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308 Chapter 21
“differently” to what the patient information leaflet tells
them and for them to give informed consent and docu-
mented in the patient notes. In palliative care this can be a
challenge as off-label use is so widespread and the burden
of these discussions for most drugs use would not be man-
ageable, so the decision remains with the prescriber
regarding how to proceed with these discussions. A joint
position statement has also been produced by the British
Pain Society and the Association for Palliative Medicine,
together with a patient information booklet [12].
Administration via feeding tubes is an unlicensed
activity for most drugs but may be necessary for patients
who are unable to swallow. Prescribers should refer to evi-
dence-based resources and liaising with the pharmacy
team on formulation options, timings or interaction con-
cerns with feeds or other medicines and ensuring the tube
is not at risk of the patency being affected by the drugs
being administered.
Medication Compliance Aids
Patients taking multiple medicines may have difficulty in
adhering to the regimen prescribed. Supporting patients
struggling with compliance to medication regimens is a
complex issue that should be approached in a way tailored
to each individual [13, 14].
Certain patients find compliance aids helpful that
contain tablets for the day indicating the time to be
taken like “Redidose” boxes and blister packs. Some
devices include alarms and electronic dispensers to aid
patients in remembering to take medications when due.
Other aids available include downloadable apps which
alarm when medications are due or send text reminders
to patients.
There is little evidence to suggest whether these
devices improve compliance, safety, satisfaction, or
convenience with taking medications [15]. Patients inter-
viewed about their use of compliance aids reported that
most had purchased the systems because taking multiple
medicines did not fit well in their lives and some found
them helpful in giving them more control over their
medicines. Rather than reminding them “to take” medi-
cation, the devices allowed patients to check whether
“they had taken” medication and thus relieved the anx-
iety. Often, other measures were employed in addition to
the compliance aid itself [16].
Many commonly prescribed medicines may not be suit-
able for use in compliance aids as storage outside of the
original manufacturer packaging may negatively affect sta-
bility. Drugs for when required use or those subject to fre-
quent dose changes are not appropriate for use in
compliance aids.
No system is optimal for all patients and their ability to
cope at home with a particular device should always be
assessed before recommending [17]. The pharmacist may
be able to offer alternative solutions such as the use of large
print labels, diaries, and charts. Preparation of Pharmacy
issued blister packs is time-consuming and expensive pro-
cess; therefore, they should only be initiated for patients
following review by a suitably trained healthcare
professional.
Deprescribing
Deprescribing is “the process of tapering, stopping, dis-
continuing, or withdrawing drugs, with the goal of
managing polypharmacy and improving outcomes.
Clinicians typically attempt to taper or stop agents based
on clinical experience, rather than using an evidence-
based approach” [18].
• St. Anne’s Hospice in Manchester reported patients who
had one-week prognosis still took on average 11 regular
tablets [19].
• This reveals a large drug burden on elderly patients and
those with limited life remaining. Therefore, deprescribing
is an important consideration.
• A Dutch study investigated patient, relative and HCP
perceptions towards end-of-life medication management.
Figure 1 The Redidose 7 day pill dispenser.
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Medicines Management in Palliative Care Including Syringe Pumps 309
They identified multiple factors that can influence depre-
scribing decisions including lack of time, burdens for
patients, lack of guidelines, uncertainty about life
expectancy, and unknown consequences of withdrawing
medication [20].
Deprescribing is an intentional planned process super-
vised by healthcare professionals, and with the patient and
their carer. The aims of this process are to:
•
Improve quality of life by reducing medications which
may be contributing to symptoms, for example, increased
falls, dry mouth affecting nutritional intake.
•
Reduce medication burden – As life expectancy
increases, so does the risk of multi-morbidities and subse-
quently the risk of polypharmacy [21].
•
Avoid worsening of disease or causing withdrawal.
In the presence of life-limiting illness, the need to con-
tinue preventative medicines becomes less certain as
they are unlikely to improve health or offer continued
long-term health benefits [22]. Statins are one of the
most common medications that are discontinued by
specialist palliative care professionals; not only do they
have multiple side-effects and interactions, but in
patients with short prognosis they are more likely to
cause harm than benefit.
