This study examined syringe driver medications and combinations used at Mercy Hospice Auckland over two time periods. The top five medications were morphine, haloperidol, midazolam, metoclopramide, and dexamethasone. The most common combination was an analgesic plus anti-emetic with or without sedative. While medications and combinations remained similar, there was an increase in non-cancer patients and lack of compatibility data for combinations used. The study calls for further research on compatibility testing and guidelines to minimize risks.

1. Syringe driver medications
A study of combinations and
compatibilities
Derryn Gargiulo
Dr Jeff Harrison
Dr Bruce Foggo
Emma Griffiths
Lauren Doherty, Sana Khan, Kate Kilpatrick,
Guangda Ma, Caitlin Renouf, Susan Wilson

2. Introduction
• Medicine combinations
• Physical and chemical compatibility
• Diluents and site reactions
• One previous NZ study (1995)1
1Lichter I, Hunt E. Drug combinations in syringe
drivers. NZ Med J. 1995;108(1001):224-226.

3. Aims
• Medicines combinations
• Syringe driver demographics
• Medicine compatibility
 Available literature
• Site reactions
• Change in practice

4. Methods
• Study design
 retrospective, observational, longitudinal
 2006/7 and 2013
• Mercy Hospice Auckland
 in-patients
• Data collection and management
• Comparison of data

5. Result 1: demographics
2006/7 2013
Time (months) 18 4
Number of syringes 1103 675
Non-cancer diagnoses (%) 5 12

6. Result 2: top five medicines
Medicine 2006/7
Frequency
of use (%)
Morphine
(S or T)
67
Haloperidol 55
Midazolam 39
Metoclopramide 37
Dexamethasone 16

7. Result 3: most common combination
• Analgesic + anti-emetic +/- sedative
 Pain, nausea/vomiting and delirium
• 3 medicines most commonly combined
 Morphine + haloperidol + midazolam

8. Result 3: top five combinations 2006/7
1 2 3 D No. of
patients
(n)
Total syringes
administered
%
MS Haloperidol Midazolam WFI 34 7.5
MT Metoclopramide Midazolam WFI 20 6.8
MT Haloperidol Midazolam WFI 30 4.9
MT Metoclopramide Dexamethasone WFI 12 4.6
MT Haloperidol WFI 18 4.4

9. Result 3: top five combinations 2013
1 2 3 D No. of
patients
(n)
Total syringes
administered
%
MT Haloperidol Midazolam NS 21 7.9
Oxy Haloperidol NS 24 7.6
MT Levomepromazine Midazolam WFI 14 5.8
Oxy Levomepromazine Midazolam NS 19 5.6
MT Midazolam NS 6 4.7

10. Result 4: medicine incompatibilities
• 2006/7
1 2 3 Diluent Incompatibility
MT Metoclopramide Midazolam WFI Crystallisation2,3
MT Cyclizine Hyoscine butylbromide WFI Crystallisation2,3
• No incompatibilities in 2013

11. Result: medicine compatibility 2013
• 21 combinations with no data
• 30 combinations with clinical evidence
• 18 combinations with lab-based
evidence2,3,4
2Palliative Drugs http://www.palliativedrugs.com/index.html.
3Smith, S. Compatibility of syringe driver admixtures for continuous
subcutaneous infusion. Auckland: Auckland District Health Board. 2002.
4Dickman A, Schneider J. The syringe driver: continuous subcutaneous
infusions in palliative care. 3rd ed. Oxford: Oxford University Press. 2011.

12. Result 5: site reactions
30
25
20
15
10
5
0
2006/7 2013
1 2 3 4 5 6 7 8
Percentage of patients
Number of site reactions

13. Result 6: drug in syringes where site
reactions occurred
2006/7
Medicine
Site
reaction
(%)
Dexamethasone 18.3
Methadone 18.3
Cyclizine 15.1
Metoclopramide 13.6
Phenobarbitone 12.5
2013
Medicine
Site
reaction
(%)
Levomepromazine 12.8
Dexamethasone 12.1
Metoclopramide 10.4
Morphine 10
Oxycodone 8

14. Result 6: drug in syringes where site
reactions occurred
2006/7
Medicine
Site
reaction
(%)
Dexamethasone 18.3
Methadone 18.3
Cyclizine 15.1
Metoclopramide 13.6
Phenobarbitone 12.5
2013
Medicine
Site
reaction
(%)
Levomepromazine 12.8
Dexamethasone 12.1
Metoclopramide 10.4
Morphine 10
Oxycodone 8

15. Key findings
• Increase in non-cancer patients with CSCI
• Medicines used and combinations same
• Top five combinations
• Lack of information about in-vitro testing
of compatibilities of combinations used

16. Implications and future research
• Collaborative approach in palliative care
• Need for in vitro compatibility studies
• Generation of national compatibility
guidelines
• Site reaction research

17. Acknowledgements
• Mercy Hospice Auckland
• Dr Bruce Foggo
• Mrs Emma Griffiths

18. Syringe driver medications
A study of combinations and
compatibilities
Derryn Gargiulo
Dr Jeff Harrison
Dr Bruce Foggo
Emma Griffiths
Lauren Doherty, Sana Khan, Kate Kilpatrick,
Guangda Ma, Caitlin Renouf, Susan Wilson

19. Pharmacy/Hospice PC research
• Nation-wide network
– Gather data
– Large amount of data
– Compare regions and NZ internationally
• SoP at Auckland University
– Ethics, funding applications
– Data analysis, statistical help
– Publication, dissemination
• Year 4 research project

20. Possible research topics
• Drug mixes with ranitidine, octreotide,
lignocaine, phenobarbitone and furosemide
• An exploration of patient’s and families
feelings regarding medicines management in
palliative care and what would help them
manage their medicines
• Alternative/complimentary therapies. What is
used? Does it work? Does it interact?