[[continuous_subcutaneous_infusions]]

Authors: Dr Graham Grove, Lorna Chess-Williams

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

Depending on the region and the devices used, there are various common usage terms to refer to CSCIs including syringe drivers, CADD pumps, NIKI pumps and Baxter pumps.

Dying patients often require parenteral medications as they lose the ability to take medications orally. 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
  • Allow patient to retain more mobility (IV site typically on hand or arm; subcutaneous sites include chest, thigh and abdomen)
  • More comfortable for patient
  • Less susceptible to occlusion or dislodgement
  • 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
Medication Approximate oral dose and subcutaneous dose equivalent
Alfentanil
Clonidine 50microg oral = 50microg subcut
Clonazepam
Cyclizine
Dexamethasone 4mg oral = 4mg subcut (use as state doses)
Diclofenac 150mg oral = 75mg subcut (use only as CSCI as tissue necrosis has been reported with stat doses)
Esomeprazole
Fentanyl
Frusemide 40mg oral = 20mg subcut
Glycopyrrolate
Granisetron 2mg oral = 1mg subcut
Haloperidol 2mg oral = 1mg subcut
Hydromorphone 3mg oral = 1mg subcut
Hyoscine butylbromide
Hyoscine hydrobromide
Ketamine 10mg oral = 10mg subcut
Ketorolac 10mg oral = 10mg subcut
Levetiracetam 25mg oral = 12.5mg subcut
Lignocaine
Methadone 10mg oral = 5mg subcut
Metoclopramide 10mg oral = 10mg subcut
Morphine 15mg oral = 5mg subcut
Neostigmine
Octreotide
Omeprazole
Ondansetron 8mg oral = 4mg subcut
Oxycodone 10mg oral = 5mg subcut
Paracetamol
Phenobarbitone 100mg oral = 100mg subcut
Ranitidine 100mg oral = 50mg subcut
Remifentanil
Sufentanil
Valproate 200mg oral = 200mg subcut
2019/07/03 22:57 · Graham Grove

Mixing medications 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 Combinations

Second Drug 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
2019/07/03 23:06 · Graham Grove

3 Drug Morphine Combinations

Second Drug Third Drug Diluent
Morphine + Cyclizine + Midazolam Water
Halperidol + Cyclizine Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Midazolam Water or Saline
Octreotide Water or Saline
Hyoscine butylbromide + Octreotide Saline
Ondansetron Saline
Ranitidine Water
Levomepromazine + Hyoscine butlybromide 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
2019/07/03 23:10 · Graham Grove

4 Drug Morphine Combinations

Second Drug Third Drug Fourth Drug Diluent
Morphine + Haloperidol + Cyclizine + Octreotide Water
Ranitidine Water
Hyoscine butlybromide + 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
Octreotide Water or Saline
Ondansetron + Octreotide Saline
Midazolam + Hyoscine butylbromide + Octreotide Saline
Cyclizine + Ondansetron Water
* ​​Add ranitidine last once all other drugs and diluent have been combined. Precipitation reported with high doses of levomepromazine > 75mg
2019/07/03 23:15 · Graham Grove

Oxycodone Compatibilities

2 Drug Oxycodone Combinations

Second Drug 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
Ondansetron Water or Saline
Ranitidine Water or Saline
2019/07/08 09:19 · Graham Grove

3 Drug Oxycodone Combinations

Second Drug Third Drug Diluent
Oxycodone Halperidol + Cyclizine * Water
Ketamine Saline
Midazolam Water or Saline
Octreotide Water or Saline
Hyoscine butylbromide + Octreotide Water
Ondansetron Water
Ranitidine Saline
Levomepromazine + Hyoscine butlybromide Water or Saline
Ketamine Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide 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
2019/07/08 09:21 · Graham Grove

4 Drug Oxycodone Combinations

Second Drug Third Drug Fourth Drug Diluent
Oxycodone + Haloperidol + Hyoscine butylbromide + Ranitidine Saline
Hyoscine butylbromide + Levomepromazine + Ranitidine Saline
Octreotide Water
Midazolam + Haloperidol + Cyclizine * Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Octreotide Water
Hyoscine butylbromide + Ondansetron Water
Levomepromazine Water or Saline
Levomepromazine + Ketamine Saline
Octreotide Water or Saline
Ondasetron Saline
Metoclopramide + Levomepromazine Water
Ondansetron + Octreotide Water
Hyoscine butylbromide + Levomepromazine + Ranitidine # Saline
Octreotide Water
* Precipitation reported with higher doses of oxycodone > 100mg
# Precipitation has been reported with higher doses of oxycodone >100 mg or levomepromazine >100mg
2019/07/08 09:22 · Graham Grove

Fentanyl Compatibilities

2 Drug Fentanyl Combinations

Second Drug Diluent
Fentanyl + Haloperidol Water
Hyoscine butylbromide Water
Levomepromazine Water
Metoclopramide Water
Midazolam Water
Ondansetron Saline
Ranitidine Saline
2019/07/08 09:25 · Graham Grove

