01Purpose and principlesWhat the treatment does and how it fits into care.
A syringe driver, more accurately a portable syringe pump, delivers a continuous subcutaneous infusion over a programmed period, commonly 24 hours. It can maintain symptom medicines when dysphagia, vomiting, bowel obstruction, severe weakness or impaired consciousness makes the oral route unreliable. It is also used outside the last days. Starting a pump should follow a clinical route decision, not act as a symbolic transition to dying.
Assess each symptom and medicine independently. Reconcile regular and actually administered rescue doses over the previous 24 hours and decide which drugs have demonstrated benefit. Convert oral opioid to subcutaneous exposure using the current local table and renal assessment. A new symptom may need one test dose before inclusion. Unused anticipatory prescriptions do not prove a continuous requirement.
Prescription precision is critical. Write generic name, total dose over the full infusion period, units in words, diluent, final volume, route and duration. Distinguish milligrams from micrograms and total 24-hour dose from an hourly rate. Prescribe rescue separately by symptom, dose, route, minimum interval and escalation action. The device settings follow the prescription; the machine does not determine the dose.
Mixing introduces compatibility and stability risk. Drug, salt, concentration, diluent, temperature, light exposure, syringe material and duration all matter. Use the organisation's current palliative compatibility resource or specialist pharmacy; do not infer compatibility from two drugs being injectable or from a clear-looking solution. When compatibility is uncertain, use separate infusions or another route rather than experimenting at the bedside.
Set-up requires a trained practitioner and an independent check under local policy. Confirm patient identity, allergies, prescription, calculation, ampoule strength and expiry, diluent, syringe size, device program, battery and line. Label the syringe and tubing, document start time and site and lock controls. Account for priming volume according to device policy so that the programmed delivery remains accurate.
The subcutaneous site should be intact, away from oedema, infection, irradiated or damaged skin, joints and bony prominences. Common sites include upper chest, abdomen, upper arm or thigh according to local practice and patient preference. Inspect for pain, erythema, swelling, hardness, leakage and dislodgement. A reaction may result from drug concentration, local irritancy, infection or poor perfusion and should trigger compatibility and site review.
Monitoring combines patient and equipment. Assess whether pain, nausea, agitation or secretion improved; count rescue doses; observe arousal, respiratory rate, delirium and myoclonus; and check syringe contents, line, site, battery, rate and volume remaining. If symptoms remain uncontrolled, verify delivery before increasing doses. An occluded or disconnected pump cannot be corrected by prescribing more medicine into it.
Handover is a high-risk moment. Communicate the exact mixture, start time, rate, last rescue, site, remaining volume, next change time, compatibility source and who may adjust it. Provide backup rescue and out-of-hours contact for home use. At discontinuation, consider residual drug in the line, stop and remove according to policy and dispose of controlled-drug waste with the required witnesses and records.
Key points
- Use a continuous subcutaneous infusion when oral or transdermal delivery is unreliable and a reasonably stable 24-hour medicine requirement exists.
- First-line preparation reconciles the last 24 hours of scheduled and rescue medicines, symptoms, renal and hepatic function, allergies and current route.
- Calculate the infusion from actual effective need and route conversion; do not place all anticipatory medicines into the pump simply because they are available.
- The prescription states each generic medicine and total dose over 24 hours, diluent, total volume, subcutaneous route, duration, device and separate breakthrough doses.
- Local formularies and specialist pharmacy compatibility data govern mixtures and concentration; visual clarity does not prove chemical stability.
- An independent trained check should verify patient, calculation, units, medicines, ampoules, diluent, syringe, device program and line before connection.
- Choose a healthy site, secure and label the line and keep it separate from intravenous access; never flush the subcutaneous line as an unscheduled bolus.
- The gold-standard review assesses symptom response, rescue use, sedation, breathing, site, syringe, battery, remaining volume, rate and prescription at least daily and after every change.
- Explain to patients and families that a pump supplies steady medicine through a route and does not itself accelerate dying.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Dysphagia, persistent vomiting, bowel obstruction, malabsorption or reduced consciousness makes established oral treatment unreliable.
Repeated effective rescue across 24 hours or loss of an established oral route provides evidence for a calculated continuous dose.
Unchanged syringe volume, alarm, occlusion, disconnection, wet dressing or sudden symptom recurrence suggests interruption before drug failure.
Erythema, induration, pain, swelling, leakage or bleeding can reduce absorption and may indicate irritancy, infection or poor siting.
Cloudiness, colour change, crystals or precipitation is unsafe, although an apparently clear mixture can still be chemically unstable.
New sedation, respiratory slowing, hallucination or myoclonus after starting or changing a pump requires immediate dose and device review.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line symptom and route reviewFirst stepFirst line - Why
- Confirm the indication, symptom mechanism, oral or patch failure, expected duration and whether needs are stable enough for continuous delivery.
- Interpretation and limitations
- A pump is appropriate only when it solves a route or continuity problem; rapid crisis still requires rescue and urgent reassessment.
- 02
Previous 24-hour medicine reconciliation - Why
- Calculate actual regular and effective rescue exposure by drug, formulation and route and identify medicines without demonstrated benefit.
- Interpretation and limitations
- This total informs the starting infusion; prescribed but unused rescue is not included and toxicity demands a reduction or rotation, not full transfer.
- 03
Renal, hepatic and interaction assessment - Why
- Determine clearance, metabolite, sedative and compatibility risks before converting or combining medicines.
- Interpretation and limitations
- Renal decline may make morphine or diamorphine unsuitable and requires a specialist-selected alternative rather than a route-only conversion.
- 04
Compatibility and stability check - Why
- Verify every proposed drug, concentration, diluent, volume, syringe and infusion duration in an approved current source.
- Interpretation and limitations
- All components must be compatible together at the prescribed concentrations; absence of data is not evidence of safety.
- 05
Independent prescription-device check - Why
- Confirm patient, allergies, calculation, units, ampoule strengths, final volume, rate, duration, label, line and pump program.
- Interpretation and limitations
- This is the gold-standard barrier against decimal, route, concentration and programming error and must be repeated after changes.
- 06
Patient-site-device review - Why
- Assess symptom relief, rescue need, toxicity, skin, line, syringe appearance, battery, rate and expected residual volume.
- Interpretation and limitations
- Differentiate pharmacological failure from interrupted delivery; correct device or site faults before dose escalation.
04Treatment approachPreparation, options, escalation and aftercare.
01Pump initiationCalculate from need and verify deliveryFirst stepAn established symptom medicine is needed continuously and the oral route is no longer reliable.+
- 1Assess symptoms and route, reconcile actual 24-hour exposure, check organ function and calculate each medicine and rescue through the local palliative protocol.
- 2Verify compatibility, diluent and concentration with an approved source or pharmacy and complete an independent prescription and device check.
- 3Connect at a suitable labelled site, explain purpose and alarms, document start and arrange patient, site, pump and symptom review within the required interval.
02Uncontrolled symptomRescue first and troubleshoot the systemPain, nausea, agitation or secretion remains severe while a pump is running.+
- 1Give the separately prescribed rescue by the correct route and urgently assess symptom mechanism and any disease emergency.
- 2Check site, line, syringe, battery, program, remaining volume, start time and compatibility before assuming the continuous dose is insufficient.
- 3Use rescue response and actual 24-hour requirement to make an independently checked dose or drug change and monitor after the replacement infusion begins.
03Suspected incompatibilityStop uncertain mixing and obtain evidenceThe mixture changes appearance, blocks the line, causes repeated site reaction or lacks compatibility data.+
- 1Stop administration of a visibly abnormal or unverified mixture, preserve it for review and maintain symptom control with compatible separate rescue.
- 2Check prescription, preparation sequence, concentrations, diluent, environmental exposure and approved compatibility references with specialist pharmacy.
- 3Prepare a verified replacement, use separate pumps or routes if needed and document the finding and incident review to prevent recurrence.
04Transfer or discontinuationControl residual medicine and ownershipThe patient moves setting, changes route, dies or no longer needs continuous subcutaneous delivery.+
- 1Reconcile contents, rate, start time, residual volume, site and rescue exposure and identify the receiving authorised professional.
- 2For transfer, secure the device and send prescription and administration records; for stopping, account for line contents and avoid accidental bolus or duplication with the new route.