Barriers to deprescribing medicines include:
•
Patient and/or family reluctance – it may be viewed that
the healthcare professional is “giving up” on them.
• Prognostication particularly in non-malignant condi-
tions being unclear.
•
Fear of predisposing a clinical event.
•
Fear of the patient upsetting their other doctor or con-
sultant – “I’ve always been told to take bisoprolol by my
cardiologist.”
•
Differing opinions between specialists and/or generalists.
•
Fear by the healthcare professional of where the
discussion may lead – “does this mean I’m dying?”
Deprescribing requires good communication skills to start
discussions and have honest conversations with patients
and their families/carers. Most patients are happy to not
take medication, but for some patients their medicines are
the only element of control left in their life – to give this up
means they perceive they have lost all control.
At the time of writing, there are no specific guidelines
around stopping medicines for patients with a short prog-
nosis. Guidance tends to focus on reducing medicines in
relation to risk of side-effects in the elderly (STOPP/
START) but research is ongoing to help support healthcare
professionals in making these decisions alongside clinical
judgements. More recently the OncPal deprescribing
guideline has been published to support clinicians with
discontinuation of medications which have limited benefit
in palliative cancer patients [23].
Considerations:
•
It is sometimes better not to start a medicine than to
tackle deprescribing in the future, particularly in certain
therapeutic areas.
•
Older people, those who are approaching the end-of-life
and those with increasing frailty are frequently prescribed
unnecessary or higher risk medicines and should have
more frequent medication reviews.
• Initiating discussions around deprescribing can be
opportunistic with a changing patient, for example, loss of
swallow but can ideally be approached during other
advanced decision-making.
•
Don’t forget the inhalers – if the patient does not have
the lung capacity and/or dexterity to use their devices then
they are going to only be more prone to oral thrush than
benefit from the inhaled medicine.
Complementary and Alternative
Medicines
Complementary and alternative medicines (CAMs) are
treatments that fall outside mainstream healthcare. These
range from acupuncture and homeopathy, to aroma-
therapy, and colonic irrigation. The availability of CAMs
on the NHS is limited and varies by region.
Herbal medicines contain active ingredients made from
plant parts, such as leaves, roots, or flowers. Not all herbal
products are medicines, some can be classified as food sup-
plements or cosmetics. In the UK this is regulated by the
“Traditional Herbal Medicine Scheme” [24].
Homeopathy is a system of medicine which is regulated
by the Homeopathic National Rules Scheme in the UK.
Homeopathic products should not be confused with
herbal remedies. Some homeopathic products are derived
from herbal active ingredients, but the important distinc-
tion is that homeopathic products are extremely diluted
and administered according to specific principles. No
legal regulation of homeopathic practitioners currently
exists in the UK.
Many cancer patients (around 36% in one European
study) use CAMs during or after therapy [25, 26]. Usage
may depend on previous approaches to conventional medi-
cines, lifestyle, and healthcare choices but also on the stage of
disease, treatment decisions, and often at the point in time
where patients/families are willing to try anything. Stories
on social media of “cancer cures” bring hope to affected
people. Patients are more likely to source information on
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310 Chapter 21
alternative treatments from online and neighbours/friends
than they are healthcare professionals [26]. This cohort of
people are vulnerable and can become a target for fraudulent
business [27].
It is important to address patient’s queries and concerns
around CAMs – failure to do so may mean the patient does
not disclose important information on products they are
using which may contribute to their symptoms, or feels
they are not being listened to by their healthcare profes-
sionals and that their questions are being dismissed. To
help patients make informed decisions, we need to listen to
their queries and find the information out to discuss with
them. Using reliable sources of information such as access-
ing medicines information services can help gain
information to discuss with patients and guide discussions
around risk and benefits of using such treatments.
Counselling points:
•
There is a risk of adverse effects with herbal medicines
and the potential for interaction with conventional
medicines.
•
Some herbal medicines may not be suitable for younger
or older patients.
• If a patient has an adverse effect to the herbal medicine
they are taking, they should stop taking the herbal medi-
cine and inform a healthcare professional such as a phar-
macist or a doctor.
