluidsEoL