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Announcements and latest updates

Right Decision Service newsletter: September 2024

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

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

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

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 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.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

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