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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Compatibility and stability tables for subcutaneous infusion (2a to 7) - using syringe pumps (syringe drivers)

Tables are best viewed in landscape mode on mobile devices

Table 2a: Subcutaneous morphine sulfate infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signsof precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22 ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Morphine Sulfate

Cyclizine*

270mg

150mg

350mg

150mg

380mg

150mg

760mg

150mg

Morphine Sulfate

Haloperidol

225mg

6mg

290mg

8mg

315mg

8mg

730mg

10mg

Morphine Sulfate

Hyoscine butylbromide

170mg

90mg

220mg

120mg

240mg

120mg

480mg

120mg

Morphine Sulfate

Hyoscine hydrobromide

370mg

1200micrograms

480mg

1200micrograms

520mg

1200micrograms

1000mg

1200micrograms

Morphine Sulfate

Levomepromazine

230mg

50mg

300mg

65mg

320mg

70mg

640mg

100mg

Morphine Sulfate

Metoclopramide

120mg

50mg

160mg

70mg

175mg

75mg

350mg

120mg

Morphine Sulfate

Midazolam

85mg

40mg

110mg

55mg

120mg

60mg

240mg

80mg

Morphine Sulfate

Octreotide

115mg

460micrograms

150mg

600micrograms

160mg

650micrograms

320mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 2b: Subcutaneous morphine sulfate infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Morphine sulfate

Cyclizine*

Haloperidol

210mg

150mg

6mg

275mg

150mg

8mg

300mg

150mg

9mg

600mg

150mg

10mg

Morphine Sulfate

Cyclizine*

Midazolam

150mg

150mg

20mg

200mg

150mg

30mg

220mg

150mg

30mg

440mg

150mg

60mg

Morphine Sulfate

Glycopyrronium

Midazolam

150mg

900micrograms

35mg

200mg

1200micrograms

45mg

220mg

1200micrograms

50mg

440mg

1200micrograms

80mg

Morphine Sulfate

Haloperidol

Hyoscine butylbromide

50mg

4mg

90mg

65mg

5mg

120mg

70mg

5mg

120mg

140mg

10mg

120mg

Morphine Sulfate

Haloperidol

Midazolam

110mg

6mg

40mg

140mg

8mg

55mg

150mg

9mg

60mg

300mg

10mg

80mg

Morphine Sulfate

Hyoscine butylbromide

Levomepromazine

100mg

90mg

12mg

130mg

120mg

15mg

140mg

120mg

15mg

280mg

120mg

30mg

Morphine Sulfate

Hyoscine butylbromide

Midazolam

110mg

90mg

15mg

140mg

120mg

20mg

150mg

120mg

20mg

300mg

120mg

40mg

Morphine Sulfate

Levomepromazine

Midazolam

120mg

45mg

50mg

160mg

60mg

70mg

175mg

65mg

75mg

350mg

130mg

150mg

Morphine Sulfate

Metoclopramide

Midazolam

80mg

60mg

40mg

100mg

80mg

50mg

110mg

85mg

55mg

220mg

170mg

110mg

*Use water for injection as diluent for cyclizine

 

Table 3a: Subcutaneous diamorphine infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22 ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Diamorphine

Cyclizine*

340mg

150mg

440mg

150mg

480mg

150mg

950mg

150mg

Diamorphine

Glycopyronnium

425mg

1200micrograms

550mg

1200micrograms

600mg

1200micrograms

1000mg

1200micrograms

Diamorphine

Haloperidol

800mg

10mg

1000mg

10mg 

1000mg

10mg 

1000mg

10mg

Diamorphine

Hyoscine butylbromide

1000mg

120mg

1000mg

120mg 

1000mg

120mg 

1000mg

120mg

Diamorphine

Hyoscine hydrobromide

1000mg

1200micrograms

1000mg

1200micrograms

1000mg

1200micrograms 

1000mg

1200micrograms 

Diamorphine

Levomepromazine

850mg

100mg

1000mg

100mg

1000mg

100mg 

1000mg

100mg

Diamorphine

Metoclopramide

1000mg

85mg 

1000mg

110mg

1000mg

120mg

1000mg

120mg

Diamorphine

Midazolam

560mg

80mg 

720mg

80mg

1000mg

80mg

1000mg

80mg

Diamorphine

Octreotide

425mg

1200micrograms 

550mg

1200micrograms 

1000mg

1200micrograms 

1000mg

1200micrograms 

*Use water for injection as diluent for cyclizine

 

Table 3b: Subcutaneous diamorphine infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Diamorphine

