If more information is required please seek help from specialist palliative care pioid dose conversion chart, syringe driver doses, rescue/prn doses and opioid patches Use the conversion chart to work out the equivalent doses of different opioid drugs by different routes. he formula to work out the dose is under each drug name. Examples are given as a guide ral opioid mg /24 hour (Divide 24 hour dose by six for 4 hourly prn oral dose ) Morphine 24 hour xycodone 24 hour ubcutaneous infusion of opioid yringe driver (D) dose in mg per (or micrograms for alfentanil where stated) Diamorphine Morphine xycodone ubcutaneous prn opioid in mg every 4 hours injected as required prn NB Alfentanil in lower doses in micrograms Alfentanil Diamorphine 4 hour Morphine 4 hour xycodone Alfentanil 4 hour Fentanyl 2 to 4 hour normally change every 72 hours (00microgram/ ml) (00microgram/mL) dividing 24hr oral morphine dose by 2 dividing oral morphine dose by 3 dividing oral morphine dose by 2 dividing oral oxycodone dose by 2 dividing 24 hour oral morphine dose by 70 11 0 270 31 1 0 7 0 10 2 240 70 11 0 270 31 3 0 70 1 13 00mcg 100mcg 3mg 00mcg mg 700mcg 9mg mg 1mg 1mg 21mg 24mg 0 2 270 0 40 7 Renal failure/impairment GFR<mL/min: Morphine/Diamorphine metabolites accumulate and should be avoided. Fentanyl patch if pain is stable. xycodone orally or by infusion if mild renal impairment If patient is dying & on a fentanyl or buprenorphine patch top up with appropriate sc oxycodone or alfentanil dose & if necessary, add into syringe driver as per renal guidance If GFR<1mL/min and unable to tolerate oxycodone use alfentanil sc Morphine or xycodone: 1/th of 24 hour oral dose ubcutaneous: Morphine & xycodone: 1/th of 24 hour sc syringe driver (D) dose Alfentanil: 1/th of 24 hour sc D dose o hort action of up to 2 hours o eek help If reach Maximum of prn doses in (For ease of administration, opioid doses over mg, prescribe to nearest mg) 2 3 7 1 3 0 0 1 2 3 1 Buprenorphine B=Butrans change 7 days = ranstec change 9 hrs (4 days) Conversions use UK PC 0mcg 0mcg 00mcg 70mcg 1mg mg mg 2mg mg 3mg mg 4mg () 37 0 2 7 0 10 17 0 B B 3 70 70 + 3 70 + 0 - 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. alfentanil or oxycodone in patients with o poor renal function, o morphine intolerance o where morphine is contraindicated Consult pink table when prescribing 4 hourly prn subcutaneous opioids Adding a syringe driver (D) to a fentanyl or buprenorphine patch Equivalent doses if converting from oral to sc opioid Calculation of breakthrough/ rescue / prn doses ral prn doses: Prn dose is one sixth (1/th) of 24 hour subcutaneous (sc) syringe driver dose plus opioid patches if in situ. NB Alfentanil injection is short acting. Maximum prn doses in. If require more seek help 1 2 1 3 40 pioid by patch microgram/hour If 2 or more rescue/ prn doses are needed in, start a syringe driver with appropriate opioid and continue patch(es). he opioid dose in the D should equal the total prn doses given in the previous up to a maximum of 0% of the existing regular opioid dose. Providing the pain is opioid sensitive continue to give prn sc opioid dose & review D dose daily. E.g. Patient on 0 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 1 mg sc morphine are required over the previous, the initial syringe driver prescription will be morphine mg/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. If unsure please seek help from palliative care Copyright wner: Anne Garry, Palliative Care eam & acy Group eptember Version. Review date eptember 17. Approved by York D& Committee. Modified from Northern Cancer Network ELC Page Anticipatory Drugs and yringe Driver Chart his chart is intended for use in all care settings Cut ut Information for nurses Use clear adhesive dressing over the infusion site Patients with syringe drivers should be checked every 4 hours in institutions and as a minimum every in a patient's home. If the patient requires additional medication (analgesic/ sedative/antiemetic etc) give a subcutaneous dose of the appropriate drug, as prescribed on the prn section of the drug chart. If ineffective seek medical advice. NB each non-opioid drug has a 24 hour maximum. If you are giving opioids (e.g.morphine, oxycodone, alfentanil) to a patient who has not