Anticipatory drugs and syringe driver chart V2 drug… · Page 12 Page 1 This chart is in t ended f or use in all car e se Opioid dose conversion chart, syringe driver doses, rescue/prn

In h

ours

Ou

t of hou

rs

Dis

co

ntin

ue p

res

crip

tion

s b

y c

lea

rly c

ros

sin

g

th

rou

gh

the w

ho

le p

rescrip

tion

, with

the d

ate

d

isco

ntin

ued

& s

ign

atu

re.

Do n

ot a

lter a

n e

xisting p

rescrip

tion a

lways

rew

rite a

new

syringe d

river p

rescrip

tion in

a

new

box

There

is spa

ce fo

r 4 syrin

ge d

river p

rescrip

tions

Alw

ays c

hec

k fo

r alle

rgie

s.

Information for prescribers

Cancel D

rugs

Opioids

U

se 2

0m

L syrin

ges o

r 30m

L if la

rger vo

lum

e

require

d.

Syringes

Information for n

urses

St Leo

na

rd’s H

osp

ice

cY

ork T

ea

chin

g H

osp

ital N

HS

Fo

un

da

tion

Tru

st.

Ow

ne

r: Dr A

nn

e G

arry. Issu

e D

ate

: No

vem

be

r 20

15

. Re

view

Da

te: N

ove

mb

er 2

01

8V

ersio

n: 2

Ap

pro

ved

by: D

rug

an

d T

he

rap

eu

tic Co

mm

ittee

Ord

er n

um

be

r: FY

03

00

00

81

we

bsite

for a

lgo

rithm

s and co

nve

rsion

charts

ww

w.y

ork

.nh

s.u

k/O

ur S

erv

ices/G

P h

ub

or

w

ww

.yo

rk.n

hs

.uk

/Ou

r Serv

ices

/pallia

tive c

are

U

se cle

ar a

dhesive

dre

ssing

ove

r the

infu

sion

site

Patie

nts w

ith syrin

ge d

rivers sh

ould

be

che

cked

eve

ry 4 h

ours

in in

stitutio

ns a

nd

as a

min

imum

eve

ry 24

hou

rs in a

pa

tien

t's hom

e.

If th

e p

atie

nt re

quire

s ad

ditio

nal m

ed

icatio

n (a

nalg

esic/

sedative

/an

tiem

etic e

tc) give

a su

bcu

tan

eo

us d

ose

of th

e

appro

pria

te d

rug, a

s pre

scribed

on

the p

rn se

ction o

f the

dru

g ch

art. If in

effe

ctive se

ek m

edica

l ad

vice.

N

B e

ach

no

n-o

pio

id d

rug

has a

24 h

ou

r ma

ximu

m.

If yo

u a

re g

iving o

pio

ids (e

.g.m

orp

hin

e, o

xycodo

ne

, alfe

nta

nil)

to a

patie

nt w

ho

has n

ot h

ad o

ne

befo

re (o

pio

id n

aïve

), or to

a

pa

tien

t who h

as h

ad a

dose

incre

ase

obse

rve fo

r sign

s of:

D

row

sine

ss

C

on

fusio

n/h

allu

cina

tions

■■

N

ause

a / vo

mitin

g

Red

uce

d re

spira

tory ra

te

■■

T

witch

ing

■

Obse

rve p

atie

nts c

lose

ly an

d re

po

rt an

y sympto

ms yo

u a

re

con

cern

ed a

bou

t to th

e d

octo

r. Th

e o

pio

id m

ay n

eed

to b

e

disco

ntin

ued, re

duce

d o

r cha

ng

ed

to a

diffe

ren

t opio

id.

In

exce

ptio

nal ca

ses n

alo

xon

e m

ay b

e re

quire

d to

reve

rse

opio

id sid

e e

ffects. R

efe

r to n

alo

xon

e in

fusio

n g

uid

elin

es.