Cyclizine*

Haloperidol

340mg

150mg

10mg

440mg

150mg

10mg

480mg

150mg

10mg

960mg

150mg

10mg

Diamorphine

Haloperidol

Midazolam

800mg

7mg

65mg

1000mg

10mg

80mg

1000mg

10mg

80mg

1000mg

10mg

80mg

Diamorphine

Haloperidol

Hyoscine butylbromide

320mg

5mg

90mg

410mg

6mg

115mg

450mg

7mg

120mg

900mg

10mg

120mg

Diamorphine

Hyoscine butylbromide

Midazolam

120mg

80mg

20mg

150mg

100mg

25mg

165mg

110mg

27mg

320mg

120mg

55mg

Diamorphine

Levomepromazine

Metoclopramide

850mg

100mg

50mg 

1000mg

100mg

60mg

1000mg

100mg

65mg

1000mg

100mg

120mg

Diamorphine

Levomepromazine

Midazolam

800mg

100mg

60mg

1000mg

100mg

75mg

1000mg

100mg

80mg

1000mg

100mg

80mg

Diamorphine

Metoclopramide

Midazolam 

420mg

60mg

20mg

540mg

75mg

25mg

590mg

80mg

27mg

1000mg

120mg

55mg

Diamorphine

Hyoscine butylbromide

Levomepromazine

1000mg

120mg

50mg

1000mg

120mg

65mg

1000mg

120mg

70mg

1000mg

120mg

100mg

*Use water for injection as diluent for cyclizine

 

Table 4a: Subcutaneous oxycodone infusion using 10mg/ml, 20mg/2ml or 50mg/ml injection. TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Oxycodone

Cyclizine*

100mg

150mg

130mg

150mg

140mg

150mg

280mg

150mg

Oxycodone

Glycopyrronium

380mg

900micrograms

500mg

1200micrograms

540mg

1200micrograms

1080mg

1200micrograms

Oxycodone

Haloperidol

640mg

10mg

840mg

10mg

910mg

10mg

1820mg

10mg

Oxycodone

Hyoscine butylbromide

640mg

75mg

840mg

100mg

910mg

105mg

1820mg

120mg

Oxycodone

Hyoscine hydrobromide

525mg

900micrograms

680mg

1200micrograms

740mg

1200micrograms

1480mg

1200micrograms

Oxycodone

Levomepromazine

470mg

75mg

610mg

100mg

665mg

100mg

1330mg

100mg

Oxycodone

Metoclopramide

270mg

50mg

360mg

70mg

390mg

75mg

780mg

120mg

Oxycodone

Midazolam

270mg

50mg

360mg

70mg

390mg

75mg

780mg

80mg

Oxycodone

Octreotide

390mg

1200micrograms

500mg

1200micrograms

550mg

1200micrograms

1100mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 4b: Subcutaneous oxycodone infusion using 10mg/ml, 20mg/2ml or 50mg/ml injection THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Oxycodone