had one before (opioid naïve), or to a patient who has had a dose increase observe for signs of: Drowsiness Confusion/hallucinations Nausea / vomiting Reduced respiratory rate witching bserve patients closely and report any symptoms you are concerned about to the doctor. he opioid may need to be discontinued, reduced or changed to a different opioid. In exceptional cases naloxone may be required to reverse opioid side effects. Refer to naloxone infusion guidelines. Resources for information For dying patients refer to care plan for last days of life documentation For all other information consult website for algorithms and conversion charts www.york.nhs.uk/ur ervices/gp hub or www.york.nhs.uk/ur ervices/palliative care Please seek advice if uncertain about drug compatibilities pecialist palliative care/ hospice Medicines information he yringe Driver: Continuous subcutaneous infusions in palliative care 3rd edition Andrew Dickman, Jenny chneider For patients with renal failure Look at information in red on: Anticipatory drugs section use oxycodone or alfentanil as sc opioid of choice If GFR<1mL/min and unable to tolerate oxycodone use alfentanil (00microgram/mL) If a patient transfers to a care home the original chart should remain in the hospital notes and a new chart written to go with the patient. All other transfers, to patient's own home, community hospital, community unit or hospice the original chart should go with the patient. Information for prescribers Prescribe approved name of drug entered in CAPIAL Cancel Drugs Discontinue prescriptions by clearly crossing through the whole prescription, with the date discontinued & signature. Do not alter an existing prescription always rewrite a new syringe driver prescription in a new box here is space for 4 syringe driver prescriptions Always check for allergies. Diluents Generally use water for injection. Never use 0.9% sodium chloride with cyclizine as it will crystallise Use 0.9% sodium chloride for Levomepromazine by itself yringe driver combinations containing octreotide, methadone, ketorolac, ketamine or furosemide yringes Use ml syringes or ml if larger volume required. pioids Prescriptions for opioids & CDs must be prescribed in words and figures. CDs now include midazolam & phenobarbitone Write in whole numbers and where possible avoid decimals. Document dose calculations in the medical notes. he prn dose ranges should reflect the total amount of regular opioid the patient is receiving from all routes (ie syringe driver and fentanyl or buprenophine patch if in situ). he prn dose is one sixth of the 24 hour dose of regular opioids if patient can tolerate this. Calculate the increased opioid dose requirements for the next syringe driver based on the number of additional prn doses over the previous (ensuring the pain is opioid sensitive) Remember to prescribe regular medications (including opioid patches) and prn medications (when required) on the chart. Community (macmillans) 01723 43 Hospital PC 01723 34244 t Catherine s Hospice 01723 321 Contact for further help & advice In hours carborough pecialist Palliative Care eam (PC) Community PC 014 72447 Hospital PC 014 73 t Leonard's Hospice 014 703 York pecialist Palliative Care eam (PC) In hours 01723 Palcall t Leonard s Hospice ut of hours aint Catherine's Hospice GP H 0 0 00 t Leonard's Hospice 014 703 c York eaching Hospital NH Foundation rust. wner: Dr Anne Garry. Issue : November 1. Review : November 1 Version: 2 Approved by: Drug and herapeutic Committee rder number: FY00001 ut of hours Page 1
Prn Chart for Anticipatory Drugs If patient on opioid patch and syringe driver the prn opioid dose should reflect this Frequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures Antiemetics Antiemetics used together Haloperidol (mg/ml) prescribed as an anticipatory Indications: pioid or chemically induced nausea Haloperidol + Cyclizine NB use Levomepromazine if above ineffective Levomepromazine (mg/ml) prescribed as anticipatory Indications: Broad spectrum antiemetic (also anti-agitation medication) Metoclopramide (mg/ml) not prescribed routinely unless clinically indicated Indications: Prokinetic, pushes gut contents forward :mg tds /prn yringe driver D to 0mg / Cyclizine (0mg/mL) not prescribed routinely unless