QuestionPrescription
QuestionComment
am i missing something, the q said syringe driver so why are we prescribing s/c?
17537
QuestionComment
syringe drivers are SC in palliative care
17543
User
subscriber
Loose Contusion
QuestionComment
Syringe drivers are known as continuous subcutaneous injections CSCI
39141
User
subscriber
Digiti Minimi
User
subscriber
Lipsyncope
QuestionComment
Can Oxycodone be given in this case? (If the dosage and route is correct?)
40141
QuestionComment
I do not see why not

40413
User
subscriber
Parok
User
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Acute DNA
QuestionComment
can you give 30 mg morphine twice a day?
61852
User
subscriber
Juice Defibrillator
Concept
Chapter
# Assessing fluid status 

- ABCDE approach

- Indications a patient may require fluid resuscitation:
  - Systolic BP <100mmHg
  - Heart rate >90bpm
  - Capillary refill >2s
  - Cool peripheries
  - Respiratory rate >20bpm
  - NEWS ≥5
  - Dry mucous membranes

# Fluid resuscitation 

- Identify cause of fluid deficit and respond appropriately
- Fluid bolus of 500mL crystalloid over <15 minutes
- Reassess using ABCDE approach
- Further fluid boluses (up to 2000mL) may be required

# Maintenance fluids 

- Assess ability to meet fluid needs enterally
- Assess fluid deficits, excess losses, abnormal fluid distribution

Normal daily fluid requirements:

- 25-30mL/kg/day water
- 1mmol/kg/day sodium
- 1mmol/kg/day potassium
- 1mmol/kg/day chloride
- 50–100g/day glucose to limit ketosis

#  IV fluids 

- Crystalloid = solution containing small molecules e.g. sodium, chloride
- Colloid = solution containing larger molecules e.g. albumin

**Commonly used fluids**

| Fluid Type                           | Na+ (mmol/L) | K+ (mmol/L | Cl-     | HCO3- | Glucose (mmol/L) |
| ------------------------------------ | ------------ | ---------- | ------- | ----- | ---------------- |
| Human plasma (for comparison)        | 135-145      | 3.5–5.0    | 100-110 | 22-26 | 3.5-5.5          |
| Sodium chloride 0.9% (Normal saline) | 154          |            | 154     |       |                  |
| Hartmann's                           | 131          | 5          | 111     | 29    |                  |
| Sodium chloride 0.18%/Glucose 4%     | 31           |            | 31      |       | 222 (40g)        |
| Sodium chloride 0.45%/Glucose 4%     | 77           |            | 77      |       | 222 (40g)        |
| 5% dextrose                          |              |            |         |       | 278 (50g)        |

# External links 

- [Life In The Fast Lane: Fluids](https://litfl.com/category/ccc/fluids/)
- [NICE: Algorithms for IV fluid therapy in adults](https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-hospital-algorithm-poster-set-191627821)
- [NICE: Composition of commonly used crystalloids](https://www.nice.org.uk/guidance/cg174/resources/composition-of-commonly-used-crystalloids-table-191662813)

1102
3589
Fluid prescribing
Topic
128
Palliative
## Drug choice feedback
Morphine sulphate and Diamorphine hydrochloride are opioids used in palliative care to manage pain. Opioids also help relieve dyspnoea and slow the respiratory rate. As this patient was already established on oral morphine, morphine sulphate would be an appropriate choice. Diamorphine hydrochloride can also be used and is more soluble and can be delivered in a smaller volume. Guidance on palliative prescribing in the BNF in the medicines guidance section under 'prescribing in palliative care'.

## Dose/Route/Frequency/Duration feedback
Subcutaneous morphine should be given at half the daily dose of oral morphine. 120/2 = 60

Subcutaneous diamorphine should be given at a third of the daily dose of oral morphine. 120/3 = 40

Syringe drivers are a machine used to infuse medications slowly via a subcutaneous needle, they are used in palliative care as they are less invasive than intravenous and intramuscular delivery.

Subcutaneous medications are generally prescribed in 24 hourly doses.

*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. 
10057
PrescriptionAnswer
PrescribeAnswerData
60 mg
PrescribeAnswerData
morphine sulfate 10 mg/mL injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
daily (OD)
PrescribeAnswerData
subcutaneous (SC)
PrescriptionAnswer
PrescribeAnswerData
40 mg
PrescribeAnswerData
diamorphine hydrochloride 10 mg injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
daily (OD)
PrescribeAnswerData
subcutaneous (SC)
Case Presentation: A 83-year-old gentleman was admitted to the acute medical ward 4 days ago unwell with a cough and worsening shortness of breath. He has Stage IV small cell lung cancer with spinal metastases. He has been treated with intravenous antibiotics but unfortunately, his condition has worsened. He is now considered to be end-of-life. He was previously on 120mg of oral morphine daily but can no longer tolerate oral medication. 


## PMH
Stage IV small cell lung cancer

## DH
Midazolam 20mg SC over 24 hours

Hyoscine Hydrobromide 40mg SC over 24 hours

Discontinued: Morphine Sulphate 60mg BD, Amlodipine 5mg OD

## On examination
The patient is drowsy.

On auscultation of the chest, there is reduced air entry and bronchial breath sounds bilaterally.

HR 90, RR 24, BP 110/84, Temperature 37.5°C

# Prescribing Request

Write a prescription for one drug that to treat this patient's pain and dyspnoea to be given via a syringe driver.