CSCI IN PALLIATIVE CARE

• The administration of medication by continuous infusion into the subcutaneous tissue via a pump
• commonly used in palliative care to achieve symptom control

• Use oral route as long as practical and effective
• Consider CSCI in palliative patients who require regular medication to control symptoms but are unable to take or absorb oral medications because they:
• are semi-conscious, unconscious or very fatigued
• are vomiting or nauseated
• have dysphagia
• have abdominal pathology likely to reduce absorption e.g. bowel perforation or obstruction
• are in last hours or days of life when it is anticipated patient will deteriorate and be unable to take oral medications

Guidance

• For detailed guidance on which drugs can be given by CSCI and which drugs can be combined in a single infusion, contact the Palliative Care Team, Medicines Information or see BNF section on prescribing in palliative care 

Drugs commonly administered by CSCI

Analgesics

• Morphine
• Oxycodone
• Alfentanil

Anti-emetics

• Metoclopramide
• Cyclizine
• Haloperidol
• Levomepromazine 

Anxiolytics

• Midazolam

Antisecretory

• Hyoscine butylbromide
• Hyoscine hydrobromide

Drugs NOT suitable for CSCI

• Diazepam
• Antimicrobials
• Chlorpromazine
• Prochlorperazine

• Remember equivalent SC doses may differ from the oral dose for opioid analgesics
• If help needed contact the Palliative Care Team or Medicines Information

Patients who are not currently on opioids

• Patients who have not previously been on opioids, a suitable starting dose is morphine 5–10 mg over 24 hr

Patients already on regular opioids

• When converting from oral morphine to subcutaneous morphine a 2:1 ratio is a useful guide e.g. 2 mg oral morphine = 1 mg subcutaneous morphine
• Always add up total of the regular and breakthrough doses of morphine over a 24-hr period

Example 1

• Patient on modified release morphine (e.g. Zomorph®) 15 mg 12-hrly, total daily dose = 30 mg
• Subcutaneous morphine dose = 30 ÷ 2 = 15 mg/24 hr 

Example 2

• Patient on modified release morphine (e.g. Zomorph^®) 30 mg 12-hrly and has had 3 x 10 mg breakthrough doses of morphine sulphate solution in last 24 hr
• Total daily dose = 90 mg
• Subcutaneous morphine dose = 90 ÷ 2 = 45 mg/24 hr

Patients already on fentanyl patch

• If patient already on fentanyl patch and requiring CSCI:
• if pain controlled, continue fentanyl patch to maintain pain control
• if pain not controlled, refer to Palliative Care Team for advice and do not discontinue patch

Types of pump/driver

McKinley T34 syringe pump

• Battery powered, portable

Alaris GS or GH syringe pump

• Mains electricity powered, non-portable

Prescribing CSCI on prescription chart

• List of drugs to be added and doses
• e.g. Morphine 10 mg and metoclopramide 30 mg
• Diluent – unless instructed otherwise by Palliative Care Team, use water for injection
• e.g. Made up with water for injection
• Volume to be made up to, rate of administration and pump to be used
• e.g. McKinley T34: Make up to 17 mL and infuse over 24 hr
• e.g. Alaris: Make up to 24 mL and infuse at 1 mL/hr or Make up to 48 mL and infuse at 2 mL/hr
• Route: SC

Checking

• Continue infusion during transfer
• Replenish pump before transfer
• Ensure adequate supply of medication to replenish pump sent home with patient
• especially before a weekend or bank holiday

Communication

• If patient going home, ensure CSCI prescribed on district nurse authorisation document
• When booking transport, inform transport co-ordinator McKinley T34 pump is in use

Contact receiving nurse

• Discharging home – district nurse
• Discharging to nursing home, hospice or community hospital – nurse on duty
• Instruct the receiving nurse to:
• change to a community pump on 1^st visit
• return pump to hospital
• Include CSCI details in discharge letter to GP
• specify name and dose of all medications in the infusion