• Patients should be advised to continue taking their pre-
scribed medication if they are taking a herbal medicine;
any changes to a prescribed medication should only be
done following consultation with the prescriber.
As with standard medicines, reporting of adverse effects
from herbal medicines is essential to understand more
about these products and their interactions. Patients and
professionals can report these online at the yellow card
scheme.
Cannabis Oil (CBD)
CBD oil is available to buy legally as a food supplement
from health stores, however there is no guarantee of prod-
uct quality or robust evidence of health benefits [28]. The
claims made in the press for CBD use are:
• Anxiety
• Pain
• Insomnia
• Treat/cure cancer
The main pharmacologically active compounds of
Cannabis sativa are cannabidiol (CBD) and tetrahydrocan-
nabinol (THC). Unlike THC, pure CBD is not psychoactive
and is not a controlled substance. The CBD oils that are on
sale at time of publication contain low concentrations of
CBD; however, it is difficult to purify CBD from plants to
the point that no trace of THC remains [28]. The MHRA
states that if a CBD product “contains any controlled can-
nabinoids, unintentionally or otherwise then it is highly
likely that the product would be controlled” under the
Misuse of Drugs regulations.
Some cannabis-based products are available to buy over
the internet without a prescription. It’s likely most of these
products will be illegal to possess or supply as they will
likely contain THC and may not be safe to use. CBD and
THC can affect how other medicines work and interfere
with liver function.
At the time of writing, there is ongoing research into
medicinal cannabis and currently there are only three
licensed forms for specific indications in the UK:
•
Sativex (MS spasticity)
•
Epidyolex (rare forms of childhood epilepsy)
•
Nabilone (nausea and vomiting post chemotherapy
when other treatments have not worked)
Claims of CBD “curing cancer” are not evidence based and
so it is important to guide patients to respected sources of
information so they can make informed decisions. The
Macmillan and Cancer Research websites are useful
resources to help guide those discussions.
Anticipatory Prescribing and Accessing
Medicines
Deficiencies in communication, forward planning, pain
management, and co-ordination of care can lead to avoid-
able suffering for patients with terminal illness. The Dying
Without Dignity report (2015) highlighted that end-of-life
care could be improved for 350,000 people a year in
England alone [29]. One of the main themes highlighted
was the importance of achieving good round-the-clock
symptom control for all patients.
Certain symptoms including pain, nausea, vomiting,
agitation, breathlessness, and terminal secretions are very
common at the end-of-life, regardless of the cause of
terminal illness. Due to the predictability of these symp-
toms occurring, the practice of anticipatory prescribing or
“planning ahead” is common within palliative care and
should be considered alongside making decisions about
resuscitation and other advanced care plans. Not all
patients will develop all symptoms listed above, however, it
is considered best practice to prescribe and supply antici-
patory medications in advance of need.
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Medicines Management in Palliative Care Including Syringe Pumps 311
The purpose of anticipatory prescribing is to ensure:
•
a supply of drug is available in a patient’s home for
immediate use needed (including diluent)
•
all appropriate equipment including needles and
syringes are available to administer the drugs
•
appropriate medications can be administered in a timely
fashion by a clinician without delays
•
reduced distress to patients and families/carers
•
avoid unnecessary hospital admissions
All healthcare professionals involved with end-of-life care
should familiarise themselves with their local guidance
and drug formularies. Guidelines are often prescriptive in
terms of doses and medications to be used for management
of symptoms in terminal illness, however it is important
that practitioners always apply these in a patient-centred
way, for example, patients with reduced renal function may
require alternate opioids or dose reductions to those out-
lined in guidelines. Ensuring individualisation of care and
treatments to meet the patient’s clinical and social situation
is essential to providing good quality symptom control.
Unfamiliarity with the drugs is a risk and so liaising with
specialist palliative care teams is necessary to ensure
appropriate prescribing.
