Eastern Metropolitan Region Palliative Care Consortium (Victoria)
Clinical Working Party
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
July 2011
These guidelines have been copyrighted. The Eastern Metropolitan Region Palliative Care Consortium (EMRPCC) grants permission to reproduce parts of this publication for clinical and educational use only, provided that the EMRPCC is acknowledged. Requests to reproduce this document, for purposes other than those stated above, should be addressed to:
Consortium Manager Eastern Metropolitan Region Palliative Care Consortium
c/o PO Box 227, Nunawading Victoria 3131
Australia or
Page 2 of 17
The EMRPCC Working Party welcomes feedback regarding recommendations for the planned review process in June 2013. Please send your comments to the Consortium Manager at: [email protected]
INSTRUCTIONS FOR USE
These guidelines work best if used electronically. The Contents have hyperlinks to each section. Printing: It is highly recommended these guidelines are printed in colour, to aid ease of use.
Contents DISCLAIMER .................................................................................................................................................................................... 3 KEY .................................................................................................................................................................................................... 3
Compatibility definitions…………………………………………………………………………………………………………4
Infusion site problems……………………………………………………………………………………………………………4
Points on mixing medications…………………………………………………………………………………………………..4 Diluent information ........................................................................................................................................................................ 5 Some Drug Information ................................................................................................................................................................ 5 Drug Availability in Australia July 2011 ................................................................................................................................... 5
Atropine .......................................................................................................................................................................... 6
Clonazepam ................................................................................................................................................................... 6
Cyclizine ......................................................................................................................................................................... 7
Fentanyl .......................................................................................................................................................................... 8
Glycopyrrolate .............................................................................................................................................................. 9
Haloperidol ................................................................................................................................................................... 10
Hydromorphone ......................................................................................................................................................... 11
Hyoscine Butylbromide (Hyoscine BBr) .............................................................................................................. 12
Hyoscine Hydrobromide (Hyoscine HBr) ............................................................................................................ 12
Ketamine....................................................................................................................................................................... 13
Ketorolac ...................................................................................................................................................................... 13
Levomepromazine ..................................................................................................................................................... 13
Lignocaine ................................................................................................................................................................... 14
Methadone ................................................................................................................................................................... 14
Metoclopramide .......................................................................................................................................................... 14
Midazolam .................................................................................................................................................................... 15
Morphine ....................................................................................................................................................................... 15
Octreotide ..................................................................................................................................................................... 15
Ondansetron…………………………………………………………………………………………………………………….16
Oxycodone…………………………………………………………………………………………………………………...….16
Sufentanil……………………………………………………………………………………………………………………...…16
REFERENCES & BIBLIOGRAPHY…………………………………………………………………………………………….17
Acknowledgements……………………………………………………………………………………………………………..17
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 3 of 17
DISCLAIMER
The information in this document is intended as a guideline only. It is the responsibility of the user to ensure information in this document is used correctly. These guidelines reflect current Australian/Victorian palliative care practice, and published evidence. Caution should be used when combining drugs in syringe drivers; mixtures should be closely monitored for discolouration, precipitation and crystallisation. All drug compatibility combinations derived from these guidelines should be checked and prescribed by a medical doctor with appropriate experience before administering. If you require further information regarding drug combinations and compatibility data, contact a specialist hospital-based pharmacy drug information service. Drug doses should be modified in response to the patient/client’s clinical situation and status, including previous exposure to opioids and concurrent medications. When administering opioids, and setting up syringe drivers, follow your organisation’s policy and procedures. All patients should be monitored closely when commencing and/or switching opioid medications.
