Palliative Care Guidelines - NHS Lanarkshire

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Palliative Care Guidelines: Subcutaneous medicationSingle drugs used in a subcutaneous infusion in Palliative CareDiluent: water for injectionsSingle agent Indications and dose range CommentsMORPHINE10mg, 30mg in 1ml60mg in 2mlIndications: opioid responsive pain,breathlessness.Dose: See Choosing & Changing opioids• 1st line opioid analgesic.DIAMORPHINE10mg, 30mg, 100mg,500mg powderampoulesOXYCODONE10mg in 1ml20mg in 2mlALFENTANIL1mg (1000micrograms)in 2ml, 5mg in 10mlAntiemeticsCYCLIZINE50mg in 1mlMETOCLOPRAMIDE10mg in 2mlHALOPERIDOL5mg in 1ml10mg in 2mlLEVOMEPROMAZINE25mg in 1mlIndications: opioid responsive pain,breathlessness.Dose: See Choosing & Changing opioidsIndications: opioid responsive pain,breathlessness.Dose: See Choosing & Changing opioidsIndications: opioid responsive pain,breathlessness.Dose: See Choosing & Changing opioidsIndications: nausea and vomiting (bowelobstruction or intracranial disease).Dose: 50-150mg / 24 hoursIndications: nausea and vomiting (gastricstasis/outlet obstruction, opioid)Dose: 20-120mg / 24 hoursIndications: opioid or metabolic inducednausea, delirium.Dose: 2.5-5mg / 24 hoursIndications: complex nausea, terminaldelirium/ agitation.Dose: 5-25mg / 24 hours - antiemetic.Dose: 25-100mg / 24 hours - terminalsedation.Anticholinergics for chest secretions or bowel colicHYOSCINEBUTYLBROMIDE(Buscopan)20mg in 1mlGLYCOPYRRONIUM200 micrograms in 1ml600 micrograms in 3mlHYOSCINEHYDROBROMIDE400 micrograms in 1ml600 micrograms in 1mlSedativeMIDAZOLAM10mg in 2ml (preferred)10mg in 5mlIndications: chest secretions, bowelobstruction (colic, vomiting).Dose: 40-120mg / 24 hoursIndications: chest secretions or colic.Dose: 600-1200 micrograms /24 hoursIndications: chest secretions.Dose: 400-1200 micrograms / 24 hoursIndications: anxiety, muscle spasm/myoclonus, seizures, terminal delirium/agitation.Dose: titrate according to symptoms andresponse.Other medication occasionally given by SC route in palliative careDEXAMETHASONE4mg in 1mlKETOROLAC10mg in 1ml30mg in 1mlOCTREOTIDE200micrograms/ml(5ml multi-dose vial)Indications: bowel obstruction, raisedintracranial pressure or intractable nauseaand vomiting.Dose: 2-16mg / 24 hoursIndication: bone/ inflammatory pain if patientin last days of life.Dose: 10- 30mg / 24 hoursIndications: intractable vomiting due tobowel obstruction, fistula discharge.Dose: 300–900 micrograms / 24 hours• Can be diluted in a small volume.• Preferred for high opioid doses.• 2nd line opioid analgesic if morphine/diamorphine not tolerated.• 3rd line opioid; seek specialist advice.• 1st line in stages 4 /5 chronic kidneydisease.• Anticholinergic; reduces peristalsis.• Can cause redness, irritation at site.• Do not mix with oxycodone or hyoscine.• Prokinetic.• Avoid if complete bowel obstruction orcolic.• Long half life: can also be given as aonce daily SC injection.• Lowers blood pressure.• Long half life: can be given as a once ortwice daily SC injection.• See: Levomepromazine.• 1st line; non-sedative.• 2nd line; non-sedative.• Longer duration of action than hyoscine.• 2nd line; sedative.• Can precipitate delirium.• Anxiolytic (5-10mg/ 24 hours).• Muscle relaxant (5-20mg/ 24 hours).• Anticonvulsant (20-30mg/ 24 hours).• 1st line sedative (20-80mg / 24 hours).• Subcutaneous dose is the same as oral.• Available as different dose formulationsso check preparation.• Can be given as a daily SC injection (inthe morning).• Given as a single drug infusion, mixes poorly.• Specialist supervision only.• Give an oral PPI if still able to swallow.• Long half life particularly in frail patients;can be given as a twice daily SCinjection.• Some formulations very expensive.• Potent antisecretory agent.• Does not treat nausea.• Limit fluid intake to 1-1.5 litre/ 24 hours.2 Issue date: January 2009 Review date: March 2012 © NHS Lothian
Palliative Care Guidelines: Subcutaneous fluidsSubcutaneous Fluids in Palliative CareIntroductionArtificial hydration is occasionally indicated in palliative care. Before fluids are started, the goals ofthis treatment must be clarified by the healthcare team, discussed with the patient and family, andthen reviewed regularly.PreparationsSodium chloride 0.9%500ml or1 litre500-1500ml can be given subcutaneously over24hours.Indications for artificial hydration• Patient has persistent symptoms due to dehydration that are not responding to othermanagement options (eg. intractable nausea, marked postural hypotension).• Dehydration is contributing to poor renal clearance of opioids (eg. morphine, diamorphine)that are causing symptoms of toxicity such as delirium. The opioid dose and general painmanagement should also be reviewed.• The subcutaneous route (SC) can be used if it can meet the patient’s fluid requirements in theshort term when oral intake is inadequate and maintaining an intravenous line is difficult orinappropriate.Cautions / contraindications• If a patient is imminently dying, hydration will not improve survival or symptom control andincreases the risk of distressing respiratory secretions.• Fluid overload, ascites, peripheral oedema due to hypoalbuminaemia.• Patients on fluid restriction or at risk of fluid overload (heart failure, haemodialysis).• Site problems due to tissue or skin disorders, thrombocytopenia or coagulopathy.• Intravenous hydration is more effective in some situations (eg hypercalcaemia, hypovolaemia,acute renal failure).Dose and administration: See local protocol.• An overnight SC infusion of 500ml will often meet baseline fluid requirements.• Choose a suitable site: abdominal wall, thigh or chest wall.• Avoid areas with skin damage/ disease, oedema or lymphoedema, scarring or previousradiotherapy, near a stoma or a mastectomy scar.• Fluids are infused by gravity feed; 500ml can be given over 8-12 hours.• Check site daily and rotate at least every 48 hours to minimise tissue damage.• Re-site the infusion if there is fluid leakage from the site or significant local pooling of fluidconsistent with poor absorption.Practice points• Artificial hydration will not improve a dry mouth or associated thirst and is never a substitute forgood mouth care. (see: Mouth Care)• In the last days of life, artificial fluids and feeding that have been started previously should bereviewed and usually discontinued. (see: Last days of life)• Maintaining hydration can be an emotive issue for families and their concerns need to beaddressed sensitively when decisions are being made about artificial hydration and nutrition.(See patient leaflet on website: What happens when someone is dying)Key referenceCampbell C. Artificial nutrition and hydration. National Council for Palliative Care /Association for PalliativeMedicine. 2007 London. National Council for Hospice & Palliative Care Services.Further reading: http://www.palliativecareguidelines.scot.nhs.uk© NHS Lothian Issue date: January 2009 Review date: March 20121
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Palliative Care Guidelines - NHS Lanarkshire

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