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In h
ours
Ou
t of hou
rs
Dis
co
ntin
ue p
res
crip
tion
s b
y c
lea
rly c
ros
sin
g
th
rou
gh
the w
ho
le p
rescrip
tion
, with
the d
ate
d
isco
ntin
ued
& s
ign
atu
re.
Do n
ot a
lter a
n e
xisting p
rescrip
tion a
lways
rew
rite a
new
syringe d
river p
rescrip
tion in
a
new
box
There
is spa
ce fo
r 4 syrin
ge d
river p
rescrip
tions
Alw
ays c
hec
k fo
r alle
rgie
s.
Information for prescribers
Cancel D
rugs
Opioids
U
se 2
0m
L syrin
ges o
r 30m
L if la
rger vo
lum
e
require
d.
Syringes
Information for n
urses
St Leo
na
rd’s H
osp
ice
cY
ork T
ea
chin
g H
osp
ital N
HS
Fo
un
da
tion
Tru
st.
Ow
ne
r: Dr A
nn
e G
arry. Issu
e D
ate
: No
vem
be
r 20
15
. Re
view
Da
te: N
ove
mb
er 2
01
8V
ersio
n: 2
Ap
pro
ved
by: D
rug
an
d T
he
rap
eu
tic Co
mm
ittee
Ord
er n
um
be
r: FY
03
00
00
81
we
bsite
for a
lgo
rithm
s and co
nve
rsion
charts
ww
w.y
ork
.nh
s.u
k/O
ur S
erv
ices/G
P h
ub
or
w
ww
.yo
rk.n
hs
.uk
/Ou
r Serv
ices
/pallia
tive c
are
U
se cle
ar a
dhesive
dre
ssing
ove
r the
infu
sion
site
Patie
nts w
ith syrin
ge d
rivers sh
ould
be
che
cked
eve
ry 4 h
ours
in in
stitutio
ns a
nd
as a
min
imum
eve
ry 24
hou
rs in a
pa
tien
t's hom
e.
If th
e p
atie
nt re
quire
s ad
ditio
nal m
ed
icatio
n (a
nalg
esic/
sedative
/an
tiem
etic e
tc) give
a su
bcu
tan
eo
us d
ose
of th
e
appro
pria
te d
rug, a
s pre
scribed
on
the p
rn se
ction o
f the
dru
g ch
art. If in
effe
ctive se
ek m
edica
l ad
vice.
N
B e
ach
no
n-o
pio
id d
rug
has a
24 h
ou
r ma
ximu
m.
If yo
u a
re g
iving o
pio
ids (e
.g.m
orp
hin
e, o
xycodo
ne
, alfe
nta
nil)
to a
patie
nt w
ho
has n
ot h
ad o
ne
befo
re (o
pio
id n
aïve
), or to
a
pa
tien
t who h
as h
ad a
dose
incre
ase
obse
rve fo
r sign
s of:
D
row
sine
ss
C
on
fusio
n/h
allu
cina
tions
■■
N
ause
a / vo
mitin
g
Red
uce
d re
spira
tory ra
te
■■
T
witch
ing
■
Obse
rve p
atie
nts c
lose
ly an
d re
po
rt an
y sympto
ms yo
u a
re
con
cern
ed a
bou
t to th
e d
octo
r. Th
e o
pio
id m
ay n
eed
to b
e
disco
ntin
ued, re
duce
d o
r cha
ng
ed
to a
diffe
ren
t opio
id.
In
exce
ptio
nal ca
ses n
alo
xon
e m
ay b
e re
quire
d to
reve
rse
opio
id sid
e e
ffects. R
efe
r to n
alo
xon
e in
fusio
n g
uid
elin
es.
If GF
R<
15m
L/m
in a
nd
un
ab
le to
tole
rate
ox
yc
od
on
e u
se
alfe
nta
nil (5
00m
icro
gra
m/m
L)
Look a
t info
rmatio
n in
red
on:
Anticip
ato
ry dru
gs se
ction
use
oxyco
do
ne
or a
lfen
tanil a
s sc op
ioid
of ch
oice
Pre
scrip
tion
s fo
r op
ioid
s &
CD
s m
ust b
e
pre
scrib
ed
in w
ord
s a
nd
fig
ure
s. C
Ds n
ow
in
clude m
ida
zola
m &
phenobarb
iton
e
Write
in w
ho
le n
um
be
rs a
nd w
here
possib
le
avo
id d
ecim
als
. D
ocu
men
t dose
calcu
latio
ns in
the m
edica
l note
s. T
he p
rn d
ose ra
nges sh
ou
ld re
flect th
e to
tal
am
ount o
f reg
ula
r opio
id th
e p
atie
nt is re
ceivin
g
from
all ro
ute
s (ie syrin
ge
drive
r and fe
nta
nyl o
r b
up
ren
op
hin
e p
atch
if in situ
). The p
rn d
ose
is one sixth
of th
e 2
4 h
ou
r do
se o
f regu
lar o
pio
ids if
patie
nt ca
n to
lera
te th
is.C
alcu
late
the
incre
ase
d o
pio
id d
ose
require
men
ts fo
r the n
ext syrin
ge
drive
r base
d o
n th
e n
um
ber o
f additio
nal p
rn d
ose
s ove
r the p
revio
us 2
4 h
ours
(ensu
ring th
e p
ain
is opio
id se
nsitive
) R
em
em
ber to
pre
scribe re
gula
r medica
tions
(inclu
din
g o
pio
id p
atch
es) a
nd p
rn m
edica
tions
(when re
quire
d) o
n th
e ch
art.