KEY
Instructions for reading the list of drugs
All drugs are listed in alphabetical order. When searching for drug combinations, search by the drug which occurs first alphabetically. Drug compatibilities are not repeated in reverse order Example: Haloperidol Haloperidol, Hydromorphone Haloperidol, Hydromorphone, Metoclopramide
Symbol Explanation
Compatible
A,B,C,D
Compatible, read note for special considerations
A,B,C,D
Compatible, but conflicting data: read note for special considerations
Incompatible
NaCl 0.9%
Diluent = Sodium Chloride 0.9% (NaCl 0.9%)
WFI
Diluent = Water For Injection (WFI)
NaCl 0.9%
WFI Diluent = Sodium Chloride 0.9% (NaCl 0.9%) or Water for Injection
NOTE A Chemically compatible in tests
NOTE B Physically compatible in tests (including visually)
NOTE C Potential for site reaction – see ‘Infusion Site Problems’
NOTE D Conflicting information regarding compatibility with one or more drugs – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 4 of 17
Compatibility definitions from: www.palliativedrugs.com
Definition of chemical compatibility data (note A) If mixing two or more drugs does not result in a chemical change leading to loss or degradation of one or more of the drugs, the mixture is said to be chemically compatible. Chemical compatibility data are generally obtained by analysing the drug mixture by high-performance liquid chromatography (HPLC) at specified concentrations and several time points when kept under controlled conditions. Definition of physical compatibility data (note B) Drug combinations are considered physically compatible if there is no observed evidence of physical changes during the time period studied e.g. discolouration, clouding, precipitation of particles or crystals. Assessment may be visual (which may be subjective, limited and imprecise), or involve a more rigorous microscopic assessment under polarised light at specified concentrations and several time points when kept under controlled conditions. It may include other laboratory tests to determine whether any physical changes have taken place. It is more robust than observational data, but is still not definitive, as a solution may remain physically clear even when there is chemical incompatibility. When referring to references reporting physical compatibility it is important to have an understanding of these different levels of assessment and their respective limitations.
Infusion site problems (note C) from: www.palliativedrugs.com
A plastic (Teflon™ or Vialon™) cannula should be used rather than a metal butterfly needle to reduce site inflammation. A skin reaction at the infusion site is most commonly found with cyclizine, ketamine, levomepromazine (methotrimeprazine) and methadone. Excluding mixtures containing cyclizine, NaCl 0.9% can be used as the diluent in an attempt to reduce site reactions with irritant infusions. Sites may last up to a week, depending on the drugs used. The site should be changed if painful or inflamed. Routine rotation to a different subcutaneous site every 72h reduces the frequency of site problems. If frequent resiting is necessary, e.g. every 24–48h, consider the following strategies:
Use a larger syringe to enable a more dilute mixture to be used, thereby decreasing the final drug concentrations
Change to a q12h regimen, thereby permitting further dilution of the drugs
Change an irritant drug to a less irritant alternative
Inject dexamethasone 1mg directly into the infusion site, via the cannula to be used. Flush with NaCl 0.9% then
connect the syringe driver and commence (reference 4, 13).
Points on mixing medications (adapted from Palliative Care Matters website: www.pallcare.info )
When combining medications for syringe driver use, be aware there is data available from compatibility studies for only a few combinations. It is recommended that the number of medications in one syringe driver be limited to three. If several medications are required, consider using more than one syringe driver where this is practical. The more medications that are mixed in one syringe, the higher the potential for interaction, particularly where pH differs. There is also the possibility that medications could interact to form a new, potentially toxic compound, without any obvious signs. When considering using a combination of drugs not previously used, or, where there is little information regarding the particular combination you wish to use, consider the following points (adapted from Palliative Care Information website):
1. Refer to the evidence, where it exists 2. Be aware of risks 3. Consult relevant palliative care literature – The Syringe Driver in Palliative Care (reference 4), Palliative care
websites: Palliativedrugs.com ( www.palliativedrugs.com ) and Palliative Care Matters ( www.pallcare.info ) 4. Consult experienced palliative care staff, or palliative care organisations 5. Consult a hospital pharmacist, or drug information centre (preferably with palliative care experience) 6. Consider using more than one syringe driver 7. Carefully inspect the solution before commencing for precipitation/crystallisation 8. Observe the patient carefully for signs the medications may not be working as they should
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 5 of 17
Diluent information
Sodium Chloride 0.9% (NaCl 0.9%) and Water for Injection (WFI) are suitable for subcutaneous infusions. Diluting syringe contents as much as possible is recommended to reduce site irritation. NaCl 0.9% is recommended as the diluent of choice when drugs are compatible with more than one solution. It is closest to physiological tonicity, therefore less likely to cause irritation. The main exception to this is cyclizine which should always be diluted in WFI. Glucose 5% as a diluent was included as a diluent in the 2008 guidelines. It is not included here as it is not used in the Australian setting.
