If 2 or more doses of midazolam required in 24 hours commence syringe driver 1. Syringe driver drug compatibilities guide to practice 20. When added to a syringe driver the recommended diluent is water for injection. Anticipatory medication stat dose and syringe pump driver guidance. Syringe drivers are often required to provide medicines for symptom. Midazolam has a very short duration of action and for sustained effect requires to be given in a continuous infusion. There should be appropriate treatment of these problems. The general principle that injections should be given into separate sites and should not be mixed does not apply to the use of syringe drivers in palliative care. Use of alfentanil in renal failure in palliative care in. Midazolam is a watersoluble benzodiazepine available as a sterile, nonpyrogenic parenteral dosage form for intravenous or intramuscular injection.
Syringe driver drug compatibilities guide to practice 20 july 20 these guidelines have been ed. Dose range may vary according to advice from specialist diluent. Unlike nearly all other benzodiazepine conversions, the conversion between intravenous midazolam and lorazepam has been well studied in mechanically ventilated patients. If the patient is breathless and anxious, consider midazolam 2. If a continuous infusion is required, syringe driver of midazolam 510mg over 24hrs. The use of a subcutaneous or intravenous infusion using a syringe driver to deliver medications has certain advantages. Midazolam 1 mgml solution for injection or infusion. Prescribing anticipatory drugs nhs north kirklees ccg. Prescribe a syringe driver of cyclizine 150 mg over 24 hours start if two or more prn doses required. Nb if uncontrolled on a maximum of 60mg midazolam 30mg in renal failure consider. This gives a subcutaneous dose of 30mg over 24 hours. Hepatic impairment a dose reduction of 3050% may be necessary. Prescribing in palliative care medicines guidance bnf. A subcutaneous cannula with a side injection port should be used when starting the infusion.
When and how to use a syringe driver in palliative. Drugs for subcutaneous administration in syringe drivers. It can be diluted with water for injection or normal saline. Prescribing for end of life care oxleas nhs foundation trust. For prolonged seizure or status epilepticus administer midazolam phenobarbital as normal importance of discussion with patient or next of kin as offlicence group creatinine clearance mlmin1. Starting dose for seizures over 24 hours sedating effect.
Diamorphine midazolam syringe driver download the dose and frequency is adjusted according to the level of patient distress and the response. If the patient is in pain, vomiting or very agitated, give a stat sc injection of appropriate medication while setting up the syringe driver. Diazepam, chlorpromazine and prochlorperazine are too. Anticipatory medication stat dose and syringe pump driver.
Its used in a syringe driver when a continuous dose of medicine is needed to relieve these symptoms throughout the day. Starting setting up a syringe driver mckinley t34 if symptomatic give stat dose as syringe driver takes 2 4 hours from setting up to achieve effect. Agitation in the dying patient midazolam 5mg24 hrs max 30mg respiratory secretions in. Dose escalation schedules may vary depending on the clinical condition the patient. Oral sc prn dose syringe driver dose 24 hours conversion from oral to sc morphine 10mg1ml 30mg1ml 10mg 4hrly 5mg 4hrly 20mg. Subcutaneous ketamine infusion in a syringe pump 2 drug combinations. In general, syringe drivers are safe, reliable and dont need a. An aseptic technique should be used when preparing and setting. Rate of infusion levetiracetam should be infused via csci over 24 hours. Midazolam subcutaneous and nasal palliative care adults.
The use of alfentanil in a syringe driver in palliative. Not all types of medication can be used in a subcutaneous infusion. Berkshire adult palliative care guidelines 3 end of. Whenever a patient is transferred from one strong opioid to another they should be monitored for signs of. Syringe driver check list and community subcutaneous medications record sheet community or. Thcontinue with prn midazolam calculate dose as 16 of syringe driver dose. Haloperidol antiemetic dose is 1 2 mg for 24 hours. Hyoscine hydrobromide daily dose nil x20 ampoules 0. It does not replace adequate assessment and individual. This is because the niki t34 syringe driver simplifies administration by detecting the syringe size and volume of medicine, and sets the rate to deliver the infusion over the required time period, e. Renal failure dose reductions are not usually required. If midazolam 30mg in syringe driver is reached and symptoms are not controlled, please seek advice.
