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CSCI stands for Continuous Subcutaneous Infusion and is a common method of administration of medications in palliative medicine, especially for patients near the end of their life. It is typically used in preference to the IV route it is a simpler method of administration and seen as kinder.
==Background==
*Abbreviation: CSCI
*Common method of medication administration in palliative medicine, especially for patients near the end of their life.
*These patients typically require parenteral medications as they lose the ability to take PO meds.
*Subcutaneous route has many advantages over IV<ref name="Gabriel">Gabriel J., The use of subcutaneous infusion in medication administration. Br J Nurs. 2013 Jul 25-Aug 7;22(14):S6, S8, S10 passim.</ref>
**No risk of phlebitis or air embolus
**Allows patient to retain more mobility (IV site typically on hand or arm; subcutaneous sites include chest, thigh, abdomen)
**More comfortable for patient
**Less susceptible to occlusion or dislodgement
**Simpler method of administration
**Seen as kinder


== Indications ==
==Indications==
Generally used when oral route is unavailable, e.g.<ref name="Menahem">Menahem S, Shvartzman P. Continuous subcutaneous delivery of medications for home care palliative patients-using an infusion set or a pump? Support Care Cancer. 2010 Sep;18(9):1165-70.</ref>
*Weakness, drowsiness or coma
*Severe nausea/vomiting
*Severe dysphagia


Use when the oral route is unavailable, e.g.
==Comparative Dosing==
* In patients too drowsy to swallow
*[[Dexamethasone]]: 4mg orally = 4mg SC (use as stat doses)
* In patients who are vomiting
*[[Diclofenac]]: 150mg oral = 75mg SC (use only as CSCI as tissue necrosis has been reported with stat doses)
 
*[[Haloperidol]]: 2mg oral = 1mg SC
== Comparative dosing ==
*[[Hydromorphone]]: 3mg oral = 1mg SC
 
*[[Levetiracetam]]: 250mg oral = 250mg SC (use only as CSCI)
* Dexamethasone: 4mg orally = 4mg SC (use as stat doses)
*Levomepromazine: 25mg oral = 12.5mg SC
* Diclofenac: 150mg oral = 75mg SC (use only as CSCI as tissue necrosis has been reported with stat doses)
*[[Methadone]]: 10mg oral = 5mg SC (typically used as a stat dose rather than via CSCI)
* Haloperidol: 2mg oral = 1mg SC
*[[Morphine]]: 30mg oral = 10mg SC (use as stat doses for break-through pain and via CSCI for background pain)
* Hydromorphone: 3mg oral = 1mg SC
*[[Ondansetron]]: 8mg oral = 4mg SC (typically used as a stat dose rather than via CSCI)
* Levetiracetam: 250mg oral = 250mg SC (use only as CSCI)
*[[Oxycodone]]: 10mg oral = 5mg SC (use as stat doses for break-through pain and via CSCI for background pain)
* Levomepromazine: 25mg oral = 12.5mg SC
*[[Ranitidine]]: 100mg oral = 50mg SC
* Methadone: 10mg oral = 5mg SC (typically used as a stat dose rather than via CSCI)
*[[Valproate]]: 200mg oral = 200mg SC (use as CSCI)
* Morphine: 30mg oral = 10mg SC (use as stat doses for break-through pain and via CSCI for background pain)
* Ondansetron: 8mg oral = 4mg SC (typically used as a stat dose rather than via CSCI)
* Oxycodone: 10mg oral = 5mg SC (use as stat doses for break-through pain and via CSCI for background pain)
* Ranitidine: 100mg oral = 50mg SC
* Valproate: 200mg oral = 200mg SC (use as CSCI)
 
== Combinations ==


==Combinations==
Mixing mediations in subcutaneous infusions can cause problems if there are drug incompatibilities that cause reactions. Look for crystallization when mixing medications.
Mixing mediations in subcutaneous infusions can cause problems if there are drug incompatibilities that cause reactions. Look for crystallization when mixing medications.


