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  2. Scottish Palliative Care Guidelines
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  6. Syringe driver compatibles
  7. Compatibility and stability tables for subcutaneous infusion (2a to 7)
Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Compatibility and stability tables for subcutaneous infusion (2a to 7) - using syringe pumps (syringe drivers)

Tables are best viewed in landscape mode on mobile devices

Table 2a: Subcutaneous morphine sulfate infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signsof precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22 ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Morphine Sulfate

Cyclizine*

270mg

150mg

350mg

150mg

380mg

150mg

760mg

150mg

Morphine Sulfate

Haloperidol

225mg

6mg

290mg

8mg

315mg

8mg

730mg

10mg

Morphine Sulfate

Hyoscine butylbromide

170mg

90mg

220mg

120mg

240mg

120mg

480mg

120mg

Morphine Sulfate

Hyoscine hydrobromide

370mg

1200micrograms

480mg

1200micrograms

520mg

1200micrograms

1000mg

1200micrograms

Morphine Sulfate

Levomepromazine

230mg

50mg

300mg

65mg

320mg

70mg

640mg

100mg

Morphine Sulfate

Metoclopramide

120mg

50mg

160mg

70mg

175mg

75mg

350mg

120mg

Morphine Sulfate

Midazolam

85mg

40mg

110mg

55mg

120mg

60mg

240mg

80mg

Morphine Sulfate

Octreotide

115mg

460micrograms

150mg

600micrograms

160mg

650micrograms

320mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 2b: Subcutaneous morphine sulfate infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Morphine sulfate

Cyclizine*

Haloperidol

210mg

150mg

6mg

275mg

150mg

8mg

300mg

150mg

9mg

600mg

150mg

10mg

Morphine Sulfate

Cyclizine*

Midazolam

150mg

150mg

20mg

200mg

150mg

30mg

220mg

150mg

30mg

440mg

150mg

60mg

Morphine Sulfate

Glycopyrronium

Midazolam

150mg

900micrograms

35mg

200mg

1200micrograms

45mg

220mg

1200micrograms

50mg

440mg

1200micrograms

80mg

Morphine Sulfate

Haloperidol

Hyoscine butylbromide

50mg

4mg

90mg

65mg

5mg

120mg

70mg

5mg

120mg

140mg

10mg

120mg

Morphine Sulfate

Haloperidol

Midazolam

110mg

6mg

40mg

140mg

8mg

55mg

150mg

9mg

60mg

300mg

10mg

80mg

Morphine Sulfate

Hyoscine butylbromide

Levomepromazine

100mg

90mg

12mg

130mg

120mg

15mg

140mg

120mg

15mg

280mg

120mg

30mg

Morphine Sulfate

Hyoscine butylbromide

Midazolam

110mg

90mg

15mg

140mg

120mg

20mg

150mg

120mg

20mg

300mg

120mg

40mg

Morphine Sulfate

Levomepromazine

Midazolam

120mg

45mg

50mg

160mg

60mg

70mg

175mg

65mg

75mg

350mg

130mg

150mg

Morphine Sulfate

Metoclopramide

Midazolam

80mg

60mg

40mg

100mg

80mg

50mg

110mg

85mg

55mg

220mg

170mg

110mg

*Use water for injection as diluent for cyclizine

 

Table 3a: Subcutaneous diamorphine infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22 ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Diamorphine

Cyclizine*

340mg

150mg

440mg

150mg

480mg

150mg

950mg

150mg

Diamorphine

Glycopyronnium

425mg

1200micrograms

550mg

1200micrograms

600mg

1200micrograms

1000mg

1200micrograms

Diamorphine

Haloperidol

800mg

10mg

1000mg

10mg 

1000mg

10mg 

1000mg

10mg

Diamorphine

Hyoscine butylbromide

1000mg

120mg

1000mg

120mg 

1000mg

120mg 

1000mg

120mg

Diamorphine

Hyoscine hydrobromide

1000mg

1200micrograms

1000mg

1200micrograms

1000mg

1200micrograms 

1000mg

1200micrograms 

Diamorphine

Levomepromazine

850mg

100mg

1000mg

100mg

1000mg

100mg 

1000mg

100mg

Diamorphine

Metoclopramide

1000mg

85mg 

1000mg

110mg

1000mg

120mg

1000mg

120mg

Diamorphine

Midazolam

560mg

80mg 

720mg

80mg

1000mg

80mg

1000mg

80mg

Diamorphine

Octreotide

425mg

1200micrograms 

550mg

1200micrograms 

1000mg

1200micrograms 

1000mg

1200micrograms 

*Use water for injection as diluent for cyclizine

 

