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  6. Single drugs used in a subcutaneous infusion over 24 hours in palliative care (tables 1a to 1f)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 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.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   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

 

 

Single drugs used in a subcutaneous infusion over 24 hours in palliative care (tables 1a to 1f) - using syringe pumps (syringe drivers)

Tables are best viewed in landscape mode on mobile devices

Single drugs used in a subcutaneous infusion over 24 hours in palliative care (tables 1a to 1f)

Diluent:water for injection unless stated and make up to
17ml in 20ml syringe or 22ml in 30ml syringe using a CME T34 pump or
24ml or 48ml in a 50ml syringe in a non-ambulatory pump.

Single agents

Indications/off label uses and dose range

Comments

Table 1a: Opioids – refer to Choosing and changing opioids guideline

Alfentanil

1mg in 2ml

5mg in 1ml (use may
be restricted in some areas)

Opioid responsive pain, breathlessness

Dose: Specialist advice
and supervision required

 

3rd line opioid; specialist advice needed.

1st line in stages 4/5 chronic kidney disease.

Caution with high strength preparation

(5mg in 1ml); only use in line with local policy.

Diamorphine

5mg, 10mg, 30mg, 100mg,
500mg powder ampoules

Opioid responsive pain, breathlessness

Dose: 5mg to 10mg over 24hours,
if no opioid before

Can be diluted in a small volume.

Preferred for high opioid doses.

Caution in stage 4/5 chronic kidney disease.

Hydromorphone

10mg in 1ml

20mg in 1ml

50mg in 1ml

Opioid responsive pain, breathlessness

Dose: specialist advice
and supervision required

3rd line opioid; specialist advice needed.

Caution in stage 4/5 chronic kidney disease.

Morphine sulfate

10mg, 30mg in 1ml

60mg in 2ml (other
strengths available but
not used commonly)

Opioid responsive pain, breathlessness

Dose: 5mg to 10mg over 24 hours,
if no opioid before

1st line opioid analgesic.

Caution in stage 4/5 chronic kidney disease.

 

Oxycodone

10mg in 1ml

20mg in 2ml

50mg in 1ml (use may
be restricted in some areas)

Opioid responsive pain, breathlessness

Dose: 2mg to 5mg over
24 hours, if no opioid before

2nd line opioid analgesic if
morphine/diamorphine not tolerated.

Caution in stage 4/5 chronic kidney disease.

Table 1b: Anti-emetics

Cyclizine

50mg in 1ml

 

Nausea and vomiting
(bowel obstruction or intracranial disease)

Dose: 50mg to 150mg over 24 hours

Anticholinergic; reduces peristalsis.

Can cause redness, irritation at site.

Incompatible with 0.9% saline,
always use water for injection.

Haloperidol

5mg in 1ml

10mg in 2ml

Opioid or metabolic induced nausea, delirium

Dose: 2mg to 5mg over 24 hours

Long half life: can also be given
as a once daily SC injection.

Extrapyramidal side effects.

Levomepromazine

25mg in 1ml

 

Complex nausea, terminal delirium / agitation

Dose: 5mg to 15mg over
24 hours – anti-emetic

Dose: 25mg to 100mg over 24 hours - sedative

Protect from light, exposure can cause
purple/yellow discolouration; discard if this occurs.

Lowers blood pressure.

Long half life: can be given
as a once or twice daily SC injection.

Second line sedative if midazolam ineffective.

Refer to Levomepromazine guideline.

Metoclopramide

10mg in 2ml

 

Nausea and vomiting

(peristaltic failure, gastric
stasis/outlet obstruction, opioid)

Dose: 20mg to 120mg over 24 hours

Prokinetic.

Avoid if complete bowel obstruction.

Worsens colic, use with caution.

Possible risk of extrapyrimidal side effects.

Table 1c: Anticholinergics for chest secretions or bowel colic

Glycopyrronium

200 micrograms in 1ml

600 micrograms in 3ml

Chest secretions or colic

Dose: 600 micrograms to
1200 micrograms over 24 hours

2nd line; non-sedative.

Longer duration of action than hyoscine.

Hyoscine butylbromide
(Buscopan®)

20mg in 1ml

Chest secretions, bowel
obstruction (colic, vomiting)

Dose: 40mg to 120mg over 24 hours

1st line; non-sedative.

Hyoscine hydrobromide

400 micrograms in 1ml

600 micrograms in 1ml

Chest secretions

Dose: 400 micrograms to
1200 micrograms over 24 hours

3rd line; sedative.

Can precipitate delirium.

 

 

Table 1d: Non Steroidals (NSAIDS)

Diclofenac

75mg in 3ml

Relief of pain and inflammation

Dose: 75mg to 150mg over 24 hours

Administer in separate syringe pump,
incompatible with most drugs.

Avoid in patients with history of,
or risk factors for, heart disease.

Monitor renal function.

Injection is irritant, dilute maximally with 0.9% saline.

Ketorolac

10mg in 1ml

30mg in 1ml

Short term management of pain

Dose: 60mg to 90mg over 24 hours

Likely to cause more GI irritation than diclofenac,
concurrent gastro protection recommended.

Avoid in patients with history of,
or risk factors for, heart disease.

Monitor renal function.

Injection is irritant, dilute maximally with 0.9% saline.

Table 1e Sedative

Midazolam

10mg in 2ml

Myoclonus, seizures, terminal delirium / agitation

Dose: titrate dose according
to symptoms and response

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.

Doses above 30mg midazolam seek specialist advice

Table 1f: Other medication occasionally given by the subcutaneous (SC) route in palliative care

Dexamethasone – refer to
medicine information sheet
for conversion.

3.3mg in 1ml

Bowel obstruction, raised
intracranial pressure or
intractable nausea and vomiting

Dose: 1.65mg to 13.2mg over 24 hours

Check preparation: available
as different dose formulations.

Give as a once or twice daily SC injection in the
morning and lunchtime or via syringe pump.

If given by SC bolus do not give
after 2pm to prevent insomnia.

Ketamine

10mg in 1ml (20ml vial)

50mg in 1ml (10ml vial)

100mg in 1ml (10ml vial)

 

Refractory chronic pain

Dose: initial dose 50mg to 100mg, titrate up as
needed to maximum 600mg over 24 hours

Can also be given by burst
treatment; refer to guideline.

Injection is irritant, dilute maximally with 0.9% saline.

Specialist advice required before commencing.

Levetiracetam

100mg in 1ml (5ml vial)

Seizures

Dose: 1g to 3g over 24 hours.
Doses above 2g will
need to be split over 2 pumps

1:1 conversion between oral and subcutaneous.

Limited compatibility with other medicines.

Higher doses will need multiple syringe pumps.

Octreotide

200micrograms/ml

(5ml multi-dose vial)

100 micrograms in 1ml

500 micrograms in 1ml

Intractable vomiting due to
bowel obstruction, fistula discharge

Dose: 250micrograms to
900 micrograms over 24 hours

Potent antisecretory agent.

Does not treat nausea.

Fridge item, let injection reach room
temperature before use to reduce pain.

Rotate injection sites.

Seek advice for higher doses.

Ranitidine

25mg in 1ml (2ml amp)

Bowel obstruction

Dose: 100mg to 200mg over 24 hours

Limited compatibility information.

Add last to avoid precipitation.