Common medications prescribed in anticipation of
patient need include:
•
an opioid – for pain and dyspnoea
•
a benzodiazepine (usually midazolam) – for restlessness
and agitation
• an anti-emetic – for nausea and vomiting
•
an anti-cholinergic medication – for terminal secretions
Planning ahead for end-of-life symptom management in
complex patients is critical, not only in terms of medica-
tion supply, but also addressing issues that may contribute
to symptoms, for example, stopping smoking suddenly
therefore needing nicotine patches to prevent agitation, or
patients becoming unable to take oral anti-epileptics and a
plan needed for prevention of seizures. Anticipatory pre-
scribing for management of terminal haemorrhage is also
encouraged if patients are at risk of developing these
symptoms.
Some areas of the UK use Just in Case (JIC) box initia-
tives to support the practice of anticipatory planning. The
JIC is an approved, readily identifiable container which
contains all appropriate medications, equipment, and
necessary documentations to facilitate prompt medication
administration once symptoms develop. As these JIC boxes
commonly contain controlled drugs it is essential that the
security of the box, while in the patient’s home, is main-
tained to minimise the risk of medications being unlaw-
fully diverted.
Several regions have implemented commissioned
schemes working with community pharmacies to hold a
stock of essential end-of-life care medicines to ensure
timely access to common medications used in palliative
care [30]. These schemes are not fool proof and with issues
around wholesaler deliveries, supply disruptions and man-
ufacturing delays, a back-up system with hospital phar-
macies may be required.
Overall, the best practice is to plan and access medicines
not too soon before needed but before a distressing
situation arises. Regular review of the symptom control
needs of these patients over time is essential.
Use of the “Syringe Pump” for
Continuous Subcutaneous Infusion of
Medications in Palliative Care
Oral administration of medications may become inap-
propriate for several reasons during a patient’s illness and
drug administration by continuous infusion can be an
alternative way to achieve symptom control. In the UK
the subcutaneous (SC) route is primarily used for contin-
uous infusion in palliative care, as it is well tolerated by
patients and easily achievable in community settings.
Administration of medications via continuous infusion
provides steady-state plasma concentrations thus
providing constant therapeutic benefit and reduced need
for repeated bolus injections.
Continuous subcutaneous infusions (CSCI) are deliv-
ered using a portable, battery-operated device called a
syringe pump. These devices deliver precise doses of med-
ications over a set period of time, most commonly over 24
hours. An example is the T34 syringe pump. Use of CSCI is
as effective as continuous IV infusion and intermittent
bolus injections. In settings where it may be difficult to
guarantee that regular intermittent injections will be
administered on time, a CSCI is likely to provide better
round-the-clock symptom management. Within palliative
care the use of the syringe pump is firmly established to
administer drugs for symptom control, either alone or in
combinations according to the recognised compatibilities
of different drugs [31–37].
The use of these devices is not without risk – between
January 1, 2005 and June 30, 2010, the NPSA received
reports of 8 deaths and 167 non-fatal incidents involving
ambulatory syringe pumps [38]. Following concerns, a
harmonised European Standard was drawn up identifying
features of syringe pumps that would reduce the risk of
incidents in practice – the recommendations include:
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312 Chapter 21
• all syringe pumps to be calibrated in millilitres per hour
•
mechanisms to stop the infusion if connections and fit-
tings are incorrect
• alarms to indicate if the syringe becomes disconnected
from the pump
• locks to prevent tampering with the syringe/device
•
internal log memory to record pump events
Indications for Using the CSCI
For patients able to take and absorb oral drugs,
administration of medications via CSCI is unlikely to
improve symptom control and may be burdensome, with
increased reliance on healthcare professionals to set up and
manage the infusion device. However, continuous subcu-
taneous infusion can be useful route of medication
administration when used appropriately. Common indica-
tions include:
•
Persistent nausea and/or vomiting
•
Swallowing difficulties
• Intestinal obstruction
• Oral/pharyngeal lesions
• Profound weakness/cachexia
• Patient preference
• Comatose or moribund patient
Prescribing of continuous infusions involves anticipating
and responding to a patient’s medication requirements
over the next 24 hours. Any changes in symptoms experi-
enced may necessitate additional injections to supplement
the infusion therefore, medication should also be pre-
scribed and be available, for immediate administration in
case of breakthrough symptoms. This is sometimes
referred to as “rescue medication.”