Table 3b: Subcutaneous diamorphine infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Diamorphine

Cyclizine*

Haloperidol

340mg

150mg

10mg

440mg

150mg

10mg

480mg

150mg

10mg

960mg

150mg

10mg

Diamorphine

Haloperidol

Midazolam

800mg

7mg

65mg

1000mg

10mg

80mg

1000mg

10mg

80mg

1000mg

10mg

80mg

Diamorphine

Haloperidol

Hyoscine butylbromide

320mg

5mg

90mg

410mg

6mg

115mg

450mg

7mg

120mg

900mg

10mg

120mg

Diamorphine

Hyoscine butylbromide

Midazolam

120mg

80mg

20mg

150mg

100mg

25mg

165mg

110mg

27mg

320mg

120mg

55mg

Diamorphine

Levomepromazine

Metoclopramide

850mg

100mg

50mg 

1000mg

100mg

60mg

1000mg

100mg

65mg

1000mg

100mg

120mg

Diamorphine

Levomepromazine

Midazolam

800mg

100mg

60mg

1000mg

100mg

75mg

1000mg

100mg

80mg

1000mg

100mg

80mg

Diamorphine

Metoclopramide

Midazolam 

420mg

60mg

20mg

540mg

75mg

25mg

590mg

80mg

27mg

1000mg

120mg

55mg

Diamorphine

Hyoscine butylbromide

Levomepromazine

1000mg

120mg

50mg

1000mg

120mg

65mg

1000mg

120mg

70mg

1000mg

120mg

100mg

*Use water for injection as diluent for cyclizine

 

Table 4a: Subcutaneous oxycodone infusion using 10mg/ml, 20mg/2ml or 50mg/ml injection. TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Oxycodone

Cyclizine*

100mg

150mg

130mg

150mg

140mg

150mg

280mg

150mg

Oxycodone

Glycopyrronium

380mg

900micrograms

500mg

1200micrograms

540mg

1200micrograms

1080mg

1200micrograms

Oxycodone

Haloperidol

640mg

10mg

840mg

10mg

910mg

10mg

1820mg

10mg

Oxycodone

Hyoscine butylbromide

640mg

75mg

840mg

100mg

910mg

105mg

1820mg

120mg

Oxycodone

Hyoscine hydrobromide

525mg

900micrograms

680mg

1200micrograms

740mg

1200micrograms

1480mg

1200micrograms

Oxycodone

Levomepromazine

470mg

75mg

610mg

100mg

665mg

100mg

1330mg

100mg

Oxycodone

Metoclopramide

270mg

50mg

360mg

70mg

390mg

75mg

780mg

120mg

Oxycodone

Midazolam

270mg

50mg

360mg

70mg

390mg

75mg

780mg

80mg

Oxycodone

Octreotide

390mg

1200micrograms

500mg

1200micrograms

550mg

1200micrograms

1100mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 4b: Subcutaneous oxycodone infusion using 10mg/ml, 20mg/2ml or 50mg/ml injection THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Oxycodone