Gen
era
lly u
se w
ate
r for in
jectio
n.
N
eve
r use
0.9
% so
diu
m ch
lorid
e w
ith cyclizin
e a
s it w
ill crystallise
Use 0
.9%
so
diu
m c
hlo
ride
for
Levo
me
pro
ma
zine b
y itself
S
yringe d
river co
mbin
atio
ns co
nta
inin
g
octre
otid
e, m
eth
adone, ke
toro
lac, ke
tam
ine o
r fu
rose
mid
e
Prescribe approved name of drug entered in CA
PITALS
Dilu
ents
Resources for information
For patients with ren
al failure
P
lease
if un
certa
in a
bo
ut d
rug
com
patib
ilities
se
ek
ad
vic
e
S
pecia
list pallia
tive ca
re/ h
osp
ice
Medicin
es in
form
atio
n
T
he
Syrin
ge D
river: C
on
tinu
ou
s subcu
tan
eo
us in
fusio
ns in
pallia
tive ca
re 3
rd e
ditio
n A
nd
rew
Dickm
an
, Jenn
y Sch
ne
ide
r
Fo
r dyin
g p
atie
nts
refe
r to
care
pla
n fo
r last d
ays o
f life d
ocu
me
nta
tion
Fo
r all o
ther in
form
atio
n c
on
su
lt
If more information is required please seek help from specialist palliative care
Page 12
Page 1 This chart is intended for use in all care settings
Opioid dose conversion chart, syringe driver doses, rescue/prn doses and opioid patchesUse the conversion chart to work out the equivalent doses of different opioid drugs by different routes.
The formula to work out the dose is under each drug name. Examples are given as a guide
Fentanyl and buprenorphine patches in the dying/moribund patient· Continue fentanyl and buprenorphine patches in these patients.
o Remember to change the patch(es) as occasionally this is forgotten!o Fentanyl patches are more potent than you may think
If pain occurs whilst patch in situ· Prescribe 4 hourly prn doses of subcutaneous(sc) morphine unless contraindicated.· Use an alternative sc opioid e.g. or in patients withalfentanil oxycodone
o poor renal function, o morphine intolerance o where morphine is contraindicated
· Consult when prescribing 4 hourly prn subcutaneous opioidspink tableAdding a syringe driver (SD) to a fentanyl or buprenorphine patchIf 2 or more rescue/ prn doses are needed in 24 hours, start a syringe driver with appropriate opioid and continue patch(es). The opioid dose in the SD should equal the total prn doses given in the previous 24 hours up to a maximum of 50% of the existing regular opioid dose. Providing the pain is opioid sensitive continue to give prn sc opioid dose & review SD dose daily. E.g. Patient on 50 micrograms/hour fentanyl patch, unable to take prn oral opioid and in last days of life. Keep patch on. Use appropriate opioid for situation or care setting. If 2 extra doses of 15 mg sc morphine are required over the previous 24 hours, the initial syringe driver prescription will be morphine 30mg/24 hour. Remember to look at the dose of the patch and the dose in the syringe driver to work out the new opioid breakthrough dose each time a change is made.
Always use the chart above to help calculate the correct doses.
