A brief guide to drugs for the syringe driver
There is ONE indication for using a syringe driver and that is the patient’s inability to take oral medication. The commonest reasons for this are severe dysphagia, vomiting or reduced conscious level.
Inadequate pain control indicates a need for pain management review, if necessary seeking additional help or advice.
Diazepam, Chlorpromazine and Prochlorperazine are too irritant to be given subcutaneously.
For Pain
| Drug | Dose (sc) | Comments |
| Diamorphine | If NO oral morphine 10-20mg/24 hours. Otherwise, total oral morphine given in mg over last 24 hours and divide by 3. | Prescribe 1/6 of total 24 hour dose prn for breakthrough pain. Increase 24 hour dose by 1/3 if pain persists. |
| Hyoscine butyl bromide (buscopan) | 60-120mg/24 hours. | Antispasmodic; for bowel or ureteric colic. |
For Vomiting
| Drug | Dose (sc) | Comments |
| Cyclizine (1) | 75-150mg/24 hours. Stable with Diamorphine concentrations up to 20mg/ml (approximates to 200mg Diamorphine/24 hours). May precipitate at higher concentrations. | For vomiting of intestinal obstruction, hepatomegaly or raised intracranial pressure. May cause drowsiness and anticholinergic side effects. |
| Haloperidol | 2.5-10mg/24 hours. | For vomiting due to opiates (rarely need more than 3mg/24 hours), uraemia, hypercalcaemia and intestinal obstruction (starting dose 5mg/24 hours). Non-sedating. Dyskinetic side effects rare at these doses. |
| Metoclopramide | 30-60mg/24 hours | For vomiting secondary to gastric stasis or gastric compression by ascites, hepatomegaly or intra-abdominal tumour mass. |
| Levomepromazine (Methotrimeprazine) | 6.25-100mg/24 hours. | Second-line antiemetic for vomiting of intestinal obstruction or in a very agitated patient, or where other antiemetics have failed. Very sedating at higher doses. |
For Terminal Agitation/Confusion
After excluding untreated pain, full bladder or full rectum.
| Drug | Dose (sc) | Comments |
| Haloperidol | 5-15mg/24hours. Give 1.5mg s/c (elderly) up to 5mg s/c (young) and adjust 24h dose according to response. | Antipsychotic. For confusion with evidence of hallucinations. Risk of dyskinetic side effects above 10mg/24 hours - avoid higher doses if possible. |
| Midazolam | 10-100mg/24 hours. Give 2.5-5mg stat while setting up infusion | Water soluble benzodiazepine. For agitation where there is no evidence of hallucinations. Also used as an anticonvulsant. |
| Hyoscine hydrobromide (Scopolamine) | 1.6-2.4mg/24 hours. | Sedative. Antispasmodic. Antiemetic. |
For Excess Respiratory Secretions
| Drug | Dose (sc) | Comments |
| Hyoscine hydrobromide (Scopolamine) | 1.6-2.4mg/24 hours. | Reduces secretions (give early to prevent build up of secretions). Paradoxical agitation particularly in the elderly. |
| Glycopyrrollate | 0.6-1.2mg/24 hours. | 0.2mg stat dose. 2.5 times potency of hyoscine. No central side effects. |
1. Dilute diamorphine as much as possible BEFORE Cyclizine is added, to avoid concentration dependant crystallisation.