Alternative routes of drug administration such as sub-
lingual, buccal, rectal, or transdermal should be consid-
ered where appropriate. Long-term delivery of medications
via subcutaneous infusion is rarely indicated but may be
necessary for some patients. For many patients once symp-
toms are controlled, it is often possible to reconvert to oral
formulations.
Explanation to the Patient and Carers
Before initiating a CSCI, explanation should be provided
to the patient and their carers on the nature and intention
of the procedure. It is important to explain to the patient
and family:
• the reason for administering medication via this route
•
how the device works (including the need for a battery
change every 24 hours)
• the advantages and possible disadvantages of using a
syringe pump
• how to seek assistance when the CSCI alarms
•
The process for returning them after the patient has
died.
Some patients may find the syringe pump obtrusive and
disconcerting, many may have reservations and some fear
that the implementation of a syringe pump equates with
impending death. Questions should be invited, anxieties
acknowledged, and appropriate reassurance given.
Medications Used in Syringe Pump
The administration of medications via CSCI is off-label for
the majority of drugs administered this way. However,
there is extensive clinical experience and reputable refer-
ence sources to support prescribing and administration of
drugs via this route [6, 39–42]. Advice should be sought
from local palliative care specialists on unusual drugs or
combinations before prescribing. Many of the medications
used are found in Table 1. Note that while the heading
“sedative” is used for some medications, as they cause
Figure 2 The T34 syringe pump.
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Medicines Management in Palliative Care Including Syringe Pumps 313
Table 1 Drugs used in syringe pump.
Medication Ampoule Size Indication
Dose Range Per 24
Hours Comments
Opioids
Morphine Sulfate 10 mg/ml, 15 mg/ml,
20 mg/ml, 30 mg/ml
(1 and 2 ml amps)
Pain, dyspnoea Start: For opioid naive
patients – refer to
regional guidelines* for
initial dose. For patients
already on oral Morphine
start at 50% of current
total daily dose. Increase
as necessary by 30–50%
increments. No
maximum dose.
• Is first-line choice of opioid in
most areas.
• Regular administration should
be avoided in patients with
GFR<30 ml/min
Diamorphine Crystalline powder
5 mg, 10 mg, 30 mg,
100 mg, 500 mg
amps. Must be
reconstituted with
water prior to
administration.
Pain, dyspnoea Start: For opioid naive
patients – refer to
regional guidelines* for
initial dose. For patients
already on oral Morphine
start at one-third of
current total daily dose of
oral morphine. Increase
as necessary by 30–50%
increments. No
maximum dose.
• Alternative opioid to
Morphine if high doses are
required in a syringe pump.
• Highly soluble
• Final concentration should not
exceed 250 mg/ml in syringe
for administration via CSCI
Oxycodone 10 mg/ml (1 and 2
ml amps)
50 mg/ml (1 ml
amps)
Pain, Morphine
intolerance
Start: For opioid naive
patients – refer to
regional guidelines* for
initial dose. For patients
already on oral
Oxycodone start at 50%
of current total daily dose
of oral Oxycodone.
Increase as necessary by
30–50% increments. No
maximum dose.
• If mixing with Cyclizine do
not exceed 3 mg/ml Cyclizine
Alfentanil 1 mg/2 ml, 5 mg/10
ml and 5 mg/1 ml
amps
Alternative to
Morphine on advice
of palliative care
specialist,
particularly in renal
failure.
For opioid naive patients
– refer to regional
guidelines* or local
palliative care team for
initial dose. If converting
from other opioids seek
specialist palliative care
advice
• Incompatibility may occur
with Cyclizine
Hydromorphone 10 mg/ml, 20 mg/ml,
50 mg/ml amps
(unlicensed special
order)
Alternative to
Morphine in cases
of intolerance – on
advice of palliative
care specialist.
Start: At 50% of current
total daily dose of oral
Hydromorphone.
If converting from other
opioids seek specialist
palliative care advice
• Unlicensed product is
available as a special order
from Martindale Pharma
• Expensive
(Continued)
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314 Chapter 21
Fentanyl 100 micrograms/2 ml
and 500
micrograms/10 ml
amps
Alternative to
Morphine on advice
of palliative care
specialist,
particularly in renal
failure.