Calculation of breakthrough/ rescue / prn doses
Oral prn doses:th· Morphine or Oxycodone: 1/6 of 24
hour oral dose
Subcutaneous: th· Morphine & Oxycodone: 1/6 of 24
hour sc syringe driver (SD) doseth· Alfentanil: 1/6 of 24 hour sc SD dose
o Short action of up to 2 hourso Seek help If reach Maximum
of 6 prn doses in 24 hours
(For ease of administration, opioid doses over 10mg, prescribe to nearest 5mg)
Renal failure/impairment GFR
Prescrib
er’s sign
ature b
leep:
Enter details of know
n allergies/sensitivities and reaction or write ‘nil know
n’
Th
is section
MU
ST
be co
mp
leted b
efore m
edicin
es are given
Prn Chart for Anticipatory DrugsFrequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures
Opioid Is patient renally compromised? If so avoid morphine and use oxycodone or alfentanil Dose depends on whether patient opioid naïve or has been on regular opioidsAnti agitation Midazolam start low Respiratory secretions Hyoscine Butylbromide (Buscopan) 20mgAntiemetic Was drug effective orally? If so continue with same drug sc If patient requires two drugs to control nausea prescribe both For compatibility consult antiemetic table (to the left)
Prescribing Anticipatory drugs - up to five depending on antiemetic combination
LEVOMEPROMAZINE(25mg/mL)
Date Time Route Dose Sig Date Time Route Dose Sig
Date Dose
Full Signature & bleep SupplyPharm
SC
Date Dose
Full Signature & bleep SupplyPharm
SC
Date Dose
Full Signature & bleep SupplyPharm
5 to 6.25mg
NOTE ON RECORDING: Enter actual dose given in DOSE column
MIDAZOLAM (10mg/2mL)
Nausea Max: 25mg in 24 hoursAgitation consult Palliative Care Team
Prescriber may alter frequency if indicated.
Max: 5mg in 24 hours (prn + S/driver) Lower max in renal failure
8 hourly prn
2 to 4 hourly prn
Date Dose
Full Signature & bleep Supply
HALOPERIDOL (5mg/mL) (nausea)
500 micrograms to 1mg
Pharm
Date Time Route Dose Sig Date Time Route Dose Sig
SC
Date Dose
Full Signature & bleep SupplyPharm
SC
NOTE ON RECORDING: Enter actual dose given in DOSE column
HYOSCINE BUTYLBROMIDE (20mg/mL)
Date Dose
Full Signature & bleep Supply
Drug
Pharm
SC20mg
Start low in renal patients
BUSCOPAN for colic & resp secretions
Max 240mg in 24 hours (prn +S/driver)
3
Drug 2
Drug Appropriate opioid1
Drug 6
Drug 5
Drug 4
Max 60mg in 24 hours (prn +S/driver) Max usually 30mg in 24 hours in renal failure (prn +S/driver)
2 - 4 hourly prn. May need 10mg for bleeds
Instructions
Instructions
Instructions
Instructions
Page 2
Page 11
First n
am
e:
Surn
am
e:
DO
B:
Hosp
No:
NH
S N
o:
G
P/C
ons:
2 to 5mgStart low in renal patients
Start low in renal patients
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice
Check drugs in syringe or line areclear with no crystallisation
Is the syringe driver working ?
Check set up Check battery
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
4 hourly prn
8 hourly prn
First n
am
e:
Surn
am
e:
DO
B:
Hosp
No:
NH
S N
o:
G
P/C
ons:
If patient on opioid patch and syringe driver the prn opioid dose should reflect this
Antiemetics Antiemetics used togetherHaloperidol + Cyclizine
Metoclopramide + Levomepromazine
Antiemetics not used togetherMetoclopramide + cyclizine: opposing effect
Haloperidol + levomepromazine: dopaminergic
Haloperidol + metoclopramide: dopaminergic
Haloperidol (5mg/mL) prescribed as an anticipatory Indications: Opioid or chemically induced nausea
Levomepromazine (25mg/mL) prescribed as anticipatory Indications: Broad spectrum antiemetic (also anti-agitation medication)
Metoclopramide (10mg/mL) unless clinically not prescribed routinelyindicated Indications: Prokinetic, pushes gut contents forward Dose:10mg tds /prn Syringe driver SD 30 to 60mg /24 hours
Cyclizine (50mg/mL) unless clinically indicated not prescribed routinelyIndications: Raised intracranial pressure and bowel obstruction Dose: to 50mg tds prn Syringe driver SD to 150mg /24 hours25 75 Start low (dose in red) or avoid in renal /heart/ liver failure
SC
O
Ward
Su
pp
lemen
tary chart
Main chart
NB use Levomepromazine if above ineffective
If patient on opioid patch and syringe driver the prn opioid dose must take account of thisFrequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures
Date Dose
Full Signature & bleep
Date Dose
Full Signature & bleep
NOTE ON RECORDING: Enter actual dose given in DOSE column
Date Dose
Full Signature & bleep
Date Dose
Full Signature & bleep
Drug 13
Drug 12
Drug 11
Drug 14
Instructions
Instructions
Instructions
Instructions
Page 10
Page 3
Prn Chart for Anticipatory Drugs
Dose
Full Signature & bleep SupplyPharm
Date Time Route Dose Sig Date Time Route Dose Sig
Dose
Full Signature & bleep SupplyPharm
NOTE ON RECORDING: Enter actual dose given in DOSE column
Dose
Full Signature & bleep SupplyPharm
Dose
Full Signature & bleep SupplyPharm
SupplyPharm
Date Time Route Dose Sig Date Time Route Dose Sig
SupplyPharm
SupplyPharm
SupplyPharm
Instructions
Instructions
Instructions
Instructions
Drug
Drug
Drug
Drug
Date
Date
Date
Date
10
7
9
8
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice
Check drugs in syringe or line areclear with no crystallisation
Is the syringe driver working ?
