Common medicines

The use of common medicines in syringe driver/pumps

Morphine should be the opioid of first choice for injection. Diamorphine availability is limited but may be appropriate when large volumes of morphine are required, due to its high solubility.

Opioids should be started at the lowest dose in the range especially in frail elderly patients; review dose every 24 hours and adjust if necessary, based on symptom control needs and response to PRN medicines if needed. 

Seek Specialist Palliative Care Team advice if needed.

Analgesics

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/2 total daily dose of oral morphine

Ampoules available
10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml as 1ml and 2ml ampoules

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/4 total daily dose of oral morphine or 1/2 total daily dose of oral oxycodone

Ampoules available
10mg/ml as 1ml and 2ml ampoules
50mg/ml as 1ml ampoules

Indication: Pain and chronic renal failure eGFR < 30

Dose: Seek Specialist palliative care advice

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/3 total daily dose of oral morphine

Ampoules available
5mg, 10mg, 30mg, 100mg, 500mg

Morphine or diamorphine should be the opioids of first choice for injection.

Antiemetics

Indication: Delayed gastric emptying

Subcutaneous starting dose over 24 hrs
30–40mg (range 30–100mg)

Ampoules available
10mg/2ml

Indication: Drug induced or metabolic cause of nausea

Subcutaneous starting dose over 24 hrs
2.5mg (range 2.5mg–10mg)

Ampoules available
5mg/1ml and 20mg/2ml

Indication: Bowel obstruction

Subcutaneous starting dose over 24 hrs
75mg

Ampoules available
50mg/1ml

Antiemetic and sedative

Start at lowest dose in the range especially in frail elderly patients

Indication: Nausea
Subcutaneous dose
PRN Dose 2.5mg – 6.25mg four hourly
Subcutaneous starting dose over 24 hrs
5mg (range 5mg – 25mg)

Indication: Agitation and Confusion
SC PRN Dose 5mg – 12.5mg four hourly
Subcutaneous starting dose over 24 hrs
10mg (range 10mg – 75mg)
Ampoules available
25mg/1ml

Sedative

Start at lowest dose in the range especially in frail elderly patients

Indication: Terminal restlessness
Subcutaneous starting dose over 24 hrs
5mg (range 5mg–30mg)

– – – – – – – – – – – – – – – – – – –

Indication: seizure prevention (no recent seizures)
Subcutaneous dose range over 24 hrs
10mg–30mg, starting dose will depend on frailty and previous medications

– – – – – – – – – – – – – – – – – – –

Indication: Ongoing seizure activity
Subcutaneous starting dose over 24 hrs
30mg (range 30mg–60mg)

– – – – – – – – – – – – – – – – – – –

Ampoules available
10mg/2ml (preferred strength for palliative care use), 10mg/5ml, 5mg/5ml

Anticholinergic

Indication: Terminal respiratory secretions with colic / Intestinal obstruction

Subcutaneous starting dose over 24 hrs
60mg (range 60mg–120mg) (SC as required dose is 20mg)

Ampoules available
20mg/1ml

Indication: Terminal respiratory secretions

Subcutaneous starting dose over 24 hrs
600micrograms – 1.2mg (SC as required dose is 200 micrograms)

Ampoules available
200micrograms/1ml and 600 micrograms/3ml

Indication: Terminal respiratory secretions with colic / intestinal obstruction.

Subcutaneous starting dose over 24 hrs
1.2mg-2mg (SC as required dose is 400 micrograms)

Ampoules available
400micrograms/1ml and 600micrograms/1ml

Steroid

Indication: See Chapter: Corticosteroids

Subcutaneous starting dose over 24 hrs
2mg–16mg

Ampoules available
Dexamethasone as dexamethasone sodium phosphate 4mg/ml, 3.3mg/ml, 3.8mg/ml

Anti-secretory

Indication: Intestinal obstruction to reduce secretions if hyoscine butylbromide ineffective (with Specialist Palliative Cares advice)

Subcutaneous starting dose over 24 hrs
500 micrograms/24hr initially
– Can be increased to 800 micrograms/24hrs if necessary
– If ineffective stop after 48 hours
– If octreotide effective titrate to lowest effective dose
See Chapter Nausea and Vomiting – Syringe Driver Use

Ampoules available
50 micrograms/1ml 100 micrograms/1ml 500 micrograms /1ml 1mg /5ml

Contraindicated

DIAZEPAM, PROCHLORPERAZINE AND CHLORPROMAZINE are too irritant to be used subcutaneously.

Disclaimer

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.