clinically indicated Indications: Raised intracranial pressure and bowel obstruction : to 0mg tds prn yringe driver D 7 to 10mg / tart low (dose in red) or avoid in renal /heart/ liver failure NE N RECRDING: Enter actual dose given in DE column ig Antiemetics not used together Metoclopramide + cyclizine: opposing effect Haloperidol + levomepromazine: dopaminergic Haloperidol + metoclopramide: dopaminergic ig NE N RECRDING: Enter actual dose given in DE column 4 Drug Drug ig First name: Hosp No: to.mg tart low in renal patients tart low in renal patients DB: GP/Cons: LEVMEPRMAZINE (mg/ml) 00 micrograms to 1mg hourly prn Nausea Max: mg in Agitation consult Palliative Care eam hourly prn Max: mg in (prn + /driver) Lower max in renal failure HALPERIDL (mg/ml) (nausea) NH No: ig 2-4 hourly prn. May need mg for bleeds Max 0mg in (prn +/driver) Max usually mg in in renal failure (prn +/driver) 2 to 4 hourly prn Prescriber may alter frequency if indicated. 2 Drug 2 to mg tart low in renal patients MIDAZLAM (mg/2ml) pioid Is patient renally compromised? If so avoid morphine and use oxycodone or alfentanil depends on whether patient opioid naïve or has been on regular opioids Anti agitation Midazolam start low Respiratory secretions Hyoscine Butylbromide (Buscopan) mg Antiemetic 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) Metoclopramide + Levomepromazine 1 Drug Appropriate opioid Prescribing Anticipatory drugs - up to five depending on antiemetic combination Drug 3 Drug HYINE BUYLBRMIDE (mg/ml) BUPAN for colic & resp secretions 4 hourly prn Max 240mg in (prn +/driver) mg urname: Page 2 urname: First name: Hosp No: yringe contents DB: GP/Cons: NH No: & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials Ward Main chart upplementary chart & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials Enter details of known allergies/sensitivities and reaction or write nil known Prescriber s signature bleep: his section MU be completed before medicines are given Page 11
& time of /D set up / check ite changed ite k yringe and line clear ignature / Initials & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials yringe contents Page Page 3 Prn Chart for Anticipatory Drugs If patient on opioid patch and syringe driver the prn opioid dose must take account of this Frequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures NE N RECRDING: Enter actual dose given in DE column ig ig NE N RECRDING: Enter actual dose given in DE column 11 Drug 7 Drug Drug Drug 13 Drug 9 Drug Drug Drug ig ig
P= A= N= = = Nil by mouth Prescription not clear Unable to administer elf medication elf medication at home Antimicrobials should have an indication and course length or review date recorded on the chart 7 9 Page 9 & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials yringe contents Pre- admission Non-administration codes 1 Medication not required 2 Refused 3 Absent from ward 4 Medication not available Unable to take Essential Regular Medication e.g. fentanyl, buprenorphine or hyoscine patches, antifungals, any topical or PR medications 1 1 1 1 1 1 Amended dose of pre-admission medicine New medicine critical medicine upplementary charts Year /Month A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep acy Medication Check and Level 1 or 2 Page 4
& time of /D set up / check ite changed ite k yringe and line clear ignature / Initials & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials yringe contents Page Page Year /Month A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep A Full ignature & Bleep Essential Regular Medication e.g. fentanyl, buprenorphine or hyoscine patches, antifungals, any topical or PR medications 1 1 1 1 1 1 1 acy Medication Check and Level 1 or 2
yringe Driver Prescription Chart Has patient consented to syringe driver? Yes / No If unable to consent has family agreed? Yes / No If Patient on opioid patch - leave patch on and refer to opioid conversion chart 1 yringe driver drug(s) 2 yringe driver drug(s) Prescriber ignature Prescriber ignature 3 yringe driver drug(s) 4 yringe driver drug(s) Prescriber ignature Prescriber ignature Page Page 7 & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials & time of /D set up / check ite changed ite k yringe and line clear ignature / Initials yringe contents