For opioid naive patients –
refer to regional
guidelines* or local
palliative care team for
initial dose. If converting
from other opioids seek
specialist palliative care
advice
• Volume issues may restrict
administration at high doses
Methadone 10 mg/ml and 50 mg/
ml amps
Only on advice of
palliative care
specialist.
Seek advice from a
palliative care specialist
• Can cause adverse reaction at
site of infusion
• Wide variation in individual
plasma concentration
• Long half-life leads to
tendency to accumulate
NSAIDs
Ketorolac 30 mg/ml amps Bone pain on
recommendation of
palliative care
specialist
30–60 mg
• Well tolerated
• Use with caution in renal
failure
• Can be nephrotoxic
• Short-term use only
• High incident of GI bleeding;
co-prescribe gastro-protective
drug
• Irritant therefore dilute with
the largest possible volume of
sodium chloride 0.9%
• Very alkaline – high risk of
precipitation in combination
Parecoxib 20 mg/ml (2 ml
amps). Need
reconstituting prior
to administration.
Bone pain on
recommendation of
palliative care
specialist
Start: 20–40 mg daily.
Increase up to maximum
of 80 mg/24 hours if
beneficial for pain
control.
• Limited compatibility data
currently available
• Use with caution in renal
failure
• May be suitable to administer
as SC bolus once or twice daily
Anti-Emetics
Haloperidol 5 mg/ml amps Drug induced
nausea; metabolic
causes;
anti-psychotic
1–5 mg reduce starting
dose in renal impairment
and elderly.
• Central dopamine receptor
antagonist – avoid in
parkinsonism
• Mildly sedating
• Settles agitation and psychosis
(Continued)
Table 1 (Continued)
Medication Ampoule Size Indication
Dose Range Per 24
Hours Comments
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Medicines Management in Palliative Care Including Syringe Pumps 315
Medication Ampoule Size Indication
Dose Range Per 24
Hours Comments
Table 1 (Continued)
Metoclopramide 5 mg/ml (2 ml amps) Impaired gastric
emptying
30–100 mg • Dopamine receptor antagonist –
avoid in parkinsonism
• Non-sedating
• Possibility of extra-pyramidal/
dystonic side effects or tardive
dyskinesia with prolonged use
in younger women
Cyclizine 50 mg/ml amps Intestinal
obstruction;
movement induced
nausea, raised
intra-cranial
pressure
50–100 mg • Anti-histamine (H
1
) and
anti-cholinergic
• May cause drowsiness
• Must not dilute with sodium
chloride
• Known compatibility
problems in some
combinations
Ondansetron 2 mg/ml (2 ml and 4
ml amps)
Chemotherapy or
radiotherapy
induced nausea and
vomiting
8–24 mg • 5HT
3
antagonist – of not
effective within 72 hours
discontinue
Sedative and Anti-Emetic
Levomepromazine 25 mg/ml amps Nausea; restlessness
and agitation;
psychosis
Nausea – 5–25 mg (doses
in excess of 35 mg cause
sedation and are rarely
necessary for nausea)
Restlessness/Agitation –
25–75 mg; titration
according to response.
Very rarely doses as high
as 200 mg/24 hours may
be needed for severe
terminal agitation, this
should be managed under
the supervision of a
specialist in palliative care
• Effective anti-emetic
• Useful for terminal agitation
• Could be administered as SC
bolus injection due to long
half-life
• May cause skin reactions at
infusion site
Sedatives
Midazolam 10 mg/2 ml preferred
in palliative care.
Other ampoules sizes
are available.