- 3Dispose of residual controlled drugs and equipment under local policy, update every prescription system and explain the next symptom and contact plan to carers.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Morphine by continuous subcutaneous infusion
Calculate the total 24-hour subcutaneous morphine from actual prior opioid exposure using the current local conversion table; many formularies approximate it as half the 24-hour oral morphine dose, then adjust for toxicity, frailty and renal function with an independent check.Avoid unreviewed use in severe renal impairment, prescribe separate subcutaneous rescue and monitor sedation, breathing, myoclonus, hallucinations, constipation and site reaction.
Midazolam for selected agitation or anxiety
In the last days a common specialist starting continuous subcutaneous dose is 5 to 10 mg over 24 hours, with 2.5 mg subcutaneous rescue when prescribed under the local protocol and after reversible causes are assessed.Pain, retention, impaction, akathisia and delirium mechanisms must be addressed; opioids compound respiratory depression and escalating sedation needs specialist review.
Haloperidol for selected nausea or delirium
A common palliative continuous subcutaneous range is 1.5 to 3 mg over 24 hours, selected by indication, prior response and the local last-days protocol with a separate patient-specific rescue dose.Review Parkinson's disease, Lewy-body dementia, QT risk, akathisia, dystonia and other dopamine blockers and do not use sedation as a substitute for delirium assessment.
Glycopyrronium for respiratory secretions
When repositioning and explanation are insufficient, a common regimen is 200 micrograms subcutaneously as rescue and 600 to 1200 micrograms over 24 hours by continuous infusion according to the local protocol and response.It does not remove existing fluid and may worsen dry mouth or urinary retention; explain that noise does not necessarily mean choking and avoid reflex escalation.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- At least daily and after every change, review the indication and each symptom, functional or comfort goal and rescue requirement.
- Check arousability, respiratory rate and effort, cognition, myoclonus, nausea, bowel and bladder function and interaction with other sedatives.
- Inspect the site and dressing for redness, hardness, swelling, pain, leakage, bleeding and secure connection at each clinical contact.
- Check syringe label, clarity, crystals, remaining volume, rate, battery, alarm history, line and expected completion time against the prescription.
- Record every rescue dose, response and adverse effect and revise continuous dosing only from actual need and mechanism.
- Reassess renal and hepatic function or clinical markers when acute illness or decline could alter medicine clearance.
- During handover state exact contents, total doses, start time, site, rate, last rescue, next change and named clinician authorised to adjust.
- Audit device incidents, compatibility queries, delayed changes and controlled-drug discrepancies and feed learning into local training.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
The pump is only a route
It can deliver a low stable dose to an alert patient and neither proves nor causes imminent dying.
Clear does not equal compatible
Chemical degradation can occur without visible precipitation, so compatibility needs evidence at the exact concentration and diluent.
Rescue remains separate
Continuous delivery changes slowly and cannot replace an immediate patient-specific dose for a severe breakthrough symptom.
Priming contains active drug
Line volume and local priming policy affect timing and residual exposure and must be included in trained device practice.
Site failure mimics tolerance
Poor absorption from oedema, leakage or inflammation can produce symptom recurrence that dose escalation will not solve.
Handover is a calculation checkpoint
Reading the prescription against the device and syringe during transfer can detect unit, concentration and timing errors before continuation.
08Common pitfallsFrequent interpretation and management errors.
- 01
Starting a pump because a patient is dying rather than because a route or continuous-need indication exists.
- 02
Copying a standard multi-drug last-days mixture.
- 03
Including prescribed but unused rescue doses in the starting calculation.
- 04
Mixing medicines from memory or because the solution appears clear.
- 05
Writing an hourly rate where the prescription requires a total 24-hour dose.
- 06
Confusing micrograms and milligrams for high-potency medicines.
- 07
Assuming the pump treats an acute crisis without separate rescue.
- 08
Increasing dose before checking the battery, line, site and remaining volume.
- 09
Flushing a subcutaneous line and unintentionally delivering a bolus.
- 10
Transferring the device without the prescription, compatibility record and named clinical owner.
- 11
Leaving old oral or patch prescriptions active and causing duplicate therapy.
- 12
Failing to account for residual controlled drug after stopping or death.