Some Drug Information
Chlorpromazine, diazepam and prochlorperazine
These drugs are not recommended to be given by subcutaneous infusion due to severe local reactions (reference 5)
Dexamethasone
Dexamethasone has been used at a dose of 1mg added to the syringe driver for site preservation (reference13). At greater doses it is recommended that dexamethasone be administered by a separate site via a stat dose or in a separate syringe driver. Dexamethasone has a long half- life and can therefore be administered as a bolus dose once daily, preferably in the morning. (reference 4) Morphine, Morphine Sulfate, Morphine Tartrate
While reviewing the literature the morphine salt was not always documented. In these cases, the entry in the guidelines is listed as morphine. Caution is urged in this situation.
Phenobarbitone Phenobarbitone has an alkaline pH and can cause tissue necrosis when administered as subcutaneous bolus injection. In practice, phenobarbitone can be initiated with a bolus intramuscular or intravenous injection, then via subcutaneous infusion with NaCl 0.9% or WFI as diluent. It should be given via a separate syringe driver. Seek specialist advice. (reference 4)
Drug Availability in Australia July 2011
The Therapeutics Goods Administration Australia approves the use of medicines. The prescriber takes responsibility if a medicine is used differently to the product information. Medicines prescribed off label, can be dispensed by pharmacists, and administered by nurses. (reference 11) PBS = Pharmaceutical Benefits Scheme www.pbs.gov.au/pbs/home SAS = Special Access Scheme www.tga.gov.au/hp/sas
Drug (Injection) Availability
Atropine PBS
Clonazepam PBS for epilepsy
Cyclizine Non PBS
Fentanyl Non PBS
Glycopyrrolate Non PBS
Haloperidol PBS
Hydromorphone PBS
Hyoscine butylbromide PBS
Hyoscine hydrobromide Non PBS
Ketamine Non PBS
Ketorolac Non PBS
Levomepromazine SAS
Lignocaine Non PBS for palliative care indication
Methadone PBS
Metoclopramide PBS
Midazolam Non PBS
Morphine sulphate PBS
Morphine tartrate PBS
Octreotide Non PBS for palliative care indication
Ondansetron PBS for nausea & vomiting associated with radiotherapy & chemotherapy
Oxycodone Non PBS
Sufentanil SAS
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 6 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Atropine NaCl 0.9%
Atropine may be administered via continuous subcutaneous infusion, but is not commonly used in Australia. Information on compatibility with other drugs is limited
15 www.palliativedrugs.com
Clonazepam NaCl 0.9% WFI There is a significant loss when infused through PVC tubing which can be addressed by using non PVC tubing or titrating the dose to desired effect
4
Clonazepam, Cyclizine, Haloperidol, Morphine Sulfate C
WFI
4
Clonazepam, Cyclizine, Morphine Sulfate C
WFI 9
www.pallcare.info
Clonazepam, Glycopyrrolate
WFI
4
Clonazepam, Haloperidol
NaCl 0.9% WFI 4
www.palliativedrugs.com
Clonazepam, Haloperidol, Hyoscine Butylbromide, Oxycodone B
NaCl 0.9% WFI
4
Clonazepam, Haloperidol, Metoclopramide
WFI
4
Clonazepam, Haloperidol, Morphine Sulphate
NaCl 0.9% WFI 9
www.palliativedrugs.com
Clonazepam, Hyoscine Butylbromide Levomepromazine, Oxycodone B,C
NaCl 0.9% WFI
4
Clonazepam, Hyoscine Hydrobromide, Levomepromazine, Oxycodone B,C
NaCl 0.9% WFI
4
Clonazepam, Hyoscine Hydrobromide, Metoclopramide
WFI
84
Clonazepam, Ketamine, Morphine Tartrate
NaCl 0.9% 4
Clonazepam, Ketamine, Oxycodone
NaCl 0.9% www.palliativedrugs.com
Clonazepam, Metoclopramide
NaCl 0.9% WFI 4
Clonazepam, Morphine Sulfate B
NaCl 0.9% WFI
3 www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 7 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Clonazepam, Oxycodone B
NaCl 0.9% WFI
4
Cyclizine
Always dilute with WFI
Note C WFI
There are compatibility issues when combined in solutions with a pH greater than 6.8. The prokinetic effect of metoclopramide is theoretically inhibited by cyclizine (and other anticholinergic drugs) and may require higher doses of metoclopramide to overcome this.
