A brief guide to drugs for the syringe driver
There is ONE indication for using a syringe driver and that is the patient’s inability to take oral medication. The commonest reasons for this are severe dysphagia, vomiting or reduced conscious level.
Inadequate pain control indicates a need for pain management review, if necessary seeking additional help or advice.
Diazepam, Chlorpromazine and Prochlorperazine are too irritant to be given subcutaneously.
|Morphine (or Diamorphine)||If NO oral morphine 10-20mg/24 hours. Otherwise, total oral morphine given in mg over last 24 hours and divide by 2 for morphine (divide by 3 for diamorphine).||Prescribe 1/6 of total 24 hour dose prn for breakthrough pain. Increase 24 hour dose by 1/3 if pain persists.|
|Hyoscine butyl bromide ("buscopan")||60-120mg/24 hours.||Antispasmodic; for bowel or ureteric colic.|
|Cyclizine (1)||75-150mg/24 hours. Stable with Diamorphine concentrations up to 20mg/ml (approximates to 200mg Diamorphine/24 hours). May precipitate at higher concentrations.||For vomiting of intestinal obstruction, hepatomegaly or raised intracranial pressure. May cause drowsiness and anticholinergic side effects.|
|Haloperidol||2.5-10mg/24 hours.||For vomiting due to opiates (rarely need more than 3mg/24 hours), uraemia, hypercalcaemia and intestinal obstruction (starting dose 5mg/24 hours). Non-sedating. Dyskinetic side effects rare at these doses.|
|Metoclopramide||30-60mg/24 hours||For vomiting secondary to gastric stasis or gastric compression by ascites, hepatomegaly or intra-abdominal tumour mass.|
|Levomepromazine (Methotrimeprazine)||6.25-100mg/24 hours.||Second-line antiemetic for vomiting of intestinal obstruction or in a very agitated patient, or where other antiemetics have failed. Very sedating at higher doses.|
For Terminal Agitation/Confusion
After excluding untreated pain, full bladder or full rectum.
|Haloperidol||5-15mg/24hours. Give 1.5mg s/c (elderly) up to 5mg s/c (young) and adjust 24h dose according to response.||Antipsychotic. For confusion with evidence of hallucinations. Risk of dyskinetic side effects above 10mg/24 hours - avoid higher doses if possible.|
|Midazolam||10-100mg/24 hours. Give 2.5-5mg stat while setting up infusion||Water soluble benzodiazepine. For agitation where there is no evidence of hallucinations. Also used as an anticonvulsant.|
|Hyoscine hydrobromide ("Scopolamine")||1.6-2.4mg/24 hours.||Sedative. Antispasmodic. Antiemetic.|
For Excess Respiratory Secretions
|Hyoscine hydrobromide (Scopolamine)||1.6-2.4mg/24 hours.||Reduces secretions (give early to prevent build up of secretions). Paradoxical agitation particularly in the elderly.|
|Glycopyrrollate||0.6-1.2mg/24 hours.||0.2mg stat dose. 2.5 times potency of hyoscine. No central side effects.|
1. Dilute diamorphine as much as possible BEFORE Cyclizine is added, to avoid concentration dependant crystallisation.
Updated March 2011