Cyclizine*

Glycopyrronium

90mg

150mg

900micrograms

120mg

150mg

1200micrograms

130mg

150mg

1200micrograms

260mg

150mg

1200micrograms

Oxycodone

Cyclizine*

Haloperidol

100mg

150mg

8mg

130mg

150mg

10mg 

140mg

150mg

10mg

280mg

150mg

10mg

Oxycodone

Cyclizine*

Midazolam

40mg

150mg

20mg

55mg

150mg

30mg

60mg

150mg

30mg

120mg

150mg

60mg

Oxycodone

Glycopyrronium

Levomepromazine

70mg

750micrograms

10mg

90mg

1000micrograms

15mg

100mg

1100micrograms

15mg

200mg

1200micrograms

30mg

Oxycodone

Glycopyrronium

Metoclopramide

40mg

450micrograms

20mg

50mg

600micrograms

30mg

50mg

650micrograms

30mg

100mg

1200micrograms

60mg

Oxycodone

Glycopyrronium

Midazolam

50mg

900micrograms

15mg

65mg

1200micrograms

20mg

70mg

1200micrograms

20mg

140mg

1200micrograms

40mg

Oxycodone

Haloperidol

Hyoscine butylbromide

80mg

4mg

100mg

100mg

5mg

120mg

105mg

6mg

120mg

210mg

10mg

120mg

Oxycodone

Haloperidol

Hyoscine hydrobromide

80mg

4mg

1000micrograms

100mg

5mg

1200micrograms

105mg

6mg

1200micrograms

210mg

10mg

1200micrograms

Oxycodone

Haloperidol

Midazolam

80mg

4mg

15mg

100mg

5mg

20mg

105mg

6mg

20mg

210mg

10mg

40mg

Oxycodone

Hyoscine butylbromide

Levomepromazine

80mg

100mg

20mg

100mg

120mg

25mg

105mg

120mg

25mg

210mg

120mg

50mg

Oxycodone

Hyoscine butylbromide

Midazolam

80mg

100mg

15mg

100mg

120mg

20mg

105mg

120mg

25mg

210mg

120mg

50mg

Oxycodone

Levomepromazine

Midazolam

40mg

40mg

25mg

50mg

50mg

30mg

50mg

50mg

30mg

100mg

100mg

60mg

Oxycodone

Metoclopramide

Midazolam

40mg

25mg

25mg

50mg

30mg

30mg

50mg

50mg

30mg

100mg

100mg

60mg

*Use water for injection as diluent for cyclizine

 

Table 5a: Subcutaneous alfentanil infusion TWO DRUG COMBINATIONS

Diluent: water for injection

Alfentanil is available in 2 strengths: 500microgram/ml (2ml amp) and 5mg/ml.
Please note: the high strength concentration (5mg/ml) may not be
available/recommended in some settings. Refer to local policy for its use.
Take care not to confuse Alfentanil with Fentanyl. These are two different strong opioids with varying potencies.

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml
    preparation, as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Alfentanil

Cyclizine*

11mg

150mg

15mg

150mg

16mg

150mg

32mg

150mg

Alfentanil

Glycopyrronium

50mg

1200micrograms

65mg

1200micrograms

72mg

1200micrograms

100mg

1200micrograms

Alfentanil

Haloperidol

70mg

10mg

90mg

10mg

100mg

10mg

100mg

10mg

Alfentanil

Hyoscine butylbromide

55mg

100mg

70mg

120mg

80mg

120mg

100mg

120mg

Alfentanil

Levomepromazine

75mg

40mg

100mg

55mg

100mg

60mg

100mg

100mg

Alfentanil

Metoclopramide

15mg

60mg

19mg

80mg

21mg

90mg

42mg

120mg

Alfentanil

Midazolam

50mg

35mg

65mg

45mg

70mg

50mg

100mg

80mg

Alfentanil

Octreotide

4mg

600micrograms

5mg

800micrograms

5mg

900micrograms

10mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 5b: Subcutaneous alfentanil infusion THREE DRUG COMBINATIONS

Diluent: water for injection

Alfentanil is available in 2 strengths: 500microgram/ml (2ml amp) and 5mg/ml.

Please note: the high strength concentration (5mg/ml) may not be
available/recommended in some settings. Refer to local policy for its use.

Take care not to confuse Alfentanil with Fentanyl. These are two different strong opioids with varying potencies.