Check set up Check battery
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
SC
O
SC
O
SC
O
SC
O
SC
O
SC
O
SC
O
SC
O
Year
Date/M
onthD
rug
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Pharm
acy M
edica
tion C
heck a
nd L
eve
l 1 o
r 2
e.g
. fenta
nyl, b
upre
norp
hin
e o
r hyo
scine p
atch
es, a
ntifu
ngals, a
ny to
pica
l or P
R m
edica
tions
Essential Regu
lar Medication
PANTSPANTSPANTSPANTSPANTSPANTS
An
timic
rob
ials
sh
ou
ld h
ave
an
ind
ica
tion
an
d c
ou
rse
le
ng
th o
r revie
w d
ate
reco
rde
d o
n th
e c
ha
rt=
Pre
- adm
issio
n
= A
mended d
ose o
f pre
-adm
issio
n m
ed
icin
e
= N
ew
medic
ine
= T
ime c
ritical m
edic
ine
= S
up
ple
me
nta
ry c
ha
rts
1
Medica
tion n
ot re
quire
d2
Refu
sed
3
Abse
nt fro
m w
ard
4
Medica
tion n
ot a
vaila
ble
5
Unable
to ta
ke
6
Nil b
y mouth
7
Pre
scriptio
n n
ot cle
ar
8
Unable
to a
dm
iniste
r9
Self m
edica
tion
10
Self m
edica
tion a
t hom
e
No
n-a
dm
inis
tratio
n c
od
es
PANTS
Page 4
Page 9
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice
Check drugs in syringe or line areclear with no crystallisation
Is the syringe driver working ?
Check set up Check battery
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
Year
Date/M
onthD
rug
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Dru
g
Date
Dose
Instru
ctions
Full S
ignatu
re &
Ble
ep
Pharm
Supply
PO
SCIV
IM
6814
12
22
18
Pharm
acy M
edica
tion C
heck a
nd L
eve
l 1 o
r 2
e.g
. fenta
nyl, b
upre
norp
hin
e o
r hyo
scine p
atch
es, a
ntifu
ngals, a
ny to
pica
l or P
R m
edica
tions
Essential Regular M
edication
PANTSPANTSPANTSPANTSPANTSPANTSPANTS
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice
Check drugs in syringe or line areclear with no crystallisation
Is the syringe driver working ?
Check set up Check battery
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
Page 8
Page 5
Syringe Driver Prescription Chart
Syringe driver drug(s) Dose(CDs to be prescribed in words and figures)
If advised by specialist palliative care team
Diluent (For advice read front sheet)
Date Prescriber Signature
1.
2.
3.
4.
Syringe driver drug(s) Dose(CDs to be prescribed in words and figures)
If advised by specialist palliative care team
Diluent (For advice read front sheet)
Date Prescriber Signature
1.
2.
3.
4.
Syringe driver drug(s) Dose(CDs to be prescribed in words and figures)
If advised by specialist palliative care team
Diluent (For advice read front sheet)
Date Prescriber Signature
1.
2.
3.
4.
Syringe driver drug(s) Dose(CDs to be prescribed in words and figures)
If advised by specialist palliative care team
Diluent (For advice read front sheet)
Date Prescriber Signature
1.
2.
3.
4.
1 2
43
Route DurationSC 24 hours
Route DurationSC 24 hours
Route DurationSC 24 hours
Route DurationSC 24 hours
Has patient consented to syringe driver? Yes / No If unable to consent has family agreed? Yes / NoIf Patient on opioid patch - leave patch on and refer to opioid conversion chart
Page 6
Page 7
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.
T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist
Date & time of S/D set up / check
Asset No
Prescription used e.g. No. 1 to 4
Site changed Yes or No
Location of site used
Line changed Yes or No
Battery % * at set up
Rate in mL
Volume to be infused (VTBI) mL
Volume infused in mL
Site Ok Yes or No
Syringe and line clear Yes or No
Battery % *
Key pad lock on
Signature / Initials
Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice
Check drugs in syringe or line areclear with no crystallisation
Is the syringe driver working ?
Check set up Check battery
Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200
4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.