• Parenteral infusions and syringe drivers
• Guidelines for using subcutaneous/intravenous infusions
• References

Parenteral infusions and syringe drivers

Whilst the preferred route of medication administration in paediatric palliative care is the oral one, there may be occasions when this is impractical or undesirable. The use of a subcutaneous or intravenous infusion using a syringe driver to deliver medications has certain advantages;

• there is less patient discomfort as the need for repeated injections is reduced compared to intramuscular or intermittent subcutaneous administration
• multiple symptoms can be controlled by combining drugs in the syringe or reservoir of the pump
• the plasma drug level remains relatively constant throughout the day
• the devices are portable and lightweight allowing the patient to maintain mobility
  Nursing support is required to maintain an infusion in the home environment but community-based services (eg. Palliative care, Royal District Nursing Service, Hospital in the Home) are available to make daily visits. It is worth noting that not all medications can be given subcutaneously (see below).

Subcutaneous (or for those children with central access devices, intravenous) infusions are a useful alternative for children who

• Can not tolerate oral medication
• Refuse to take oral medication
• Are nauseated or vomiting
• Are not able to absorb enteral forms of medication
• Are unconscious

Often families may view the institution of a subcutaneous or intravenous infusion as a sign of deterioration or a "last resort". Obviously, there are occasions where the need for a parenteral route of administration comes about as a result of the child's worsening condition but more often, a route change is initiated for pragmatic reasons. Where appropriate, families should be reassured that the parenteral administration of medication is merely another treatment option which may be more effective, more convenient or better tolerated.

There are a number of syringe drivers with varying degrees of sophistication available. As a general principle, use of a syringe driver capable of delivering a bolus of medication in addition to a continuous (background) infusion is preferred.

One of the more common types of syringe driver and one of the easiest to use is the SIMS GRASEBY range of ambulatory syringe drivers. A variety of models are available. For subcutaneous infusions, the MS26 model syringe driver is recommended as it provides the greatest flexibility in the palliative care setting with;

An infusion time of 24 hrs or longer for a 10 ml infusion volume; and,
Bolus dose capacity (limited)

The SIMS DELTEC CADD-PRIZM range of pumps utilise a reservoir cassette and are programmable for rates of background infusion, bolus dose frequency and size, and lockout period between bolus doses. In addition the pump can be programmed to allow the patient or family to change some of the operating parameters.

Guidelines for using subcutaneous/intravenous infusions

Learning Modules for subcutaneous infusions in Palliative Care