4
Cyclizine, Fentanyl C, D
WFI
www.pallcare.info
Cyclizine, Fentanyl, Haloperidol C,D
WFI www.pallcare.info
Cyclizine, Fentanyl, Midazolam C,D
WFI
4
Cyclizine, Glycopyrrolate, Haloperidol, Octreotide C
WFI
4
Cyclizine, Haloperidol C
WFI
4
Cyclizine, Haloperidol, Hydromorphone, Midazolam C
WFI
4
Cyclizine, Haloperidol, Hyoscine Hydrobromide, Midazolam C
WFI www.pallcare.info
Cyclizine, Haloperidol, Metoclopramide C,D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4 www.pallcare.info
Cyclizine, Haloperidol, Metoclopramide, Morphine C,D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4 www.pallcare.info
Cyclizine, Haloperidol, Midazolam C
WFI
4
Cyclizine, Haloperidol, Midazolam, Morphine Sulphate C
WFI www.book.pallcare.info
Cyclizine, Haloperidol, Midazolam, Morphine Tartrate C
WFI
4
Cyclizine, Haloperidol, Morphine Sulphate C
WFI
www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 8 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Cyclizine, Haloperidol, Oxycodone C
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4
Cyclizine, Hydromorphone, Octreotide C
WFI
4
Cyclizine, Hyoscine Butylbromide C,D
WFI
4 www.pallcare.info
Cyclizine, Hyoscine Hydrobromide, Morphine Tartrate C
WFI
4
Cyclizine, Ketamine, Midazolam, Morphine Tartrate C
WFI
4
Cyclizine, Ketorolac
10
Cyclizine, Levomepromazine C
WFI www.pallcare.info
Cyclizine, Metoclopramide C,D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4
Cyclizine, Metoclopramide, Midazolam, Morphine C,D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4 www.pallcare.info
Cyclizine, Metoclopramide, Morphine C,D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4 www.pallcare.info
Cyclizine, Midazolam, Morphine Sulfate C
WFI www.palliativedrugs.com
Cyclizine, Morphine Sulfate C
WFI
4
Cyclizine, Oxycodone C.D
WFI There is a risk of precipitation when combining with chloride salts such as metoclopramide and oxycodone
4
Fentanyl NaCl 0.9% WFI The volume of fentanyl injection may restrict its use in the syringe driver. A separate or 12 hourly
syringe driver may be required. 4
Fentanyl, Glycopyrrolate, Midazolam
WFI www.pallcare.info
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 9 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Fentanyl, Haloperidol
WFI www.palliativedrugs.com
Fentanyl, Hyoscine Hydrobromide
WFI www.palliativedrugs.com
Fentanyl, Hyoscine Hydrobromide, Levomepromazine C
NaCl 0.9% www.pallcare.info
Fentanyl, Hyoscine Hydrobromide, Levomepromazine, Midazolam C
NaCl 0.9% www.pallcare.info
Fentanyl, Ketamine C
WFI www.pallcare.info
Fentanyl, Ketorolac
WFI
2
Fentanyl, Levomepromazine B,C
NaCl 0.9% 4
www.pallcare.info
Fentanyl, Levomepromazine, Midazolam C
NaCl 0.9% www.pallcare.info
Fentanyl, Levomepromazine, Octreotide C
NaCl 0.9% www.pallcare.info
Fentanyl, Metoclopramide B
WFI www.palliativedrugs.com
Fentanyl, Metoclopramide, Midazolam
WFI www.pallcare.info
Fentanyl, Midazolam B
NaCl 0.9%
4
Fentanyl, Ondansetron
NaCl 0.9%
4
Glycopyrrolate NaCl 0.9% WFI
4
Glycopyrrolate, Haloperidol, Midazolam, Oxycodone
NaCl 0.9% WFI www.palliativedrugs.com
Glycopyrrolate, Ketamine, Midazolam C
WFI www.pallcare.info
Glycopyrrolate, Levomepromazine, Octreotide C
NaCl 0.9% WFI
4
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 10 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Glycopyrrolate, Midazolam
NaCl 0.9% WFI www.book.pallcare.info www.palliativedrugs.com
Glycopyrrolate, Morphine Sulfate B
WFI
7
Glycopyrrolate, Ondansetron A,B
NaCl 0.9%
4
Glycopyrrolate, Oxycodone B
WFI
6
Haloperidol NaCl 0.9% WFI
The haloperidol preparation available in Australia is the haloperidol base. In the United States, the injection is the salt, haloperidol lactate, therefore some compatibility information may not be transferable.
