Continuous Subcutaneous Infusion

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Continuous subcutaneous infusions (CSCI) are a common method of medication administration in palliative medicine, especially for patients near the end of their life.

Advantages and indications for subcutaneous infusions

Dying patients often require parenteral medications as they lose the ability to take medications orally and the subcutaneous route has many advantages over the intravenous route.[1] Some of the advantages include are listed below:

  • No risk of phlebitis or air embolus
  • Allows patient to retain more mobility (IV site typically on hand or arm; subcutaneous sites include chest, thigh, abdomen)
  • More comfortable for patient
  • Less susceptible to occlusion or dislodgement
  • Simpler method of administration
  • Seen as kinder

The main indication for continuous subcutaneous infusions is for medication delivery when the oral route is unavailable. Examples include:

  • Drowsiness
  • Severe nausea or vomiting
  • Severe dysphagia

Comparative Dosing

Medication Oral dose and subcutaneous dose equivalent
Dexamethasone 4mg orally = 4mg SC (use as stat doses)
Diclofenac 150mg oral = 75mg SC (use only as CSCI as tissue necrosis has been reported with stat doses)
Haloperidol 2mg oral = 1mg SC
Hydromorphone 3mg oral = 1mg SC
Levetiracetam 250mg oral = 250mg SC (use only as CSCI)
Levomepromazine 25mg oral = 12.5mg SC
Methadone 10mg oral = 5mg SC (typically used as a stat dose rather than via CSCI)
Morphine 30mg oral = 10mg SC (use as stat doses for break-through pain and via CSCI for background pain)
Ondansetron 8mg oral = 4mg SC (typically used as a stat dose rather than via CSCI)
Oxycodone 10mg oral = 5mg SC (use as stat doses for break-through pain and via CSCI for background pain)
Ranitidine 100mg oral = 50mg SC
Valproate 200mg oral = 200mg SC (use as CSCI)


Combinations

Mixing mediations in subcutaneous infusions can cause problems if there are drug incompatibilities that cause reactions. Look for crystallization when mixing medications.

Morphine compatibilities

2 Drug Morphine Compatibilities
Diluent
Morphine + Cyclizine Water
Haloperidol Water or Saline
Hyoscine butylbromide Water
Ketamine Saline
Levomepromazine Water or Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Saline
Ondansetron Water or Saline
Ranitidine Water
Table: Morphine compatibilities
3 Drug Morphine Compatibilities
Diluent
Morphine + Cyclizine + Midazolam Water
Haloperidol + Cyclizine Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ranitidine Water
Hyoscine butylbromide + Octreotide Saline
Ondansetron Saline
Ranitidine Water
Levomepromazine + Hyoscine butylbromide Water or Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ranitidine # & Water
Metoclopramide + Ondansetron Saline
Ranitidine Saline
Midazolam + Cyclizine Water
Hyoscine butylbromide Water or Saline
Ketamine Water or Saline
Octreotide Water or Saline
Ondansetron Saline
# Add ranitidine last once all other drugs and diluent have been combined

& Precipitation reported with high doses of levomepromazine > 75mg

Table: Morphine compatibilities
4 Drug Morphine Comptabilities
Diluent
Morphine + Cyclizine + Midazolam + Ondansetron Water
Haloperidol + Cyclizine + Octreotide Water
Ranitidine Water
Hyoscine butylbromide + Ranitidine Water
Midazolam + Cyclizine Water
Hyoscine butylbromide Water
Levomepromazine + Hyoscine butylbromide + Octreotide Saline
Ranitidine # & Water
Midazolam + Hyoscine butylbromide Water
Ketamine Saline
Metoclopramide Water or Saline
Ondansetron Water
Metoclopramide + Midazolam + Ketamine Saline
Midazolam + Hyoscine butylbromide + Octreotide Saline
Metoclopramide + Octreotide Water or Saline
Ondansetron + Metoclopramide + Octreotide Saline
# Add ranitidine last once all other drugs and diluent have been combined

& Precipitation reported with high doses of levomepromazine > 75mg

Table: Morphine compatibilties


Oxycodone compatibilities

2 Drug Oxycodone Combinations
Diluent
Oxycodone + Cyclizine Water
Haloperidol Water or Saline
Hyoscine butylbromide Water or Saline
Ketamine Water or Saline
Ketorolac Saline
Levomepromazine Water or Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ondansentron Water or Saline
Ranitidine Water or Saline
Table - Oxycodone compatibilities
3 Drug Oxycodone Combinations
Diluent
Oxycodone Haloperidol + Cyclizine & Water
Ketamine Saline
Midazolam Water or Saline
Octreotide Water or Saline
Hyoscine butylbromide + Octreotide Water
Ondansetron Water
Ranitidine Saline
Levomepromazine + Hyoscine butylbromide Water or Saline
Ketamine Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ondansetron Water or Saline
Ranitidine Saline
Metoclopramide + Ondansetron Water or Saline
Ranitidine Saline
Midazolam + Cyclizine & Water
Hyoscine butylbromide Water or Saline
Ketamine Water or Saline
Metoclopramide Water or Saline
Octreotide Water or Saline
Ondansetron Water or Saline
& Precipitation reported with higher doses of oxycodone >100mg
Table - Oxycodone compatibilities
4 Drug Oxycodone Combinations
Diluent
Haloperidol + Hyoscine butylbromide + Ranitidine % Saline
Midazolam + Cyclizine & Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Octreotide Water
Levomepromazine + Hyoscine butylbromide + Octreotide Water or Saline
Ranitidine @ Saline
Metoclopramide + Midazaolam Water
Midazolam + Hyoscine butylbromide Water or Saline
Ketamine Saline
Octreotide Water or Saline
Ondansetron Saline
Midazolam + Hyoscine butylbromide + Ondansetron Water
Midazolam + Ondansetron + Octreotide Water
@ Precipitation has been reported with higher doses of oxycodone (>100mg) or levomepromazine (>100mg)
 % Add ranitidine last once all the other drugs and diluent have been combined
Table - Oxycodone compatibilities