If GF

R<

15m

L/m

in a

nd

un

ab

le to

tole

rate

ox

yc

od

on

e u

se

alfe

nta

nil (5

00m

icro

gra

m/m

L)

Look a

t info

rmatio

n in

red

on:

Anticip

ato

ry dru

gs se

ction

use

oxyco

do

ne

or a

lfen

tanil a

s sc op

ioid

of ch

oice

Pre

scrip

tion

s fo

r op

ioid

s &

CD

s m

ust b

e

pre

scrib

ed

in w

ord

s a

nd

fig

ure

s. C

Ds n

ow

in

clude m

ida

zola

m &

phenobarb

iton

e

Write

in w

ho

le n

um

be

rs a

nd w

here

possib

le

avo

id d

ecim

als

. D

ocu

men

t dose

calcu

latio

ns in

the m

edica

l note

s. T

he p

rn d

ose ra

nges sh

ou

ld re

flect th

e to

tal

am

ount o

f reg

ula

r opio

id th

e p

atie

nt is re

ceivin

g

from

all ro

ute

s (ie syrin

ge

drive

r and fe

nta

nyl o

r b

up

ren

op

hin

e p

atch

if in situ

). The p

rn d

ose

is one sixth

of th

e 2

4 h

ou

r do

se o

f regu

lar o

pio

ids if

patie

nt ca

n to

lera

te th

is.C

alcu

late

the

incre

ase

d o

pio

id d

ose

require

men

ts fo

r the n

ext syrin

ge

drive

r base

d o

n th

e n

um

ber o

f additio

nal p

rn d

ose

s ove

r the p

revio

us 2

4 h

ours

(ensu

ring th

e p

ain

is opio

id se

nsitive

) R

em

em

ber to

pre

scribe re

gula

r medica

tions

(inclu

din

g o

pio

id p

atch

es) a

nd p

rn m

edica

tions

(when re

quire

d) o

n th

e ch

art.

Gen

era

lly u

se w

ate

r for in

jectio

n.

N

eve

r use

0.9

% so

diu

m ch

lorid

e w

ith cyclizin

e a

s it w

ill crystallise

Use 0

.9%

so

diu

m c

hlo

ride

for

Levo

me

pro

ma

zine b

y itself

S

yringe d

river co

mbin

atio

ns co

nta

inin

g

octre

otid

e, m

eth

adone, ke

toro

lac, ke

tam

ine o

r fu

rose

mid

e

Prescribe approved name of drug entered in CA

PITALS

Dilu

ents

Resources for information

For patients with ren

al failure

P

lease

if un

certa

in a

bo

ut d

rug

com

patib

ilities

se

ek

ad

vic

e

S

pecia

list pallia

tive ca

re/ h

osp

ice

Medicin

es in

form

atio

n

T

he

Syrin

ge D

river: C

on

tinu

ou

s subcu

tan

eo

us in

fusio

ns in

pallia

tive ca

re 3

rd e

ditio

n A

nd

rew

Dickm

an

, Jenn

y Sch

ne

ide

r

Fo

r dyin

g p

atie

nts

refe

r to

care

pla

n fo

r last d

ays o

f life d

ocu

me

nta

tion

Fo

r all o

ther in

form

atio

n c

on

su

lt

If more information is required please seek help from specialist palliative care

Page 12

Page 1 This chart is intended for use in all care settings

Opioid dose conversion chart, syringe driver doses, rescue/prn doses and opioid patchesUse the conversion chart to work out the equivalent doses of different opioid drugs by different routes.

The formula to work out the dose is under each drug name. Examples are given as a guide

Fentanyl and buprenorphine patches in the dying/moribund patient· Continue fentanyl and buprenorphine patches in these patients.

o Remember to change the patch(es) as occasionally this is forgotten!o Fentanyl patches are more potent than you may think

If pain occurs whilst patch in situ· Prescribe 4 hourly prn doses of subcutaneous(sc) morphine unless contraindicated.· Use an alternative sc opioid e.g. or in patients withalfentanil oxycodone

o poor renal function, o morphine intolerance o where morphine is contraindicated

· Consult when prescribing 4 hourly prn subcutaneous opioidspink tableAdding a syringe driver (SD) to a fentanyl or buprenorphine patchIf 2 or more rescue/ prn doses are needed in 24 hours, start a syringe driver with appropriate opioid and continue patch(es). The opioid dose in the SD should equal the total prn doses given in the previous 24 hours up to a maximum of 50% of the existing regular opioid dose. Providing the pain is opioid sensitive continue to give prn sc opioid dose & review SD dose daily. E.g. Patient on 50 micrograms/hour fentanyl patch, unable to take prn oral opioid and in last days of life. Keep patch on. Use appropriate opioid for situation or care setting. If 2 extra doses of 15 mg sc morphine are required over the previous 24 hours, the initial syringe driver prescription will be morphine 30mg/24 hour. Remember to look at the dose of the patch and the dose in the syringe driver to work out the new opioid breakthrough dose each time a change is made.

Always use the chart above to help calculate the correct doses.

