Syringe driver in Palliative Care Introduction: Syringe drivers are portable, battery operated devices widely used in palliative care to deliver medication as a continuous subcutaneous infusion over 24 hours. Indications: Patient unable to take medication orally due to: Persistent nausea and/ or vomiting. Dysphagia. Bowel obstruction or malabsorption. Reduced level of consciousness, such as in the last days of life. General information: Use your local protocol for setting up a syringe driver: see Lothian Policy. This guideline contains information about the stability and compatibilities of medication commonly given in a subcutaneous infusion in palliative care. Drugs, doses or combinations other than those listed in the charts should be used only on the recommendation of a palliative care specialist. Any recommendation given by the palliative care specialist should be clearly documented in the patient s notes. Practice Points: Prescribe the medication and the diluent for subcutaneous administration in a syringe driver over 24 hours. Subcutaneous medication in a syringe driver aims to maintain symptom control. If the patient has uncontrolled symptoms before the driver is started or during the 24 hour infusion, give a breakthrough dose of medication. Prescribe the correct breakthrough dose, as required, for each medication in the driver but avoid a volume over 1ml for subcutaneous bolus injection. Protect the syringe from direct light Check the syringe regularly as per local protocol for precipitation, cloudiness, particles, colour change. Prepare a new syringe every 24 hours. Contents: Detailed information about indications and doses are in other sections of the Palliative Care Guidelines Table 1: Single drug doses and indications Table 2: Morphine and one or two other drugs Table 3: and one or two other drugs Table 4: and one or two other drugs Table 5: and one or two other drugs
Table 1: Single drugs used in a subcutaneous infusion in Palliative Care Diluent: water for injections Single agent Indications and dose range Comments MORPHINE, in 1ml in 2ml DIAMORPHINE,,, 500mg powder ampoules OXYCODONE in 1ml in 2ml ALFENTANIL 1mg (1000micrograms) in 2ml, in 10ml Antiemetics CYCLIZINE in 1ml METOCLOPRAMIDE in 2ml HALOPERIDOL in 1ml in 2ml LEVOMEPROMAZINE 2 in 1ml Indications: nausea and vomiting (bowel obstruction or intracranial disease) Dose: 50- / 24 hours Indications: nausea and vomiting (gastric stasis/outlet obstruction, opioid) Dose: 20- / 24 hours Indications: opioid or metabolic induced nausea, delirium Dose: 2.5- / 24 hours Indications: Complex nausea, terminal delirium/ agitation Dose: 5-2 / 24 hours -antiemetic Dose: 25- / 24 hours - terminal sedation see Guideline Anticholinergics for chest secretions or bowel colic HYOSCINE BUTYLBROMIDE in 1ml GLYCOPYRRONIUM 200 micrograms in 1ml 600 micrograms in 3ml HYOSCINE HYDROBROMIDE 400 micrograms in 1ml 600 micrograms in 1ml Sedative MIDAZOLAM in 2ml (preferred) in 5ml Indications: chest secretions, bowel obstruction (colic, vomiting) Dose: 40- / 24 hours Indications: chest secretions or colic Dose: 600-1200 micrograms /24 hours Indications: chest secretions Dose: 400-1200 micrograms / 24 hours Indications: anxiety, muscle spasm/ myoclonus, seizures, terminal delirium/ agitation Dose: titrate according to symptoms and response Other medication occasionally given by SC route in palliative care 1st line opioid analgesic Can be diluted in a small volume Preferred for high opioid doses 2nd line opioid analgesic if morphine/ diamorphine not tolerated 3rd line opioid; seek specialist advice 1st line in stages 4 /5 chronic kidney disease Anticholinergic; reduces peristalsis Can cause redness, irritation at site Prokinetic Avoid if complete bowel obstruction or colic Long half life: can be given as a once daily SC injection Lowers blood pressure Usually combine with a benzodiazepine for terminal sedation. Long half life: can be given as a once or twice daily SC injection First line; non-sedative Second line; non-sedative Longer duration of action than hyoscine Second line; sedative Can precipitate delirium Anxiolytic (5-/ 24 hours) Muscle relaxant (5-/ 24 hours) Anticonvulsant (20-/ 24 hours) First line sedative (20- / 24 hours) DEXAMETHASONE Indications: bowel obstruction, raised Subcutaneous dose is the same as oral 4mg in 1ml intracranial pressure or intractable Available as different dose formulations so nausea and vomiting check preparation Dose: 2-16mg / 24 hours Do not mix with other drugs Can be given as a daily SC injection (in the morning) KETAMINE Indications: Complex pain Specialist supervision only see Guideline KETOROLAC in 1ml in 1ml OCTREOTIDE 200micrograms/ml (5ml multi-dose vial) Indication: bone/ inflammatory pain if patient in last days of life Dose: 10- / 24 hours Indications: intractable vomiting due to bowel obstruction, fistula discharge Dose: 300 900 micrograms / 24 hours Specialist supervision only Give an oral PPI if still able to swallow Long half life in frail patients: can be given as a twice daily SC injection High cost; some formulations v expensive Potent antisecretory agent Does not treat nausea Limit fluid intake to 1-1.5 litre/ 24 hrs
Table 2: Morphine These are not clinical doses to prescribe. Most patients will not need high doses. Read the relevant guideline(s) Glycopyrronium bromide 2 2 900micrograms 1200micrograms 3 400mg 2 3 4 900micrograms 1200micrograms 2 4 2 3 400mg 300micrograms 400micrograms Glycopyrronium 2 900micrograms 2 1200micrograms
Table 3: These are not clinical doses to prescribe. Most patients do not need high doses. Read the relevant guideline(s) Glycopyrronium bromide Ketorolac 2 3 3 42 1000micrograms 1200 micrograms 1400mg 1700mg 2 25 2 25 1200micrograms 1200micrograms 700mg 8 2 25 8 2 3 5 6 3 42 900 micrograms 900 micrograms 2 3 9 5 9 1 700mg 1 11 6 8 1600mg
Table 4: These are not clinical doses to prescribe. Most patients do not need high doses. Read the relevant guideline(s) () Ketorolac Do not mix - Do not mix - Incompatible Incompatible 1 1 1 1200micrograms 1200micrograms 8 3 3 300micrograms 400micrograms 800micrograms 1 1000micrograms 1
Table 5: These are not clinical doses to prescribe. Most patients do not need high doses. Read the relevant guideline(s) () Glycopyrronium bromide 4mg 4mg 5. 1100micrograms 1200micrograms 6mg 4. 5. 6mg 1200micrograms 1200micrograms 5. 6. 6 4 3. 6mg 700micrograms 800micrograms 3. 4. 3 4mg 2mg 5 2 2 3 3. 3 Resources 1. Palliative Care Formulary http://www.palliativedrugs.com Further reading: see website