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A syringe driver is a small battery pump that pushes medicines for pain, sickness, agitation or chest secretions slowly under the skin over 24 hours, when swallowing is hard or tablets are not working. A nurse sets it up, refills it every day and checks it regularly; you or your family should not adjust it, and should call the nurses if it alarms, the skin is sore, or symptoms are not controlled.
NICE NG31 (2015) says to consider a syringe pump for continuous symptom control in the last days of life if more than 2 or 3 as-needed doses have been given in 24 hours, to avoid intramuscular injections, to start at the lowest effective dose and to reassess at least daily. The Scottish Palliative Care Guidelines (2023 version, BD BodyGuard T) give the procedure: discuss the reasons and offer the leaflet; choose a site with loose subcutaneous tissue (outer arm, upper thigh, abdomen, chest wall, scapula for a confused person) and avoid oedema, ascites, bony prominences and irradiated or broken skin; use a dedicated cannula for the pump and a second one for breakthrough doses; mix only medicines known to be compatible, no more than three without specialist or pharmacy advice, dilute to the maximum volume and add dexamethasone or cyclizine last; change the battery in the community if it is below 50%; prime the line by hand and never connect the line to the patient while loading; keep the pump level with or below the site; select Start Infusion, not Resume, for a new syringe; lock the keypad; check 15 to 30 minutes after set-up, then 4-hourly in hospital and at least daily at home; renew the syringe every 24 hours; and report any infusion finishing more than an hour early or late. About a quarter of palliative medication incidents reported in England and Wales involve these infusions, most from failures of monitoring and supply, administration and prescribing.
Why: A steady infusion keeps symptoms controlled without repeated injections.
“Consider using a syringe pump to deliver medicines for continuous symptom control if more than 2 or 3 doses of any 'as required' medicines have been given within 24 hours.”
NICE 2015 · Not graded (NICE NG31 1.5.6, 'consider')
Why: Many people link a syringe driver with dying; talking it through first avoids fear and lets the family know who to call.
“Before setting up the syringe pump, it is important to discuss the reasons for use with the patient, family and carer.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: Medicine is absorbed poorly from swollen or damaged skin, and a cannula over bone or a waistband is uncomfortable and falls out.
“Where possible, involve the patient in the choice of suitable site(s). Ensure the area chosen has loose, subcutaneous tissue.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: Giving extra doses through the pump line interrupts the infusion and can flush a bolus of the pump medicines in.
“A single port, subcutaneous infusion device should be used for the administration of medicines via a syringe pump. An additional device should be inserted for the administration of bolus subcutaneous medications.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (Key Point)
Why: Some combinations crystallise in the syringe, which blocks the line and means the person does not get their medicine.
“Do not mix more than three medicines without seeking advice from specialist palliative care and / or pharmacy unless this has already been agreed by your health board.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: A pump that stops overnight at home leaves the person without symptom control until a nurse can come.
“In the community setting, if the battery power has less than 50% life remaining at the start of an infusion, then a new battery should be installed”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: Loading a syringe while connected can push a sudden dose into the person.
“To prevent an accidental bolus of medicines being given, please ensure the line is not attached to the patient's cannula when placing the syringe in the pump.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: A pump held above the site can siphon medicine in faster than intended.
“To reduce the risk of siphonage the syringe pump should be placed at the same level or lower than the infusion site.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (Key Point)
Why: Resume continues the old programme, so a new syringe would not run over a full 24 hours.
“When renewing or changing the syringe it is important to select ' START INFUSION ' instead of ' RESUME ' as this will ensure that the syringe pump delivers the infusion over a new 24 hour period.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (Key Point)
Why: Accidental button presses change the rate or stop the infusion.
“The patient/family/carer should be discouraged from interacting with the pump and advised to contact the nursing team caring for them if any issues occur.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (Key Point)
Why: Checking volume against time shows whether the pump is running to schedule; cloudy contents or a sore site need action.
“When set up, reloaded or resited an initial check should be carried out within the first 15-30 minutes to ensure the infusion is running correctly. Then every 4 hours in an inpatient setting and at every visit (at least daily) in the community setting.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
Why: The pump takes hours to reach a steady level, and symptoms can flare in between.
“If the patient has uncontrolled symptoms before the infusion is started or during the infusion period, give breakthrough doses of medication as required.”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (practice point)
Why: Doses usually need adjusting, and a specialist can help when they do not work.
“Regularly reassess, at least daily, the dying person's symptoms during treatment to inform appropriate titration of medicine.”
NICE 2015 · Not graded (NICE NG31 1.5.8)
Why: Pump faults and errors are common enough that every one needs to be found and fixed.
“infusions completing ahead of intended time (finishing > 1 hour early)”
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Not graded (national guideline)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
NICE NG31 (2015) decides when a syringe pump is used in the last days of life; the Scottish Palliative Care Guidelines (2023) give the most detailed public national procedure for setting it up and checking it. Neither grades its recommendations, and the procedure rests on device instructions, compatibility data and safety reporting rather than trials. National incident data (Palliat Med 2024) show where it fails: supply and monitoring, administration and prescribing, worsened by gaps in continuity and unfamiliar staff.
NICE 2015 · Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 · Palliative Medicine 2024
Where it differs: Different menus and alarms from the BD BodyGuard T on which the Scottish guideline is written.
Evidence: The Scottish guideline names them as in use and points to local standard operating procedures for the differences; no comparative outcome data.
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023
Where it differs: Changes the extension line on a fixed 72-hour schedule rather than only when needed.
Evidence: A manufacturer recommendation cited by the Scottish guideline, which notes the evidence on line duration in palliative CSCI is limited.
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023
Where it differs: Some health boards mix four or more medicines in a single pump.
Evidence: Allowed by the Scottish guideline only on specialist or pharmacy advice or local agreement; mixing in a syringe is unlicensed but supported by practice.
Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023
Where it differs: Gives each dose by separate injection, usually through an indwelling cannula.
Evidence: NICE NG31 reserves the pump for when more than 2 or 3 as-needed doses are needed in 24 hours; below that, separate doses are the default.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Avoid intramuscular injections in the last days of life “Avoid giving intramuscular injections and give either subcutaneous or intravenous injections.” | Not graded (NICE NG31 1.5.5) | NICE 2015 |
| Seek specialist advice when symptoms do not settle “Seek specialist palliative care advice if the dying person's symptoms do not improve promptly with treatment or if there are undesirable side effects, such as unwanted sedation.” | Not graded (NICE NG31 1.5.9) | NICE 2015 |
| Cannula dwell time “The cannula can remain in place for up to 7 days.” | Not graded (national guideline) | Scottish Palliative Care Guidelines (Healthcare Improvement Scotland, Right Decision Service) 2023 |
| Share of palliative medication incidents involving CSCI “About 25% of palliative medication incidents involve continuous subcutaneous infusions.” | National incident data, England and Wales 2016-2021 | Palliative Medicine 2024 |
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