Calculation of breakthrough/ rescue / prn doses

Oral prn doses:th· Morphine or Oxycodone: 1/6 of 24

hour oral dose

Subcutaneous: th· Morphine & Oxycodone: 1/6 of 24

hour sc syringe driver (SD) doseth· Alfentanil: 1/6 of 24 hour sc SD dose

o Short action of up to 2 hourso Seek help If reach Maximum

of 6 prn doses in 24 hours

(For ease of administration, opioid doses over 10mg, prescribe to nearest 5mg)

Renal failure/impairment GFR

Prescrib

er’s sign

ature b

leep:

Enter details of know

n allergies/sensitivities and reaction or write ‘nil know

n’

Th

is section

MU

ST

be co

mp

leted b

efore m

edicin

es are given

Prn Chart for Anticipatory DrugsFrequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures

Opioid Is patient renally compromised? If so avoid morphine and use oxycodone or alfentanil Dose depends on whether patient opioid naïve or has been on regular opioidsAnti agitation Midazolam start low Respiratory secretions Hyoscine Butylbromide (Buscopan) 20mgAntiemetic Was drug effective orally? If so continue with same drug sc If patient requires two drugs to control nausea prescribe both For compatibility consult antiemetic table (to the left)

Prescribing Anticipatory drugs - up to five depending on antiemetic combination

LEVOMEPROMAZINE(25mg/mL)

Date Time Route Dose Sig Date Time Route Dose Sig

Date Dose

Full Signature & bleep SupplyPharm

SC

Date Dose


SC

Date Dose


5 to 6.25mg

NOTE ON RECORDING: Enter actual dose given in DOSE column

MIDAZOLAM (10mg/2mL)

Nausea Max: 25mg in 24 hoursAgitation consult Palliative Care Team

Prescriber may alter frequency if indicated.

Max: 5mg in 24 hours (prn + S/driver) Lower max in renal failure

8 hourly prn

2 to 4 hourly prn

Date Dose

Full Signature & bleep Supply

HALOPERIDOL (5mg/mL) (nausea)

500 micrograms to 1mg

Pharm


SC

Date Dose


SC


HYOSCINE BUTYLBROMIDE (20mg/mL)

Date Dose

Full Signature & bleep Supply

Drug

Pharm

SC20mg

Start low in renal patients

BUSCOPAN for colic & resp secretions

Max 240mg in 24 hours (prn +S/driver)

3

Drug 2

Drug Appropriate opioid1

Drug 6

Drug 5

Drug 4

Max 60mg in 24 hours (prn +S/driver) Max usually 30mg in 24 hours in renal failure (prn +S/driver)

2 - 4 hourly prn. May need 10mg for bleeds

Instructions

Instructions

Instructions

Instructions

Page 2

Page 11

First n

am

e:

Surn

am

e:

DO

B:

Hosp

No:

NH

S N

o:

G

P/C

ons:

2 to 5mgStart low in renal patients

Start low in renal patients

Date & time of S/D set up / check

Asset No

Prescription used e.g. No. 1 to 4

Site changed Yes or No

Location of site used

Line changed Yes or No

Battery % * at set up

Rate in mL

Volume to be infused (VTBI) mL

Volume infused in mL

Site Ok Yes or No

Syringe and line clear Yes or No

Battery % *

Key pad lock on

Signature / Initials

Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200

4 hourly checks in Hospital/ Community Hospital/ Care Home/ Hospice. Minimum daily check in Community.

T34 set up - Complete both shaded and white area checklist T34 Monitoring - Complete white area checklist


Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on


Battery Syringe contentsCheck battery *Change if 40% in patients home Change 15% in hospital/hospice

Check drugs in syringe or line areclear with no crystallisation

Is the syringe driver working ?

Check set up Check battery

Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200


4 hourly prn

8 hourly prn

First n

am

e:

Surn

am

e:

DO

B:

Hosp

No:

NH

S N

o:

G

P/C

ons:

If patient on opioid patch and syringe driver the prn opioid dose should reflect this

Antiemetics Antiemetics used togetherHaloperidol + Cyclizine

Metoclopramide + Levomepromazine

Antiemetics not used togetherMetoclopramide + cyclizine: opposing effect

Haloperidol + levomepromazine: dopaminergic

Haloperidol + metoclopramide: dopaminergic

Haloperidol (5mg/mL) prescribed as an anticipatory Indications: Opioid or chemically induced nausea

Levomepromazine (25mg/mL) prescribed as anticipatory Indications: Broad spectrum antiemetic (also anti-agitation medication)

