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Scottish Palliative Care Guidelines print pdf

Syringe Pumps

Introduction

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.

 Indications

A patient is unable to take medication orally due to:

• Reduced level of consciousness, such as in the last days of life.

General information

  • 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.

Assessment

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.

Table 0a Single Agents - Opioids

Table 0b Single Agents - Anti Emetics

Table 0c Single Agents - Anticholinergics

Table 0d Single Agents - Non-Steroidals

Table 0e Single Agents - Sedatives

Table 0f Single Agents - Other Medications

Table 1a Subcutaneous Morphine infusion in a syringe pump (2 Drug Combinations)

Table 1b Subcutaneous Morphine infusion in a syringe pump (3 Drug Combinations)

Table 2a Diamorphine 2 Drugs in Combination

Table 2b Diamorphine 3 Drugs in Combination

Table 3a Oxycodone using 10mg/ml and 20mg/2ml 2 Drugs in Combination

Table 3b Oxycodone using 50mg/ml 2 Drugs in Combination

Table 3c Oxycodone using 10mg/ml and 20mg/2ml 3 Drugs in Combination

Table 4a Alfentanil 2 Drugs in Combination

Table 4b Alfentanil 3 Drugs in Combination

Table 5a Subcutaneous Hydromorphone infusion 2 Drug Combinations

Table 5b Subcutaneous Hydromorphone infusion 3 Drug Combinations

Table 6 Subcutaneous Ketamine infusion in a syringe pump (alone and 2 Drug Combinations)

Compatibility and stability tables for subcutaneous infusion

Drug

Route

Table 0 (a-f)

Single drugs used in a subcutaneous infusion over 24 hours in Palliative Care

a Opioids
b Anti-emetics
c Anticholinergics
d Non-steroidals
e Sedatives
f Other Medications

Table 1a Subcutaneous Morphine infusion in a syringe pump (2 Drug Combinations)
Table 1b Subcutaneous Morphine infusion in a syringe pump (3 Drug Combinations)
Table 2a Subcutaneous Diamorphine Infusion (2 Drug Combinations)
Table 2b Subcutaneous Diamorphine Infusion (3 Drug Combinations)
Table 3a Subcutaneous Oxycodone Infusion using 10mg/ml and 20mg/2ml injection (2 Drug Combinations)
Table 3b Subcutaneous Oxycodone Infusion using 50mg/ml injection (2 Drug Combinations)
Table 3c Subcutaneous Oxycodone infusion using 10mg/ml or 20mg/2ml injection (3 Drug Combinations)
Table 4a Subcutaneous Alfentanil infusion (2 Drug Combinations)
Table 4b Subcutaneous Alfentanil infusion (3 Drug Combinations)
Table 5a Subcutaneous Hydromorphone infusion (2 Drug Combinations)
Table 5b Subcutaneous Hydromorphone infusion (3 Drug Combinations)
Table 6 Subcutaneous Ketamine infusion in a syringe pump (2 Drug Combinations)
Stability Tables - Subcutaneous Infusion over 24 hours - Version 1 May 2014

Practice Points

  • 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.

Appendices

References