4
Haloperidol, Hydromorphone B
NaCl 0.9% WFI
2
Haloperidol, Hydromorphone, Metoclopramide
NaCl 0.9% www.pallcare.info
Haloperidol, Hyoscine Butylbromide
NaCl 0.9% WFI
4
Haloperidol, Hyoscine Butylbromide, Midazolam, Oxycodone
NaCl 0.9% WFI
4
Haloperidol, Hyoscine Hydrobromide
WFI www.pallcare.info
Haloperidol, Hyoscine Hydrobromide, Midazolam
WFI www.pallcare.info
Haloperidol, Ketamine C
NaCl 0.9%
4
Haloperidol, Ketamine, Midazolam C
WFI www.palliativedrugs.com
Haloperidol, Ketamine, Morphine Sulfate C
NaCl 0.9%
4
Haloperidol, Metoclopramide
NaCl 0.9% WFI 4
www.palliativedrugs.com
Haloperidol, Metoclopramide, Midazolam, Morphine Sulphate
WFI www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 11 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Haloperidol, Metoclopramide, Midazolam, Oxycodone
WFI www.palliativedrugs.com
Haloperidol, Metoclopramide, Morphine Sulphate
NaCl 0.9% WFI www.palliativedrugs.com
Haloperidol, Metoclopramide, Oxycodone A
WFI www.palliativedrugs.com
Haloperidol, Midazolam D
NaCl 0.9% WFI 4
www.palliativedrugs.com
Haloperidol, Midazolam, Morphine Sulphate
NaCl 0.9% WFI www.palliativedrugs.com
Haloperidol, Midazolam, Octreotide, Oxycodone
WFI www.palliativedrugs.com
Haloperidol, Midazolam, Oxycodone B
WFI www.palliativedrugs.com
Haloperidol, Morphine Sulfate
NaCl 0.9% WFI
4
Haloperidol, Morphine Tartrate
NaCl 0.9%
4
Haloperidol, Morphine Sulfate, Octreotide
NaCl 0.9% WFI www.palliativedrugs.com
Haloperidol, Oxycodone A,B
NaCl 0.9% WFI
4, 6
Hydromorphone NaCl 0.9% WFI
4
Hydromorphone, Hyoscine Butylbromide, Midazolam
NaCl 0.9% www.palliativedrugs.com
Hydromorphone, Hyoscine Hydrobromide, Levomepromazine, Midazolam
NaCl 0.9% WFI www.pallcare.info www.palliativedrugs.com
Hydromorphone, Ketamine, Metoclopramide
NaCl 0.9% www.pallcare.info
Hydromorphone, Ketamine, Midazolam
NaCl 0.9%
4
Hydromorphone, Levomepromazine B,C
NaCl 0.9% WFI
2 www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 12 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Hydromorphone, Metoclopramide B
WFI 4 www.palliativedrugs.com
Hydromorphone, Metoclopramide, Midazolam
NaCl 0.9%
4
Hydromorphone, Midazolam B
WFI 4 www.palliativedrugs.com
Hyoscine Butylbromide (Hyoscine BBr) NaCl 0.9% WFI
4
Hyoscine BBr, Levomepromazine, Midazolam, Oxycodone B,C
NaCl 0.9% WFI
4
Hyoscine BBr, Levomepromazine, Octreotide, Oxycodone B,C
NaCl 0.9% WFI
4
Hyoscine BBr, Levomepromazine, Oxycodone B,C
NaCl 0.9% WFI
4
Hyoscine BBr, Metoclopramide
WFI www.pallcare.info
Hyoscine BBr, Metoclopramide, Midazolam
NaCl 0.9%
4
Hyoscine BBr, Midazolam
NaCl 0.9%
4
Hyoscine BBr, Midazolam, Oxycodone
NaCl 0.9% WFI www.palliativedrugs.com
Hyoscine BBr, Morphine Sulfate B
WFI www.palliativedrugs.com
Hyoscine BBr, Midazolam, Morphine Sulfate
NaCl 0.9%
4
Hyoscine BBr, Oxycodone A,B
NaCl 0.9% WFI
4, 6
Hyoscine Hydrobromide (Hyoscine HBr) NaCl 0.9% WFI
4
Hyoscine HBr, Levomepromazine, Midazolam C
NaCl 0.9% WFI 4
www.pallcare.info
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 13 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Hyoscine HBr, Levomepromazine, Octreotide, Oxycodone B,C
NaCl 0.9% WFI
4
Hyoscine HBr, Levomepromazine, Oxycodone B,C
NaCl 0.9% WFI
4
Hyoscine HBr, Midazolam
WFI www.palliativedrugs.com
Hyoscine HBr, Midazolam, Morphine Sulfate/Tartrate
NaCl 0.9%
4
Hyoscine HBr, Oxycodone A,B
NaCl 0.9% WFI
4, 6
Ketamine See Note C NaCl 0.9%
4
Ketamine, Metoclopramide C
NaCl 0.9% WFI www.pallcare.info www.palliativedrugs.com
Ketamine, Metoclopramide, Midazolam C
NaCl 0.9%
4
Ketamine, Midazolam A,C
NaCl 0.9%
4
Ketamine, Midazolam, Morphine Sulfate C
NaCl 0.9% WFI www.palliativedrugs.com
Ketamine, Morphine Sulfate B,C
NaCl 0.9%
1, 4,8, 14
Ketamine, Oxycodone B,C
NaCl 0.9%
4
Ketorolac
NaCl 0.9%
Where possible, ketorolac should not be mixed with other medications as it is unlikely to be compatible due to its alkaline pH. Long-term use is not recommended – seek specialist advice.
