Levomepromazine is used as an antiemetic; it is given by mouth or by subcutaneous injection at bedtime. Midazolam is the benzodiazepine antiepileptic of choice for continuous subcutaneous infusion. Pain management in palliative care is focused on achieving control of pain by administering the right drug in the right dose at the right time. Subcutaneous infusion solution should be monitored regularly both to check for precipitation and discolouration and to ensure that the infusion is running at the correct rate. It should be prevented if possible by the regular administration of laxatives; a faecal softener with a peristaltic stimulant e. Transdermal route Transdermal preparations of fentanyl and buprenorphine are available, they are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose. In particular, chlorpromazine hydrochloride , prochlorperazine , and diazepam are contra-indicated as they cause skin reactions at the injection site; to a lesser extent cyclizine and levomepromazine also sometimes cause local irritation.
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Symptom control Several recommendations in this section involve unlicensed indications or routes.
In particular, chlorpromazine hydrochlorideprochlorperazineand diazepam are contra-indicated as they cause skin reactions at the injection site; to a lesser extent cyclizine and levomepromazine also sometimes cause local irritation.
Dry mouth Dry mouth may be relieved by good mouth care and measures such as chewing sugar-free gum, sucking ice or pineapple chunks, or the use of artificial saliva ,dry mouth associated with candidiasis can be treated by oral preparations of nystatin or miconazolealternatively, fluconazole can be given by mouth. It is used for nausea and vomiting due to mechanical bowel drygs, raised intracranial pressure, and motion sickness.
Constipation Constipation compatiblity a common cause of distress and is almost invariable after administration of an opioid analgesic. The family may be reassured by the knowledge that the patient will be admitted to a hospital or hospice if the family cannot cope. Formulations of transdermal patches are available as hourly, hourly and 7-day patches, for further information see buprenorphine. The following are problems that may be encountered with syringe drivers and the action that should be taken:.
Restlessness and confusion Restlessness and confusion may require treatment with an antipsychotic, e. The pain of bowel colic may be reduced by loperamide hydrochloride. The number of drugs should be as few as possible, for even the taking of medicine may be an effort.
Syringe Driver Drug Compatibility | MIMS online
Cyclizine is particularly likely to precipitate if mixed with diamorphine or other drugs see under Mixing and Compatibility, below Metoclopramide hydrochloride can cause skin reactions. Glycopyrronium bromide may also be used to treat bowel colic or excessive respiratory secretions. Review pain management if rescue analgesic is required frequently twice daily or more. For the treatment of nausea and vomiting associated with cancer chemotherapy see Cytotoxic drugs.
If breakthrough pain occurs give a subcutaneous preferable or intramuscular injection equivalent to one-tenth to one-sixth of the total hour subcutaneous infusion dose.
Syringe Driver Compatibility Chart
Capillary bleeding Capillary bleeding can be treated with tranexamic acid by mouth; treatment is usually discontinued one week after the bleeding has stopped, or, if necessary, it can be continued at a reduced dose.
Dry mouth may be caused by certain medications including opioids, antimuscarinic drugs e. Levomepromazine has a sedative effect. Once their pain is controlled, patients started on 4-hourly immediate-release morphine can be transferred to the same total hour dose of morphine given as the modified-release preparation for hourly or hourly administration.
Insomnia Patients with advanced cancer may not sleep because of discomfort, cramps, night sweats, joint stiffness, or fear.
Muscle spasm The pain of muscle spasm can be helped by a muscle relaxant such as diazepam or baclofen. The dose and frequency is adjusted according to the level of patient distress and the response.
Careful assessment of symptoms and needs of the patient should be undertaken by a multidisciplinary team. The use of physiological saline sodium chloride 0. Drugs with antimuscarinic effects antagonise prokinetic drugs syrinnge, if possible, should not be used concurrently.
Indications for the parenteral route are: If these preparations do not control the pain then morphine is the most useful opioid analgesic.
Ketamine is sometimes used under specialist supervision for neuropathic pain that responds poorly to opioid analgesics. Alternatives to morphineincluding transdermal buprenorphinetransdermal fentanylhydromorphone hydrochloridemethadone hydrochlorideor oxycodone hydrochlorideshould be initiated by those with experience in palliative care. Capillary bleeding can be treated with tranexamic acid by mouth; treatment is usually discontinued one week after the bleeding has stopped, or, if necessary, it can be continued at a reduced dose.
Compatibillity is a sedative and an antiepileptic that may be used in addition to an antipsychotic drug in a very restless patient.
Syringe Driver Drug Compatibility
For the dose by subcutaneous infusion see below. Nausea and vomiting Haloperidol and levomepromazine can both be given as a subcutaneous infusion but sedation can limit the dose of levomepromazine. Gastro-intestinal pain The pain of bowel colic may be reduced by loperamide hydrochloride.