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"Reflect upon your present blessings of which every man has many - not on your past misfortunes, of which all men have some."

CHARLES DICKENS

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.

For Pain


Drug Dose (sc) Comments
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.

For Vomiting


Drug Dose (sc) Comments
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.

Drug Dose (sc) Comments
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


Drug Dose (sc) Comments
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

Important News

Important Changes in Cumbria Palliative Care Prescribing Practice

Cumbria is changing practice, from 1st April 2011.

The Area Prescribing Committee has recommended the following changes:

  • All strong opioids are to be prescribed by brand name
  • "Just in Case" prescribing is to be encouraged and promoted
  • Morphine is to replace diamorphine as the subcutaneous injectable strong opioid of choice for palliative care patients in Cumbria

21/03/2011

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North Cumbria Pallative Care website

The award winning North Cumbria Palliative Care website continues to receive around 30,000 page views a year. This is 82 page views every single day of the year, 2,500 hits every month, without any publicity or advertising program.

1/3/2011

Read More