You must check all drugs and doses in the BNF. Links provided in the drugs section. Use Oxycodone rather than Morphine if eGFR < 30
- Pain and/ or dyspnoea: Morphine 2.5-5 mg SC hourly PRN or Oxycodone 1.25-2.5mg SC hourly PRN
- Agitation: Lorazepam 0.5mg S/L PRN QDS (if oral route possible) OR Midazolam 2.5-5 mg S/C hourly PRN
- Respiratory Secretions: Glycopyrronium 0.2 mg (200 mcg) S/C 4 h PRN
- Nausea: Haloperidol 1 mg S/C 4 h PRN
- Syringe Drivers Opioid naive: Morphine 5-10mg + Midazolam 5-10 mg SC/24hrs or if eGFR < 30 then Oxycodone 5mg + Midazolam 10 mg SC/24hrs
- Syringe Drivers: Very distressed RR > 30 or severe pain or agitation consider Morphine 10-20mg + Midazolam 10-20 mg SC/24hrs or if eGFR < 30 then OR Oxycodone 10mg + Midazolam 20 mg SC/24hrs
Bowel colic and excessive respiratory secretions
- Glycopyrronium 0.2 mg PRN or 0.6-1.2 mg/24 hours by SC infusion to treat bowel colic or excessive respiratory secretions.
- Hyoscine hydrobromide reduces respiratory secretions and bowel colic and is sedative. Given as SC infusion dose of 1.2 to 2 mg/24 hours.
Confusion and restlessness
- Haloperidol has little sedative effect; it is given in a subcutaneous infusion dose of 5 to 15 mg/24 hours.
- Levomepromazine 12.5 to 50 mg/24 hours SC titrated according to response (doses greater than 100 mg/24 hours should be given under specialist supervision).
- Midazolam: sedative/seizure control. Given as SC infusion 10-20 mg/24 hours, titrated according to response (usual dose 20-60 mg/24 hours).
- 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.g. owing to uraemia) antiepileptic medication should not be stopped.
- Midazolam is the benzodiazepine antiepileptic of choice for continuous subcutaneous infusion, and it is given initially in a dose of 20 to 40 mg/24 hours.
Nausea and vomiting
- Haloperidol is given in a subcutaneous infusion dose of 2.5 to 10 mg/24 hours.
- Levomepromazine is given in a subcutaneous infusion dose of 5 to 25 mg/24 hours but sedation can limit the dose.
- Cyclizine is particularly likely to precipitate if mixed with Diamorphine or other drugs (see under Mixing and Compatibility, below); it is given in a subcutaneous infusion dose of 150 mg/24 hours.
- Metoclopramide can cause skin reactions; it is given in a subcutaneous infusion dose of 30 to 100 mg/24 hours.
- Octreotide which stimulates water and electrolyte absorption and inhibits water secretion in the small bowel, can be used by subcutaneous infusion in a dose of 250 to 500 micrograms/24 hours to reduce intestinal secretions and to reduce vomiting due to bowel obstruction. Doses of 750 micrograms/24 hours, and occasionally higher, are sometimes required.
- Oromorph 2-5 mg PRN PO for moderate to severe pain initially. Watch for respiratory depression and delirium and consider a laxative.
- Diamorphine 2.5-5 mg SC/IV stat is the preferred opioid since its high solubility permits a large dose to be given in a small volume usually starting at 5-10 mg/24 hrs S/C in the opioid-naive patient and elderly
- Morphine 5-10 mg stat SC is alternative and is given at 10-20 mg/24 hrs S/C in the opioid-naive patient and elderly
- The general principle that injections should be given into separate sites (and should not be mixed) does not apply to the use of syringe drivers in palliative care. Provided that there is evidence of compatibility, selected injections can be mixed in syringe drivers. Not all types of medication can be used in a subcutaneous infusion. In particular, chlorpromazine, prochlorperazine, and diazepam are contra-indicated as they cause skin reactions at the injection site; to a lesser extent cyclizine and levomepromazine also sometimes cause local irritation.
- In theory injections dissolved in water for injections are more likely to be associated with pain (possibly owing to their hypotonicity). The use of physiological saline (sodium chloride 0.9%) however increases the likelihood of precipitation when more than one drug is used; moreover, subcutaneous infusion rates are so slow (0.1 to 0.3 mL/hour) that pain is not usually a problem when water is used as a diluent.
- Diamorphine can be given by subcutaneous infusion in strength of up to 250 mg/mL; up to a strength of 40 mg/mL either water for injections or physiological saline (sodium chloride 0.9%) is a suitable diluent above that strength only water for injections is used (to avoid precipitation).
- The following can be mixed with Diamorphine:
Cyclizine(1) Hyoscine hydrobromide
Hyoscine butylbromide Midazolam
Subcutaneous infusion solution should be monitored regularly both to check for precipitation (and discolouration) and to ensure that the infusion is running at the correct rate.