An initial subcutaneous injection may also be required as a loading dose to manage the patient’s symptoms for the initial two to four hours of syringe driver use until the medicines in the infusion reach effective blood plasma levels. Make the solution as dilute as possible – use a larger syringe When possible, select a solution that is close to physiological tonicity – sterile water is hypotonic, normal saline is isotonic, and solutions with high concentrations of some medicines become hypertonic Use plastic cannulae as they cause less site irritation than metal cannulae In a patient who has been prone to site problems, consider rotation of the site of infusion before any localised reactions develop Avoid oedematous areas when selecting the site for infusion Use 0. Without a home care pack there may be a considerable delay in getting drugs required for symptom relief. Metoclopramide hydrochloride has a prokinetic action and is used by mouth for nausea and vomiting associated with gastritis, gastric stasis, and functional bowel obstruction. They provide continuous subcutaneous administration of medicines to enable effective symptom control when medicines given by other routes are inappropriate or no longer effective. Respirations may slow with periods of apnoea. Breathlessness at rest may be relieved by regular oral morphine in carefully titrated doses.
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The patient’s medicine requirements for 24 hours The doses that may be required for breakthrough symptoms – these need to be available for immediate use The choice of diluent The compatibility of the medicines required to manage symptoms Table 2.
Prescribing in palliative care | Medicines guidance | BNF content published by NICE
Anorexia may be helped by prednisolone or dexamethasone. The child’s hands, feet and face may be cold, pale and cyanotic. Doses of medication should be recorded for parents on a treatment sheet and drugs already drawn up in the fridge.
Dry mouth Dry mouth may be relieved by good mouth care and measures such as chewing sugar-free gum, sucking ice or pineapple chunks, or the use of artificial saliva ,dry mouth associated with candidiasis can be treated by oral preparations of nystatin or miconazolealternatively, fluconazole can be given by mouth.
Monitoring the infusion Patients being cared for at home should ideally have a daily visit from a health professional for review of symptom control and monitoring of the infusion. Compatibility of medicines When more mor;hine one medicine is used in an infusion solution there is a risk that they may not be compatible, either chemically or physically.
Most symptoms can be controlled with a continuous subcutaneous infusion In a palliative care setting, subcutaneous administration of medicines given via a syringe driver is useful for managing symptoms such as pain, nausea, anxiety and restlessness.
Further resources General Practitioners and other carers can access hour telephone help from their nearest hospice: Fungating tumours Fungating tumours can be treated by regular dressing and antibacterial drugs; systemic mmidazolam with metronidazole is often required to reduce malodour but topical metronidazole is also used.
Restlessness and agitation during the terminal phase is not uncommon and may be due to increasing pain, hypoxia, nausea, fear and anxiety. Positioning on the side or slightly head down will allow some postural drainage and this may be all that is required. In theory injections dissolved in water for injections are more likely to be associated with pain possibly owing to their hypotonicity. Many acute hospitals and teaching centres now have consultative, hospital-based teams.
syrihge It is kinder to give an intermittent bolus injection subcutaneously —absorption is smoother so that the risk of adverse effects at peak absorption is avoided an even better method is to use a subcutaneous butterfly needle. These include the site selected, the type of cannulae used and the medicine being given.
When and how to use a syringe driver in palliative care
Ministry of Health MOH. Clonazepam and chlorpromazine can also be administered rectally. It should mofphine prevented if possible by the regular administration of laxatives; a faecal softener with a peristaltic stimulant e. These measures will assist in relieving anxiety, however agitation and restlessness may continue if the cause is due to pain, morpine, nausea or metabolic disturbances. A syringe driver simply provides an alternative route for the administration of medicines.
Anticholinergic drugs can be used to reduce the production of secretions and a portable suction machine at home may be of benefit for children with chronic conditions or those who are unconscious.
BPJ When and how to use a syringe driver in palliative care
When adjusting the dose of morphinethe number of rescue doses required and the response to them should be taken into account; increments of morphine should not exceed one-third to one-half of the total daily dose every 24 hours.
Formulations of fentanyl that are administered nasally, buccally or sublingually are also licensed for breakthrough pain. There may also be ooze morphnie the mouth and nose, particularly if they roll their child to undress and wash them. At this stage oral medications may not be tolerated and alternative routes of medication are essential.
The infusion is discontinued when the first oral dose of morphine is given.
Reassurance and explanation to the family is essential as the noise of the gurgling can be very distressing to the family, while the child is usually unaware and untroubled by the noise and sensation.
If the patient becomes unable to swallow, generally morphine is administered as a continuous subcutaneous infusion for details, see Continuous Subcutaneous Infusions below.
Many patients will also be under the care of a palliative care physician. It is important to discuss with parents this possibility and how they wish to manage incontinence. A regular maintenance dose should also be considered, given twice daily either by mouth norphine by subcutaneous injection; alternatively use a continuous infusion device.
Fungating tumours can be treated by regular dressing and antibacterial drugs; systemic treatment with metronidazole is often required to reduce malodour but topical metronidazole is also used. The eyes may become sunken or bulging and glazed.
Treatment is directed at inducing sedation. If supplementary doses are required regularly for breakthrough symptoms, include these doses when calculating the amount of medicine needed for the subsequent 24 hour mieazolam.