Fentanyl compatibilities

Fentanyl 2 drug combinations
Diluent
Fentanyl + Haloperidol Water
Hyoscine butylbromide Water
Levomepromazine Water
Metoclopraimde Water
Midazolam Water
Ondansetron Saline
Ranitidine Saline
Table: Fentanyl Compatibilities
Fentanyl 3 drug combinations
Diluent
Fentanyl + Haloperidol + Midazolam Water
Levomepromazine + Hyoscine butylbromide Water
Metoclopramide Water
Midazolam Water
Ranitidine Saline
Midazolam + Cyclizine Water
Hyoscine butylbromide Saline
Metoclopramide Saline
Table: Fentanyl Compatibilities
Fentanyl 4 drug combinations
Diluent
Fentanyl + Haloperidol + Midazolam + Hyoscine butylbromide Water
Levomepromazine + Hyoscine butylbromide + Ranitidine Saline
Midazolam + Metoclopramide Water
Table: Fentanyl Compatibilities


Alfentanil compatibilities

2 Drug Alfentanil Combinations
Diluent
Alfentanil + Haloperidol Water or Saline
Hyoscine butylbromide Saline
Ketamine Water or Saline
Levomepromqzine Water or Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ondansetron Water or Saline
Table: Alfentanil compatibilities
3 Drug Alfentanil Combinations
Diluent
Alfentanil + Haloperidol + Cyclizine & Water
Ketamine Saline
Midazolam Water or Saline
Ondansetron Saline
Hyoscine butylbromide + Ketamine Saline
Levomepromazine + Hyoscine butylbromide Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ondansetron Saline
Metoclopramide + Ketamine Saline
Midazolam + Cyclizine & Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Metoclopramide Water or Saline
Octreotide Saline
Ondansetron Water or Saline
& Although various reports of this 3 drug combination, use caution because alfentanil + cyclizine alone is reported to be incompatible
Table: Alfentanil compatibilities
4 Drug Alfentanil Combinations
Diluent
Alfentanil + Haloperidol + Hyoscine butylbromide + Ketamine Saline
Midazolam + Cyclizine & Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Levomepromazine + Hyoscine butylbromide + Octreotide Saline
Ondansetron Saline
Midazolam + Hyoscine butylbromide Water or Saline
Ketamine Saline
Metoclopramide Saline
Octreotide + Ondansetron Saline
Midazolam + Hyoscine butylbromide + Ketamine Saline
Metoclopramide + Ketamine Saline
Ondansetron + Octreotide Water
& Use with caution because although this combination is reported as safe, alfentanil+cyclizine alone is not
Table: Alfentanil compatibilities


Dual opioid compatibilities

Dual opioid combinations
Methadone + Diluent
Morphine + Haloperidol + Midazolam Water
Hyoscine butylbromide Water
Hyoscine butylbromide + Midazolam Water
Levomepromazine + Hyoscine butylbromide Water
Metoclopramide Water
Midazolam & Water
Metoclopramide + Ranitidine @ Water
Oxycodone + Haloperidol + Midaolam Water
Levomepromazine + Midazolam Water
Midazolam Water
Ketorolac Saline
Alfentanil + Metoclopramide + Ranitidine @ Water
Haloperidol + Midazolam Water
Ketamine & Water
Levomepromazine + Hyoscine hydrobutylbromide Water
Midazolam + Ketamine Water
& Use caution as this combination is basde on reported experience with a 5th drug
@ Add ranitidine last once all the other drugs and diluent have been combined
Table: Dual Opioid Compatibilities

Methadone compatibilities

For methadone combined with other opioids see: Dual Opioid Compatibilities Table

Methadone 2 drug compatibilities
Diluent
Methadone + Cyclizine Water
Haloperidol Water
Ketamine Water or Saline
Levomepromazine Water
Midazolam Water
Table: Methadone Compatibilities
Methadone 3 drug combinations
Diluent
Methadone + Haloperidol + Ketamine Water or Saline
Midazolam Water
Hyoscine butylbromide + Ranitidine @ Saline
Ketamine + Midazolam Water
Levomepromazine + Hyoscine butylbromide Water
Midazolam ~ Water
Metoclopramide + Midazolam Water
Ranitidine @ Water
@ Add ranitidine last once all the other drugs and diluent have been combined
~ Precipitation reported with doses of methadone greather than 40mg
Table:Methadone compatibilities
Methadone 4 drug compatibilities
Diluent
Methadone + Haloperidol + Ranitidine + Hyoscine butylbromide Saline
Levomepromazine + Midazolam + Hyoscine butylbromide Saline
Table: Methadone compatibilities

Dexamethasone compatibilities

Template:Table dexamethasone compatibilities

Opioid-free compatibilities

Template:Table opioid free compatibilities

References

  1. Gabriel J. The use of subcutaneous infusion in medication administration. Br J Nurs. 2013 Jul 25-Aug 7;22(14).

Authors

User:Graham.grove