When should a syringe pump be used? When a patient is unable to take PO medications and needs a regular infusion to control symptoms.
What medications? 4 symptoms commonly require medications for relief of distress at end of life:
First step: Morphine SC 5mg to 10mg (if no previous opioid use) via syringe pump over 24 hours.
May also need midazolam SC 5mg to 10mg via syringe pump over 24 hours for symptom relief if breathlessness severe or ‘total’ pain (i.e. existential distress) present.
Second step: Titrate morphine and/ or midazolam with advice. Dose and rate of increase are dependent on symptoms and response to PRNs.
Note: Levomepromazine may need to be used in addition to midazolam if anxiety/ distress or delirium is severe:
If levomepromazine not available, haloperidol can be used instead e.g. haloperidol 2.5 to 5 mg over 24 hours in a syringe pump.
Step 1: Selection of anti-emetic depends on whether the patient is already on an effective anti-emetic or not. Starting doses of possible anti-emetics are:
Cyclizine 150mg via syringe pump over 24 hours OR
Haloperidol 1-2.5mg via syringe pump over 24 hours OR
Metoclopramide 30mg via syringe pump over 24 hours OR
Levomepromazine 6.25 to 12.5mg over 24 hours
Regular review ensures best care as patient’s condition deteriorates, stabilises or improves.
Use minimum effective dose and titrate according to response.
If side effects with morphine, use alternative opioid such as oxycodone (note: twice as potent as morphine, so will need dose adjustment).
If eGFR< 30ml/min, adjust dose +/- medication; seek specialist advice.
All patients should also have PRN medications (refer to anticipatory prescribing one pager).
Information on drug compatibilities available at https://www.palliativecareguidelines.scot.nhs.uk
If syringe pump not available, a regular schedule of stat doses can be prescribed- seek specialist advice.
Step 2: Titrate or change anti-emetic with advice. Dose and rate of increase are dependent on symptoms and response to PRNs.
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