Portable infusion pumps are used in palliative care to deliver a continuous subcutaneous infusion of medication over 24 hours. Mixing of medications in this manner is unlicensed but is supported by practice.
Some acute areas will use non-ambulatory pumps e.g. Alaris pump. Check which device is used in your area.
A patient is unable to take medication orally due to:
• Reduced level of consciousness, such as in the last days of life.
- Use the current local protocols for setting up and monitoring the syringe pump you are using.
- The tables in this guideline contain information about preparations, dose ranges, diluents and indications for single drugs that can be given by subcutaneous infusion for symptom control in palliative and end of life care.
The figures in these tables are NOT clinical doses to prescribe. Most patients will require much lower doses.
- Refer to relevant guidelines to obtain usual dose range for each medication
- Use minimum effective dose and titrate according to response
- Concentrations equivalent to or less than those stated in table are physically stable for 24 hours
- For doses greater than those stated in the tables seek specialist advice
- The tables contain information about the stability and compatibilities of drug combinations for use in a subcutaneous infusion in palliative care.
- The compatibility tables contain information for a subcutaneous infusion using a CME T34 syringe pump or a non-ambulatory pump containing:
- Alfentanil and one or two other drugs (see: Alfentanil guideline & seek specialist advice)
- Diamorphine and one or two other drugs
- Hydromorphone and one or two other drugs (seek specialist advice)
- Ketamine and one or two other drugs (see: Ketamine guideline & seek specialist advice)
- Morphine and one or two other drugs
- Oxycodone and one or two other drugs (using 10mg/ml and 50mg/ml preparations)
- Drug combinations, diluents or doses other than those listed in the compatibility tables are used occasionally on the recommendation of a palliative care specialist. Stability data to support this combination should be checked with a clinical pharmacist before infusion. Any recommendation given by the palliative care specialist should be documented clearly in the patient’s notes.
- A continuous subcutaneous infusion of medication aims to maintain symptom control. If the patient has uncontrolled symptoms before the infusion is started or during the infusion period, give breakthrough doses of medication as required.
- Prescribe the medication(s) for subcutaneous infusion and the diluent, calculating appropriate dose when converting from oral to subcutaneous route. The infusion is given over 24 hours.
- Prescribe the correct breakthrough dose, as required, for each medication in the infusion, a maximum volume of 2ml can be used for SC bolus but consider your patient and avoid a volume over 1ml for patients with little subcutaneous tissue. These should be administered via a separate SC site.
- Cannula does not need to be flushed prior to administering medicines, but should be flushed after with sterile water for injection and between any incompatible medications (see local guidelines for more information on SC administration of as required medication)
- Prepare a new syringe every 24 hours.
- Protect the syringe from direct light and heat.
- Check the syringe after set up and within acute setting every 4 hours for precipitation, cloudiness, particles, colour change. Make sure the pump is running to time. Check the line, connection and cannula regularly.