4
Ketorolac, Oxycodone B
NaCl 0.9%
4
Levomepromazine See Note C NaCl 0.9%
4
Levomepromazine, Methadone B,C
WFI 4
www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 14 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Levomepromazine, Metoclopramide C
NaCl 0.9% WFI www.palliativedrugs.com
Levomepromazine, Metoclopramide, Oxycodone C
NaCl 0.9% WFI www.palliativedrugs.com
Levomepromazine, Midazolam C
NaCl 0.9% WFI www.pallcare.info www.palliativedrugs.com
Levomepromazine, Midazolam, Octreotide C
NaCl 0.9% www.pallcare.info
Levomepromazine, Morphine Sulfate B,C
NaCl 0.9% WFI 4
www.palliativedrugs.com
Levomepromazine, Octreotide C
NaCl 0.9% WFI
4
Levomepromazine, Octreotide, Ondansetron C
NaCl 0.9%
4
Levomepromazine, Octreotide, Oxycodone B,C
NaCl 0.9% WFI
4
Levomepromazine, Oxycodone A,B,C
NaCl 0.9%
WFI
4, 6
Lignocaine NaCl 0.9% WFI
15
Lignocaine, Metoclopramide B
WFI
12
Lignocaine, Metoclopramide, Oxycodone
WFI www.pallcare.info
Methadone See note C NaCl 0.9% WFI
4
Methadone, Midazolam B,C
NaCl 0.9%
4
Metoclopramide NaCl 0.9% WFI
4
Metoclopramide, Midazolam
NaCl 0.9% WFI 4
www.palliativedrugs.com
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 15 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Metoclopramide, Midazolam, Morphine Sulfate
NaCl 0.9% WFI 4
www.palliativedrugs.com
Metoclopramide, Morphine Sulfate A,B
NaCl 0.9% WFI
4
Metoclopramide, Morphine Sulfate, Octreotide
NaCl 0.9%
www.palliativedrugs.com
Metoclopramide, Octreotide
WFI
4
Metoclopramide, Ondansetron A,B
NaCl 0.9%
4
Metoclopramide, Oxycodone A,B
NaCl 0.9% WFI
4, 6
Midazolam NaCl 0.9% WFI
4
Midazolam, Morphine Sulfate A,B
NaCl 0.9% WFI 4
Midazolam, Ondansetron A,B
NaCl 0.9%
4
Midazolam, Oxycodone A,B
NaCl 0.9% WFI
4, 6
Morphine NaCl 0.9% WFI
4
Morphine Sulfate, Octreotide
WFI www.pallcare.info
Morphine Sulphate, Ondansetron A,B
NaCl 0.9% WFI 4
Octreotide NaCl 0.9% WFI
4
Octreotide, Ondansetron B
NaCl 0.9% WFI 4
Octreotide, Ondansetron, Oxycodone B
NaCl 0.9% WFI 4
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
NOTE A - Chemically compatible in tests NOTE B - Physically compatible in tests (including visually) NOTE C- Potential for site reaction – see ‘Infusion Site Problems’ NOTE D- Conflicting information regarding compatibility with one or more medications – proceed with caution
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011 Page 16 of 17
DRUG COMPATIBILITY DILUENT
COMMENT REFERENCE
Octreotide, Oxycodone B
NaCl 0.9% 4
Ondansetron NaCl 0.9% WFI
4
Ondansetron, Oxycodone B
NaCl 0.9% 4
Oxycodone NaCl 0.9% WFI
4
Sufentanil NaCl 0.9%
Little compatibility data is available. Incompatibility has not been observed in combination with clonazepam, ketamine, methadone, levomepromazine, metoclopramide, midazolam and octreotide
16
Syringe Driver Drug Compatibilities - Practice Guidelines 2011
Eastern Metropolitan Region Palliative Care Consortium – Clinical Working Party 2011
Page 17 of 17
REFERENCES & BIBLIOGRAPHY 1. Anbados, F. 1995. Compatibility of morphine and ketamine for subcutaneous infusion. Australian Journal of
Hospital Pharmacy. 25:35
2. Chandler, SW, Trissel LA, Weinstein, SM. 1996. Combined administration of opioids with selected drugs to
manage pain and other cancer symptoms initial safety screening for compatibility. Journal of Pain and Symptom
Management. 12(3): 168-171.