Subcut midazolam dose equivalencies of commonly used benzodiazepines. If agitation and nausea if both present, instead of cyclizine and midazolam, consider prn dose of levomepromazine nozinan 6. Subcutaneous midazolam infusion in palliative care. All the following drugs can be prescribed for the same.
However, depending on the volume, two 12 hour drivers may be required. There is no maximum dose for midazolam however the dose should be titrated carefully according to the response. Increase in 10 mg24 hr increments to maximum 60 mg24 hrs. Subcutaneous levetiracetam keppra in palliative and. Whilst the preferred route of medication administration in paediatric palliative care is the oral one, there may be occasions when this is impractical or undesirable. Anticipatory medication stat dose and syringe pump. The dose should be reduced in hypovolaemic, vasoconstricted or hypothermic patients. The same brand of syringe should be used each time to minimise errors in setting up the syringe driver and calculating the rate6, 9. A continuous subcutaneous infusion of morphine and midazolam in a syringe driver is effective in controlling pain, agitation and restlessness. Syringe driver drug compatibilities guide to palliative care practice 2016 sodium chloride 0. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. These quantities are sufficient to provide for both a syringe driver and prn doses for 3 days.
Care of the dying severe renal failure clinical guideline. Use of a syringe driver or other suitable volumetric infusion equipment is required. Each ml contains midazolam hydrochloride equivalent to 1 mg or 5 mg midazolam compounded with 0. The syringe should be measured every time the device is set up, as different brands of syringes have different diameters and lengths9. Ensure dose adjustment is made for renal impairment. Guidelines for syringe driver management in palliative care. For information on the usual doses of drugs used in a syringe driver see. The use of alfentanil in a syringe driver in palliative medicine warning. The table below gives some guidance when starting a syringe driver, but prescribing should be considered on an individual patient basis.
Guidance for anticipatory prescribing for patients in. Many of the opioid analgesics and their metabolites may accumulate in renal failure causing toxicity with myoclonic jerks, profound narcosis and respiratory depression. District nurses able to give small doses of midazolam and glycopyrronium as bolus injection and then via a syringe driver. If doses in excess of 30mg 24 hours are required, seek advice from the palliative care team. The prn dose of opioid should be calculated from the dose of opioid in the syringe driver. The use of subcutaneous levetiracetam in palliative medicine. While benzodiazepines generally achieve effective seizure control, they also cause sedation. In a syringe driver, alfentanil is compatible with other commonly prescribed symptom control medications of midazolam, levomepromazine and hyoscine butylbromide. Provided that there is evidence of compatibility, selected injections can be mixed in syringe drivers. The eastern metropolitan region palliative care consortium emrpcc grants permission to reproduce parts of this publication for clinical and educational use only, provided that the emrpcc is acknowledged. Only use drugs that are known to be effective via the sc route. This guideline refers to the use of drugs in syringe drivers for palliative care only.
Syringe driver drug compatibilities guide to palliative. Once stable, combine midazolam with other compatible medications to simplify the syringe driver regime. Cyclizine with diamorphine, once diamorphine dose exceeds 200 mg. Rectal administration of the ampoule solution is performed by means of a plastic applicator fixed on the end of the syringe. A bolus, sc dose of medication will be needed if the patient is symptomatic when starting the infusion since the syringe driver will take 24 hours to reach an optimal level when mixing 2 or more drugs in a syringe driver, check compatibilities with the trust pharmacy department or palliative care team and ensure that diluent is compatible with. When and how to use a syringe driver in palliative care. Patients on opioid patches if a patient requires a syringe driver the patch should continue to be prescribed at the usual dose and the syringe driver used a top up and titrated as necessary. Data sources include ibm watson micromedex updated 10 apr 2020, cerner multum updated 6 apr 2020, wolters kluwer updated. The mckinley t34 is calibrated in mlhour a 30ml luer lock syringe is recommended the maximum volume of fluid in a 30ml syringe is 22ml. Anxiolytic 5mg to 10mg over 24 hours muscle relaxant 5mg to 20mg over 24 hours anticonvulsant 20 mg to 30mg over 24 hours 1st line sedative 10mg to 60mg over 24 hours 10mg in 2ml preparation for palliative care. A syringe driver takes 34 hours to establish a steady state drug level in plasma. The infusions were deliv ered subcutaneously by means of a graseby syringe driver of either ms16a or ms26 type, results the usual starting dose of midazolam was 1020 mg24 hr 0.