Anxiety; terminal
agitation and
restlessness;
dyspnoea;
anti-convulsant,
myoclonus
10–30 mg (common
range), doses of up to 100
mg can be used
• Water soluble benzodiazepine
• Large inter-individual
variability in steady-state
plasma levels
(Continued)
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316 Chapter 21
Clonazepam 1 mg/ml amps
(unlicensed in the
UK, available as a
parallel import)
Anxiety; terminal
agitation and
restlessness;
anti-convulsant,
neuropathic pain
500 micrograms–8 mg • Less water soluble than
midazolam
• May be irritant
• May cause confusion
• Expensive
Anti-Cholinergics
Glycopyrronium 200 microgram/ml (1
ml and 3 ml amps)
Terminal secretions 600 micrograms-1.2 mg
• Slower onset of action than
Hyoscine Butylbromide
• Less likely to cause confusion
than Hyoscine Hydrobromide
Hyoscine
Butylbromide
20 mg/ml (1 ml amps) Severe Colic;
Terminal Secretions;
Intestinal
Obstruction
20–120 mg (doses of up
to 240 mg may be used)
• Less likely to cause sedation
than Hyoscine Hydrobromide
Hyoscine
Hydrobromide
400 micrograms/ml
amps
600 micrograms /ml
amps
Terminal Secretions,
Sedation
600 micrograms–2.4 mg • Rarely used in practice due to
undesirable side effects and
high cost
• Dry mouth – extra attention to
good oral hygiene
Anti-Convulsants
Midazolam See above
Clonazepam See above
Levetiracetam 100 mg/ml (5 ml
amps)
Seizures 500 mg–3 grams (Doses
>2g will need to be split
into 2 syringe pumps)
• May cause infusion site
reactions – monitor site
closely upon initiation
• Volume restrictions mean
doses above 2 grams may
require splitting between
multiple T34 pumps
Sedative and Anti-Convulsant
Phenobarbital 30 mg/ml amps
60 mg/ml amps
200 mg/ml amps
Seizures, status
epilepticus, terminal
agitation
Management of Seizures:
Up to 400 mg/24 hours
Terminal Agitation:
Typical dose is 800–1,200
mg/24 hours but can
range 200–3,800 mg/24
hours.
• Stat bolus doses of IV/IM
Phenobarbital should be
trialled before initiation of
CSCI – see PCF for full dosing
information
• Phenobarbital should be
administered via a separate
syringe pump. Due to its
alkaline pH, it is likely to be
incompatible with most
drugs
Table 1 (Continued)
(Continued)
Medication Ampoule Size Indication
Dose Range Per 24
Hours Comments
https://t.me/med1917
Medicines Management in Palliative Care Including Syringe Pumps 317
Miscellaneous
Octreotide 50 micrograms/ml
amps
100 micrograms/ml
amps
200 micrograms/ml 5
ml amps
500 micrograms/ml
amps
Reduces GI
secretions; volume
of vomit in intestinal
obstruction; volume
of enterocolic fistula
500 micrograms initially
– if ineffective stop after
48 hours. If effective
titrate to lowest effective
dose (usual range 50–600
micrograms/24 hours)
• Expensive
Tranexamic Acid 100 mg/ml (5 ml
amps)
Haemostatic – for
prevention or
treatment of
bleeding
1000–2000 mg/24 hours • Limited compatibility data –
infuse in separate syringe
pump
• Case report data only
Ketamine 10 mg/ml (20 ml
vial)
50 mg/ml (10 ml
vial)
100 mg/ml (10 ml
vial)
Difficult to control
cancer pain;
especially of
neuropathic origin
on recommendation
of palliative care
specialist
Seek advice from
specialist palliative care
• Inhibits NMDA receptor
• Psychomimetic side effects
(may need Midazolam/
Haloperidol to cover)
• Contra-indication in raised
intra-cranial pressure and
seizures
• Caution in hypertension/
cardiac problems
• Irritant therefore dilute with
sodium chloride 0.9% to
largest possible volume
This list is not exhaustive; it covers many of the drugs used in palliative care. See other chapters for specific indications and usage.
SC = subcutaneous; GI = gastrointestinal; CSCI – continuous subcutaneous infusion
*Dosing in opioid naive patients should be based on regional and national guidance – physicians should always consider
patient factors including renal function and frailty when deciding on dose to prescribe and implement appropriate dose
reductions.
Table 1 (Continued)
Medication Ampoule Size Indication
Dose Range Per 24
Hours Comments
https://t.me/med1917
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