Cyclizine*

Glycopyrronium

90mg

150mg

900micrograms

120mg

150mg

1200micrograms

130mg

150mg

1200micrograms

260mg

150mg

1200micrograms

Oxycodone

Cyclizine*

Haloperidol

100mg

150mg

8mg

130mg

150mg

10mg 

140mg

150mg

10mg

280mg

150mg

10mg

Oxycodone

Cyclizine*

Midazolam

40mg

150mg

20mg

55mg

150mg

30mg

60mg

150mg

30mg

120mg

150mg

60mg

Oxycodone

Glycopyrronium

Levomepromazine

70mg

750micrograms

10mg

90mg

1000micrograms

15mg

100mg

1100micrograms

15mg

200mg

1200micrograms

30mg

Oxycodone

Glycopyrronium

Metoclopramide

40mg

450micrograms

20mg

50mg

600micrograms

30mg

50mg

650micrograms

30mg

100mg

1200micrograms

60mg

Oxycodone

Glycopyrronium

Midazolam

50mg

900micrograms

15mg

65mg

1200micrograms

20mg

70mg

1200micrograms

20mg

140mg

1200micrograms

40mg

Oxycodone

Haloperidol

Hyoscine butylbromide

80mg

4mg

100mg

100mg

5mg

120mg

105mg

6mg

120mg

210mg

10mg

120mg

Oxycodone

Haloperidol

Hyoscine hydrobromide

80mg

4mg

1000micrograms

100mg

5mg

1200micrograms

105mg

6mg

1200micrograms

210mg

10mg

1200micrograms

Oxycodone

Haloperidol

Midazolam

80mg

4mg

15mg

100mg

5mg

20mg

105mg

6mg

20mg

210mg

10mg

40mg

Oxycodone

Hyoscine butylbromide

Levomepromazine

80mg

100mg

20mg

100mg

120mg

25mg

105mg

120mg

25mg

210mg

120mg

50mg

Oxycodone

Hyoscine butylbromide

Midazolam

80mg

100mg

15mg

100mg

120mg

20mg

105mg

120mg

25mg

210mg

120mg

50mg

Oxycodone

Levomepromazine

Midazolam

40mg

40mg

25mg

50mg

50mg

30mg

50mg

50mg

30mg

100mg

100mg

60mg

Oxycodone

Metoclopramide

Midazolam

40mg

25mg

25mg

50mg

30mg

30mg

50mg

50mg

30mg

100mg

100mg

60mg

*Use water for injection as diluent for cyclizine

 

Table 5a: Subcutaneous alfentanil infusion TWO DRUG COMBINATIONS

Diluent: water for injection

Alfentanil is available in 2 strengths: 500microgram/ml (2ml amp) and 5mg/ml.
Please note: the high strength concentration (5mg/ml) may not be
available/recommended in some settings. Refer to local policy for its use.
Take care not to confuse Alfentanil with Fentanyl. These are two different strong opioids with varying potencies.

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml
    preparation, as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Alfentanil

Cyclizine*

11mg

150mg

15mg

150mg

16mg

150mg

32mg

150mg

Alfentanil

Glycopyrronium

50mg

1200micrograms

65mg

1200micrograms

72mg

1200micrograms

100mg

1200micrograms

Alfentanil

Haloperidol

70mg

10mg

90mg

10mg

100mg

10mg

100mg

10mg

Alfentanil

Hyoscine butylbromide

55mg

100mg

70mg

120mg

80mg

120mg

100mg

120mg

Alfentanil

Levomepromazine

75mg

40mg

100mg

55mg

100mg

60mg

100mg

100mg

Alfentanil

Metoclopramide

15mg

60mg

19mg

80mg

21mg

90mg

42mg

120mg

Alfentanil

Midazolam

50mg

35mg

65mg

45mg

70mg

50mg

100mg

80mg

Alfentanil

Octreotide

4mg

600micrograms

5mg

800micrograms

5mg

900micrograms

10mg

1200micrograms

*Use water for injection as diluent for cyclizine

 

Table 5b: Subcutaneous alfentanil infusion THREE DRUG COMBINATIONS

Diluent: water for injection

Alfentanil is available in 2 strengths: 500microgram/ml (2ml amp) and 5mg/ml.

Please note: the high strength concentration (5mg/ml) may not be
available/recommended in some settings. Refer to local policy for its use.

Take care not to confuse Alfentanil with Fentanyl. These are two different strong opioids with varying potencies.

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Alfentanil

Cyclizine

Haloperidol

6mg

150mg

10mg

7mg

150mg

10mg

8mg

150mg

10mg

16mg

150mg

10mg

Alfentanil

Cyclizine

Midazolam

8mg

150mg

25mg

11mg

150mg

30mg

12mg

150mg

35mg

24mg

150mg

70mg

Alfentanil

Haloperidol

Hyoscine butylbromide

1mg

1mg

90mg

1.5mg

1.5mg

120mg

1.5mg

1.5mg

120mg

3mg

3mg

120mg

Alfentanil

Haloperidol

Midazolam

9mg

8mg

45mg

12mg

11mg

60mg

13mg

12mg

65mg

26mg

15mg

130mg

Alfentanil

Hyoscine butylbromide

Levomepromazine

12mg

120mg

25mg

15mg

120mg

30mg

17mg

120mg

35mg

34mg

120mg

70mg

Alfentanil

Levomepromazine

Metoclopramide

8mg

20mg

50mg

10mg

25mg

60mg

12mg

30mg

70mg

24mg

60mg

120mg

Alfentanil

Levomepromazine

Midazolam

30mg

100mg

30mg

40mg

100mg

40mg

45mg

100mg

45mg

90mg

100mg

90mg

Alfentanil

Metoclopramide

Midazolam

8mg

25mg

25mg

10mg

30mg

30mg

12mg

35mg

35mg

24mg

70mg

70mg

*Use water for injection as diluent for cyclizine

 

Table 6a: Subcutaneous hydromorphone infusion TWO DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Hydromorphone

