Continuous subcutaneous infusions Although drugs can usually be administered by mouth to control the symptoms of advanced cancer, the parenteral route may sometimes be necessary. Parenteral route The equivalent parenteral dose of morphine subcutaneous, intramuscular, or intravenous is about half of the oral dose. Although drugs can usually be administered by mouth to control the symptoms of advanced cancer, the parenteral route may sometimes be necessary. If non-opioid analgesics alone are not sufficient, then an opioid analgesic alone or in combination with a non-opioid analgesic at an adequate dosage, may be helpful in the control of moderate pain. Codeine phosphate or tramadol hydrochloride can be considered for moderate pain. The equivalent subcutaneous dose of diamorphine hydrochloride is about one-third of the oral dose of morphine. Rectal route Morphine is also available for rectal administration as suppositories; alternatively oxycodone hydrochloride suppositories can be obtained on special order.
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For the use of midazolam by subcutaneous infusion using a continuous infusion device see below.
A suitable laxative should be prescribed routinely. If a patient has previously been receiving an antiepileptic drug or has a primary or secondary cerebral tumour or is at risk of convulsion e. A corticosteroid such as dexamethasone may help, temporarily, if there is an obstruction due to tumour.
Dry mouth may be caused by certain medications including opioids, antimuscarinic drugs e. Review pain management if rescue analgesic is compatibliity frequently twice daily or more. Pain due to nerve compression may be reduced by a corticosteroid such as dexamethasonewhich reduces oedema around the tumour, thus reducing compression.
Syringe Driver Drug Compatibility
Morphine equivalences for transdermal opioid preparations have been approximated to allow comparison with available preparations of oral morphine. The equivalent subcutaneous dose of diamorphine hydrochloride is about one-third of shringe oral dose of morphine. Provided that there is evidence of compatibility, selected injections can be mixed in syringe drivers.
Prescribers should ensure that they are familiar with the correct use of transdermal preparations, see under buprenorphine and fentanyl inappropriate use has caused fatalities. In severe chronic cholestasis, absorption of vitamin K may be impaired; either parenteral or water-soluble oral vitamin K see phytomenadione and menadiol sodium phosphate should be considered. For the administration of antiemetics by subcutaneous infusion using a continuous infusion device, see below.
Hospice care of terminally ill patients has shown the importance of symptom control and psychosocial support of the patient and family. They therefore have no liability whether in tort including negligence or otherwise for any loss or damage arising out of any reliance on this information.
Syringe driver rate settings Staff using syringe drivers should be adequately trained and different rate settings should be clearly identified and differentiated ; incorrect use of syringe drivers is a common cause of medication errors.
A corticosteroid, such as dexamethasonemay also be helpful if there is bronchospasm or partial obstruction. About this Canterbury DHB document If this fails, metoclopramide hydrochloride by mouth or by subcutaneous or intramuscular injection can be added; if this also fails, baclofenor nifedipineor chlorpromazine hydrochloride can be tried.
Not all types of medication can be used in a subcutaneous infusion. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect.
Prescribing in palliative care | Medicines guidance | BNF content published by NICE
Pain control Diamorphine hydrochloride is the preferred opioid since its high solubility permits a large dose to be given in a small volume see under Mixing and Compatibility, below. Drugs ccompatibility antimuscarinic effects antagonise prokinetic drugs and, if possible, should not be used concurrently.
Cyclizine is particularly likely to precipitate if mixed with diamorphine or other drugs see under Mixing and Compatibility, below. Transdermal route Transdermal preparations of fentanyl and buprenorphine are available, they are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose.
Conversion ratios vary and these figures are a guide only.
Syringe Driver Compatibility Chart
Pruritus Pruritus, even when associated with obstructive jaundice, often responds to simple measures such as application of emollients. Haloperidol is used by mouth for most metabolic causes of vomiting e. Midazolam is the benzodiazepine antiepileptic of choice for continuous subcutaneous infusion.
Restlessness and confusion Restlessness and confusion may require treatment with an antipsychotic, e. Problems encountered with syringe drivers The following are problems that may be encountered with syringe drivers and the action that should be taken: Midazolam is a sedative and an antiepileptic that may be used in addition to an antipsychotic drug in a very compaibility patient.
Haloperidol and levomepromazine can both be given as a subcutaneous infusion compatibillity sedation can limit the dose of levomepromazine.
This has led to the use of portable continuous infusion devices, such as syringe drivers, to give a continuous subcutaneous infusionwhich can provide good control of symptoms with little discomfort or inconvenience to the patient. Continuous subcutaneous infusions Although drugs can usually be administered by mouth to control the symptoms of advanced cancer, the parenteral route may sometimes be necessary.
The pain of bowel colic may be reduced by loperamide hydrochloride. An antiepileptic may be added or substituted if pain persists; gabapentin and pregabalin are licensed for neuropathic pain.