3. Dean A, Martin K, Yuen K, Oldham L, Ewence K. 1997. Morphine and clonazepam combinations in the
Springfusor 30 infusion device. Palliative Medicine. 11(3):256.
4. Dickman A, Littlewood C, Varga J. The Syringe Driver. Continuous subcutaneous infusions in palliative care.
Oxford: Oxford University Press. 2002, 2005.
5. Guidelines for Subcutaneous Infusion Device Management in Palliative Care – second edition 2010 available at
www.health.qld.gov.au/cpcre. Accessed May 20th 2011
6. Hines S, Pleasance S.2009 Compatibility of an injectable high strength oxycodone formulation with typical
diluents, syringes, tubings, infusion bags and drugs for potential co-administration. EJHP Practice 15 (5) 32-38
7. Ingallinera T, Kapadia AJ, Hagman D. 1979. Compatibility of glycopyrrolate injection with commonly used
infusion solutions and additives. American Journal of Hospital Pharmacy. 36: 508-510.
8. Lau MH, Hackman C, Morgan DF. 1998. Compatibility of ketamine and morphine injections. Pain. 75:389-90.
9. Lichter I, Hunt E. 1995. Drug combinations in syringe drivers. New Zealand Medical Journal. 108: 224-6.
10. Litvak K, McEvoy, GK. 1990. Ketorolac, an injectable, non-narcotic analgesic. Clinical Pharmacy. 9:921-935.
11. Palliative Care Expert Group. Therapeutic Guidelines; palliative care. Version 3.Melbourne. Therapeutic
Guidelines Limited;2010.
12. Pesko LJ, Arend KA, Hagman DE. 1988. Physical compatibility and stability of metoclopramide injection.
Parenterals. 5: 1-8.
13. Reymond L, Charles A, Bowman J, Treston P.2003 The effect of dexamethasone on the longevity of syringe
driver subcutaneous sites in palliative care patients. MJA 178 486-489
14. Schmidt R, Koren G, Klein J. 2002. The stability of a ketamine-morphine solution. Anesthesia and Analgesia.
94(4):898-900
15. Trissel LA, ed. Handbook of injectable drugs. 15th ed, Bethesda: American Society of Health-System
Pharmacists;2009.
16. White C, Hardy J, Boyd A, Hall A. 2008. Subcutaneous sufentanil for palliative care patients in a hospital setting.
Palliative Medicine 22 89-90
Websites accessed and referenced May – July 2011
Palliative Care Matters www.pallcare.info Palliativedrugs www.palliativedrugs.com
Palliative Care Adult Network Guidelines Plus www.book.pallcare.info
Acknowledgements EMRPCC- Syringe Driver Review
Project Officer: Ms S. Scholes
EMRPCC Clinical Working Group (2011) Eastern Health: Dr S Fullerton, Mr S O’Neill, Mr A Goff Eastern Palliative Care: Dr P Sherwen, Mr D Halliwell EMRPCC: Ms C Brusamarello Centre for Palliative Care: Dr J Philip, Ms K Quinn RDNS: Ms H Carr Special Acknowledgements: Jenny McCarthy, Pharmacist, Eastern Health-Wantirna Gedal Basman, Pharmacist, St Vincent’s Hospital, Melbourne
Tracey Mander and the members of the original EMRPCC Clinical Working Group (2008) and all contributors to the EMRPCC Syringe Driver Medication Compatibilities- Practice Guidelines (October 2008)