QuestionPrescription
QuestionComment
Excessive respiratory secretions in palliative care 
By subcutaneous injection

Adult
20 mg every 4 hours if required, adjusted according to response to up to 20 mg every 1 hour.
By subcutaneous infusion

Adult
20–120 mg/24 hours.
61145
QuestionComment
In a syringe driver 1.2mg in 24 hours would mean 50 micrograms per hour. So why is the correct answer not hyoscine hydrobromide 400 micrograms/mL injection, 50 micrograms SC every hour, continuous? 
61523
User
subscriber
Claire
User
subscriber
Serotonin Fracture
QuestionComment
why 5mg per hour ? : ) 
61503
QuestionComment
I did the same but I think because the BNF says '20 mg every 4 hours if required' so its 5 mg in one hour. Mean question but I can see what they're going for
61826
User
subscriber
Craniofacial 
User
subscriber
Acute Sclerosis
QuestionComment
marked wrong if you prescribe it as 1 mL of 400 micrograms/mL because you should put "400 micrograms" but in the other mock it was the other way around, so frustrating
61534
User
subscriber
Vaccine Complement
QuestionComment
Why not 20mg per hour as per bnf?
61677
User
subscriber
Metabolism Myopathy
Concept
Chapter
#### Monitoring

The BNF advises to monitor lung function (in patients with a history of obstructive airway disease).

#### Overdoses

Overdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).
Non-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.

Management
 - Airway protection 
 - Activated charcoal within 1 hour
 - IV Fluids
 
IV glucagon is the first-line management.
 
For symptomatic bradycardia, IV atropine may be used.

2618
2699
End-of-life agitation
Topic
74
Elderly Care
# Drug choice feedback

A trial of medicine to treat noisy respiratory secretions should be considered if they are causing distress to the family of the patient at the end-of-life. They can be treated using anticholinergics such as those given above, at their starting doses, before uptitrating. Atropine can also be used as recommended by NICE but it is used off-label.

# Dose/Route/Frequency/Duration feedback

If the patient continues to have significant secretions not managed with PRN subcutaneous doses, the addition of these medications to the syringe driver can be considered.
6763
PrescriptionAnswer
PrescribeAnswerData
200 micrograms
PrescribeAnswerData
glycopyrronium bromide 200 micrograms/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
every hour (Q1H)
PrescribeAnswerData
subcutaneous (SC)
PrescriptionAnswer
PrescribeAnswerData
5 mg
PrescribeAnswerData
hyoscine butylbromide 20 mg/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
every hour (Q1H)
PrescribeAnswerData
subcutaneous (SC)
PrescriptionAnswer
PrescribeAnswerData
0.25 mL
PrescribeAnswerData
hyoscine butylbromide 20 mg/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
every hour (Q1H)
PrescribeAnswerData
subcutaneous (SC)
PrescriptionAnswer
PrescribeAnswerData
1 mL
PrescribeAnswerData
hyoscine hydrobromide 400 micrograms/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
every hour (Q1H)
PrescribeAnswerData
subcutaneous (SC)
PrescriptionAnswer
PrescribeAnswerData
400 micrograms
PrescribeAnswerData
hyoscine hydrobromide 400 micrograms/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
every hour (Q1H)
PrescribeAnswerData
subcutaneous (SC)
Case Presentation: A 91-year-old gentleman has been admitted to the hospice for end-of-life care after being diagnosed with end-stage pancreatic cancer 1 year ago. The nurses looking after him has reported increased noisy respiratory secretions which is causing the family distress.


## PH

Pancreatic cancer, Hypertension, Chronic Kidney Disease, Type 2 Diabetes Mellitus.

## DH

Current: Morphine 30mg SC, cyclizine 150mg SC, midazolam 20mg SC via a syringe driver diluted with sterile water given over 24 hours. Discontinued: Ramipril 5mg PO OD, Bendroflumethiazide 2.5mg PO OD, Metformin 1g BD PO (NKDA)

## On examination

Appears comatose, noisy respiratory secretions audible from the bedside.

# Prescribing Request

Write a prescription for one additional drug that is most appropriate for treating his noisy respiratory secretions