Metoclopramide (10mg/mL) unless clinically not prescribed routinelyindicated Indications: Prokinetic, pushes gut contents forward Dose:10mg tds /prn Syringe driver SD 30 to 60mg /24 hours

Cyclizine (50mg/mL) unless clinically indicated not prescribed routinelyIndications: Raised intracranial pressure and bowel obstruction Dose: to 50mg tds prn Syringe driver SD to 150mg /24 hours25 75 Start low (dose in red) or avoid in renal /heart/ liver failure

SC

O

Ward

Su

pp

lemen

tary chart

Main chart

NB use Levomepromazine if above ineffective

If patient on opioid patch and syringe driver the prn opioid dose must take account of thisFrequency of some medications may be altered at discretion of prescriber. Remember to write opioid dose in words and figures

Date Dose

Full Signature & bleep

Date Dose



Date Dose


Date Dose


Drug 13

Drug 12

Drug 11

Drug 14

Instructions

Instructions

Instructions

Instructions

Page 10

Page 3

Prn Chart for Anticipatory Drugs

Dose



Dose



Dose


Dose


SupplyPharm


SupplyPharm

SupplyPharm

SupplyPharm

Instructions

Instructions

Instructions

Instructions

Drug

Drug

Drug

Drug

Date

Date

Date

Date

10

7

9

8


Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on


Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200




Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on






Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200


SC

O

SC

O

SC

O

SC

O

SC

O

SC

O

SC

O

SC

O

Year

Date/M

onthD

rug

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Pharm

acy M

edica

tion C

heck a

nd L

eve

l 1 o

r 2

e.g

. fenta

nyl, b

upre

norp

hin

e o

r hyo

scine p

atch

es, a

ntifu

ngals, a

ny to

pica

l or P

R m

edica

tions

Essential Regu

lar Medication

PANTSPANTSPANTSPANTSPANTSPANTS

An

timic

rob

ials

sh

ou

ld h

ave

an

ind

ica

tion

an

d c

ou

rse

le

ng

th o

r revie

w d

ate

reco

rde

d o

n th

e c

ha

rt=

Pre

- adm

issio

n

= A

mended d

ose o

f pre

-adm

issio

n m

ed

icin

e

= N

ew

medic

ine

= T

ime c

ritical m

edic

ine

= S

up

ple

me

nta

ry c

ha

rts

1

Medica

tion n

ot re

quire

d2

Refu

sed

3

Abse

nt fro

m w

ard

4

Medica

tion n

ot a

vaila

ble

5

Unable

to ta

ke

6

Nil b

y mouth

7

Pre

scriptio

n n

ot cle

ar

8

Unable

to a

dm

iniste

r9

Self m

edica

tion

10

Self m

edica

tion a

t hom

e

No

n-a

dm

inis

tratio

n c

od

es

PANTS

Page 4

Page 9


Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on


Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200




Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on






Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200


Year

Date/M

onthD

rug

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Dru

g

Date

Dose

Instru

ctions

Full S

ignatu

re &

Ble

ep

Pharm

Supply

PO

SCIV

IM

6814

12

22

18

Pharm

acy M

edica

tion C

heck a

nd L

eve

l 1 o

r 2

e.g

. fenta

nyl, b

upre

norp

hin

e o

r hyo

scine p

atch

es, a

ntifu

ngals, a

ny to

pica

l or P

R m

edica

tions

Essential Regular M

edication

PANTSPANTSPANTSPANTSPANTSPANTSPANTS


Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on


Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200




Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on






Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200


Page 8

Page 5

Syringe Driver Prescription Chart

Syringe driver drug(s) Dose(CDs to be prescribed in words and figures)

If advised by specialist palliative care team

Diluent (For advice read front sheet)

Date Prescriber Signature

1.

2.

3.

4.





1.

2.

3.

4.





1.

2.

3.

4.





1.

2.

3.

4.

1 2

43

Route DurationSC 24 hours




Has patient consented to syringe driver? Yes / No If unable to consent has family agreed? Yes / NoIf Patient on opioid patch - leave patch on and refer to opioid conversion chart

Page 6

Page 7


Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on


Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200




Asset No






Rate in mL



Site Ok Yes or No


Battery % *

Key pad lock on






Time 0200 0600 1000 1400 1800 2200 0200 0600 1000 1400 1800 2200


Documents

Anticipatory drugs and syringe driver chart V2 drug… · Page 12 Page 1 This chart is in t ended f or use in all car e se Opioid dose conversion chart, syringe driver doses, rescue/prn