Cyclizine*

6mg

150mg

8mg

150mg

8mg

150mg

16mg

150mg

Hydromorphone

Glycopyrronium

34mg

1200micrograms

44mg

1200micrograms

48mg

1200micrograms

96mg

1200micrograms

Hydromorphone

Haloperidol

170mg

10mg

200mg

10mg

200mg

10mg

200mg

10mg

Hydromorphone

Hyoscine butylbromide

8mg

120mg

11mg

120mg

12mg

120mg

24mg

120mg

Hydromorphone

Hyoscine hydrobromide

8mg

800micrograms

10mg

1100micrograms

11mg

1200micrograms

22mg

1200micrograms

Hydromorphone

Levomepromazine

170mg

100mg

200mg

100mg

200mg

100mg

200mg

100mg

Hydromorphone

Metoclopramide

200mg

120mg

200mg

120mg

200mg

120mg

200mg

120mg

Hydromorphone

Midazolam

200mg

8mg

200mg

11mg

200mg

12mg

200mg

24mg

*Use water for injection as diluent for cyclizine

 

Table 6b: Subcutaneous hydromorphone infusion THREE DRUG COMBINATIONS

Diluent: water for injection

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Hydromorphone

Cyclizine*

Midazolam

40mg

150mg

20mg

55mg

150mg

30mg

60mg

150mg

30mg

120mg

150mg

60mg

Hydromorphone

Haloperidol

Midazolam

40mg

4mg

20mg

55mg

5mg

30mg

60mg

5mg

30mg

120mg

10mg

60mg

Hydromorphone

Hyoscine butylbromide

Levomepromazine

40mg

100mg

10mg

55mg

120mg

15mg

60mg

120mg

15mg

120mg

120mg

30mg

Hydromorphone

Levomepromazine

Metoclopramide

40mg

20mg

50mg

55mg

25mg

65mg

60mg

30mg

70mg

120mg

60mg

120mg

Hydromorphone

Levomepromazine

Midazolam

40mg

40mg

20mg

55mg

55mg

30mg

60mg

60mg

30mg

120mg

100mg

60mg

Hydromorphone

Metoclopramide

Midazolam

40mg

20mg

20mg

55mg

30mg

30mg

60mg

30mg

30mg

120mg

60mg

60mg

*Use water for injection as diluent for cyclizine

 

Table 7: Subcutaneous ketamine infusion in a syringe pump TWO DRUG COMBINATIONS

Diluent: 0.9% Saline

  • The figures in these tables are NOT clinical doses to prescribe. They are the maximum amounts of each
    drug that can be mixed in the syringe and generally be considered physically stable for 24 hours.
  • Most patients will require much lower doses. Refer to relevant guidelines to obtain the usual dose
    range to prescribe for each drug. Use minimum effective dose and review according to response.
  • Mixing of drugs in this manner is unlicensed but is supported by clinical practice.
  • Seek specialist advice from a clinical pharmacist if the doses needed are greater than those stated in the tables.
  • Check the infusion after set up and in acute setting every 4 hours for any signs of precipitation, cloudiness,
    particles or colour change as external factors, for example light and heat may cause problems.
  • The doses of alfentanil stated below may not always be appropriate if using the 500micrograms/ml preparation,
    as the volume of this preparation needed would not fit into the syringe.

Type of pump

CMC T34 pump Non-ambulatory pump

Drug Combinations

Dilute using water for injection to a final volume of:

17ml in 20ml syringe and
use CME T34 pump

22ml in 30ml syringe and
use CME T34 pump

24ml in 50ml syringe and
use non ambulatory pump

48ml in 50ml syringe and
use non ambulatory pump

 

MAXIMUM amounts that can be mixed together and are considered physically stable for 24h

Ketamine (alone)

600mg

600mg

600mg

600mg

Ketamine

Alfentanil

500mg

6mg

600mg

7mg

600mg

8mg

600mg

15mg

Ketamine

Dexamethasone*

600mg

1mg

600mg

1mg

600mg

1mg

600mg

1mg

Ketamine

Diamorphine

600mg

500mg

600mg

500mg

600mg

500mg

600mg

500mg

Ketamine

Haloperidol

300mg

10mg

400mg

10mg

435mg

10mg

600mg

10mg

Ketamine

Midazolam

500mg

35mg

600mg

45mg

600mg

50mg

600mg

100mg

Ketamine

Morphine

350mg

180mg

450mg

230mg

490mg

250mg

600mg

500mg

*dilute the ketamine in 0.9% saline before adding the dexamethasone to avoid precipitation