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Alfentanil

Cyclizine

Haloperidol

6mg

150mg

10mg

7mg

150mg

10mg

8mg

150mg

10mg

16mg

150mg

10mg

Alfentanil

Cyclizine

Midazolam

8mg

150mg

25mg

11mg

150mg

30mg

12mg

150mg

35mg

24mg

150mg

70mg

Alfentanil

Haloperidol

Hyoscine butylbromide

1mg

1mg

90mg

1.5mg

1.5mg

120mg

1.5mg

1.5mg

120mg

3mg

3mg

120mg

Alfentanil

Haloperidol

Midazolam

9mg

8mg

45mg

12mg

11mg

60mg

13mg

12mg

65mg

26mg

15mg

130mg

Alfentanil

Hyoscine butylbromide

Levomepromazine

12mg

120mg

25mg

15mg

120mg

30mg

17mg

120mg

35mg

34mg

120mg

70mg

Alfentanil

Levomepromazine

Metoclopramide

8mg

20mg

50mg

10mg

25mg

60mg

12mg

30mg

70mg

24mg

60mg

120mg

Alfentanil

Levomepromazine

Midazolam

30mg

100mg

30mg

40mg

100mg

40mg

45mg

100mg

45mg

90mg

100mg

90mg

Alfentanil

Metoclopramide

Midazolam

8mg

25mg

25mg

10mg

30mg

30mg

12mg

35mg

35mg

24mg

70mg

70mg

*Use water for injection as diluent for cyclizine

 

Table 6a: Subcutaneous hydromorphone infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Hydromorphone

Cyclizine*

6mg

150mg

8mg

150mg

8mg

150mg

16mg

150mg

Hydromorphone

Glycopyrronium

34mg

1200micrograms

44mg

1200micrograms

48mg

1200micrograms

96mg

1200micrograms

Hydromorphone

Haloperidol

170mg

10mg

200mg

10mg

200mg

10mg

200mg

10mg

Hydromorphone

Hyoscine butylbromide

8mg

120mg

11mg

120mg

12mg

120mg

24mg

120mg

Hydromorphone

Hyoscine hydrobromide

8mg

800micrograms

10mg

1100micrograms

11mg

1200micrograms

22mg

1200micrograms

Hydromorphone

Levomepromazine

170mg

100mg

200mg

100mg

200mg

100mg

200mg

100mg

Hydromorphone

Metoclopramide

200mg

120mg

200mg

120mg

200mg

120mg

200mg

120mg

Hydromorphone

Midazolam

200mg

8mg

200mg

11mg

200mg

12mg

200mg

24mg

*Use water for injection as diluent for cyclizine

 

Table 6b: Subcutaneous hydromorphone infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Hydromorphone

Cyclizine*

Midazolam

40mg

150mg

20mg

55mg

150mg

30mg

60mg

150mg

30mg

120mg

150mg

60mg

Hydromorphone

Haloperidol

Midazolam

40mg

4mg

20mg

55mg

5mg

30mg

60mg

5mg

30mg

120mg

10mg

60mg

Hydromorphone

Hyoscine butylbromide

Levomepromazine

40mg

100mg

10mg

55mg

120mg

15mg

60mg

120mg

15mg

120mg

120mg

30mg

Hydromorphone

Levomepromazine

Metoclopramide

40mg

20mg

50mg

55mg

25mg

65mg

60mg

30mg

70mg

120mg

60mg

120mg

Hydromorphone

Levomepromazine

Midazolam

40mg

40mg

20mg

55mg

55mg

30mg

60mg

60mg

30mg

120mg

100mg

60mg

Hydromorphone

Metoclopramide

Midazolam

40mg

20mg

20mg

55mg

30mg

30mg

60mg

30mg

30mg

120mg

60mg

60mg

*Use water for injection as diluent for cyclizine

 

Table 7: Subcutaneous ketamine infusion in a syringe pump TWO DRUG COMBINATIONS

Diluent: 0.9% Saline

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Ketamine (alone)

600mg

600mg

600mg

600mg

Ketamine

Alfentanil

500mg

6mg

600mg

7mg

600mg

8mg

600mg

15mg

Ketamine

Dexamethasone*

600mg

1mg

600mg

1mg

600mg

1mg

600mg

1mg

Ketamine

Diamorphine

600mg

500mg

600mg

500mg

600mg

500mg

600mg

500mg

Ketamine

Haloperidol

300mg

10mg

400mg

10mg

435mg

10mg

600mg

10mg

Ketamine

Midazolam

500mg

35mg

600mg

45mg

600mg

50mg

600mg

100mg

Ketamine

Morphine

350mg

180mg

450mg

230mg

490mg

250mg

600mg

500mg

*dilute the ketamine in 0.9% saline before adding the dexamethasone to avoid precipitation