3 Drug Fentanyl Combinations

Second Drug Third Drug Diluent
Fentanyl + Hyoscine butylbromide + Levomepromazine Water
Levomepromazine + Ranitidine Saline
Metoclopramide + Levomepromazine Water
Midazolam + Cyclizine Water
Haloperidol Water
Hyoscine butylbromide Saline
Levomepromazine Water
Metoclopramide Saline
2019/07/08 09:25 · Graham Grove

4 Drug Fentanyl Combinations

Second Drug Third Drug Fourth Drug Diluent
Fentanyl + Midazolam + Haloperidol + Hyoscine butylbromide Water
Metoclopramide + Levomepromazine Water
Hyoscine butlybromide + Levomepromazine + Ranitidine Saline
2019/07/08 09:26 · Graham Grove

Alfentanil Compatibilities

2 Drug Alfentanil Combinations

Second Drug Diluent
Alfentanil + Haloperidol Water or Saline
Hyoscine butylbromide Saline
Ketamine Water or Saline
Levomepromazine Water or Saline
Metoclopramide Water or Saline
Midazolam Water or Saline
Octreotide Water or Saline
Ondansetron Water or Saline
2019/07/08 09:26 · Graham Grove

3 Drug Alfentanil Combinations

Second Drug Third Drug Diluent
Alfentanil + Haloperidol + Cyclizine * Water
Ketamine Saline
Ondansetron Saline
Hyoscine butylbromide + Ketamine Saline
Levomepromazine Saline
Levomepromazine + Octreotide Water or Saline
Ondansetron Saline
Metoclopramide + Ketamine Saline
Levomepromazine Water or Saline
Midazolam + Haloperidol Water or Saline
Cyclizine # Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Metoclopramide Water or Saline
Octreotide Saline
Ondansetron Water or Saline
Levomepromazine Water or Saline
* Although various reports of this 3 drug cominbation, use caution because alfentil + cyclizine alone is reported to be incompatible
2019/07/08 09:27 · Graham Grove

4 Drug Alfentanil Combinations

Second Drug Third Drug Fourth Drug Diluent
Alfentanil + Haloperidol + Hyoscine butylbromide + Ketamine Saline
Hyoscine butylbromide + Levomepromazine + Octreotide Saline
Ondansetron Saline
Levomepromazine + Octreotide + Ondansetron Saline
Midazolam + Haloperidol + Cyclizine Water
Hyoscine butylbromide Water or Saline
Ketamine Saline
Hyoscine butylbromide + Ketamine Saline
Levomepromazine + Hyoscine butylbromide Water or Saline
Ketamine Saline
Metoclopramide Saline
Metoclopramide + Ketamine Saline
Ondansetron + Octreotide Water
2019/07/08 09:28 · Graham Grove

Methadone Compatibilities

Methadone + second opioid compatibilities

Second Drug Third Drug Fourth Drug Diluent
Methadone + Morphine + Midazolam + Haloperidol Water
Hyoscine butylbromide Water
Levomepromazine * Water
Hyoscine butylbromide Water
Hyoscine butylbromide + Levomepromazine Water
Metoclopramide + Levomepromazine Water
Ranitidine # Water
Oxycodone + Midazolam Water
Midazolam + Haloperidol Water
Levomepromazine Water
Ketorolac Saline
Alfentanil Haloperidol + Ketamine * Water
Hysoscine butylbromide + Levomepromazine Water
Metoclopramide + Ranitidine # Water
Midazolam + Haloperidol Water
Ketamine Water
* Use caution as this combination is based on reported experience with a fifth drug
# Add ranitidine last once all the other drugs and diluent have been combined
2019/07/08 09:29 · Graham Grove

2 Drug Methadone Combinations (without another opioid)

Second Drug Diluent
Methadone + Cyclizine Water
Haloperidol Water
Ketamine Water or Saline
Levomepromazine Water
Midazolam Water
2019/07/08 09:29 · Graham Grove

3 Drug Methadone Combinations (without another opioid)

Second Drug Third Drug Diluent
Methadone + Haloperidol + Ketamine Water or Saline
Hyoscine butylbromide + Ranitidine Saline
Levomepromazine Water
Metoclopramide + Ranitidine * Water
Midazolam + Haloperidol Water
Hyoscine butylbromide Water
Ketamine Water
Levomepromazine # Water
Metoclopramide Water
* Add ranitidine last once all the other drugs and diluent have been combined
# Precipitation reported with doses of methadone greater than 40mg
2019/07/08 09:34 · Graham Grove

4 Drug Methadone Combinations (without another opioid)

Second Drug Third Drug Fourth Drug Diluent
Methadone + Hyoscine butylbromide + Haloperidol + Ranitidine Saline
Midazolam + Levomepromazine Saline
2019/07/08 09:35 · Graham Grove

1) Gabriel J. The use of subcutaneous infusion in medication administration. Br J Nurs. 2013 Jul 25-August 7;22(14).
  • continuous_subcutaneous_infusions.txt
  • Last modified: 2019/07/09 23:20
  • by Graham Grove