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  2. Scottish Palliative Care Guidelines
  3. Syringe pump / driver guidelines
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  5. Syringe pump / driver compatibles
  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

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

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 BD Bodyguard T 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 24 hours,
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.