Some common compatible combinations are noted below:
'''Some common compatible combinations include:'''
* Morphine (or oxycodone) plus
*Morphine (or oxycodone) plus
** Haloperidol
**Haloperidol
** Levomepromazine
**Levomepromazine
** Metoclopramide
**Metoclopramide
** Haloperidol plus hyoscine butylbromide
**Haloperidol plus hyoscine butylbromide
** Haloperidol plus midazolam
**Haloperidol plus midazolam
** Haloperidol plus octreotide
**Haloperidol plus octreotide
** Haloperidol plus midazolam plus hyoscine butylbromide
**Haloperidol plus midazolam plus hyoscine butylbromide
** Haloperidol plus midazolam plus metoclopramide
**Haloperidol plus midazolam plus metoclopramide
** Haloperidol plus midazolam plus hyoscine butylbromide
**Haloperidol plus midazolam plus hyoscine butylbromide
* Fentanyl plus
*Fentanyl plus
** Haloperidol
**Haloperidol
** Hyoscine butylbromide
**Hyoscine butylbromide
** Metoclopramide
**Metoclopramide
** Haloperidol plus midazolam
**Haloperidol plus midazolam
** Haloperidol plus midaozolam plus hyoscine butylbromide
**Haloperidol plus midaozolam plus hyoscine butylbromide
* Opioid-free combinations
*Opioid-free combinations
** Haloperidol plus ondansetron
**Haloperidol plus ondansetron
** Haloperidol plus hyoscine butylbromide plus octreotide plus ranitidine
**Haloperidol plus hyoscine butylbromide plus octreotide plus ranitidine
 
==Clinical example==
 
A patient on 50mg twice daily MR oxyocodone and 10mg three times daily of oral metoclopramide for bony pain from metastatic prostate cancer presents to the Emergency Department with vomiting following chemotherapy. His pain has flared up because he is vomiting up his oxycodone. To ensure he continues to receive his pain relief and to ensure he receives anti-emetics, a continuous subcutaneous infusion of analgesia is commenced.
 
Now,


*50mg of twice daily MR oxycodone = 100 mg of oral oxycodone daily = 50mg of SC oxycodone daily
==See Also==
And
*30mg of oral metoclopramide daily = 30mg of SC metoclopramide daily


A slight dose reduction of oxycodone is used as the 2:1 ratio of oral to SC varies from person to person. Thus the pump is started at:


*Oxycodone 40mg via CSCI over 24 hours AND
==References==
*[[Metoclopramide]] 30mg via CSCI over 24 hours
<References/>


[[Category:Palliative Medicine]]
[[Category:Palliative Medicine]]

Latest revision as of 13:25, 7 October 2019

Background

  • Abbreviation: CSCI
  • Common method of medication administration in palliative medicine, especially for patients near the end of their life.
  • These patients typically require parenteral medications as they lose the ability to take PO meds.
  • Subcutaneous route has many advantages over IV[1]
    • No risk of phlebitis or air embolus
    • Allows patient to retain more mobility (IV site typically on hand or arm; subcutaneous sites include chest, thigh, abdomen)
    • More comfortable for patient
    • Less susceptible to occlusion or dislodgement
    • Simpler method of administration
    • Seen as kinder

Indications

Generally used when oral route is unavailable, e.g.[2]

  • Weakness, drowsiness or coma
  • Severe nausea/vomiting
  • Severe dysphagia

Comparative Dosing

  • Dexamethasone: 4mg orally = 4mg SC (use as stat doses)
  • Diclofenac: 150mg oral = 75mg SC (use only as CSCI as tissue necrosis has been reported with stat doses)
  • Haloperidol: 2mg oral = 1mg SC
  • Hydromorphone: 3mg oral = 1mg SC
  • Levetiracetam: 250mg oral = 250mg SC (use only as CSCI)
  • Levomepromazine: 25mg oral = 12.5mg SC
  • Methadone: 10mg oral = 5mg SC (typically used as a stat dose rather than via CSCI)
  • Morphine: 30mg oral = 10mg SC (use as stat doses for break-through pain and via CSCI for background pain)
  • Ondansetron: 8mg oral = 4mg SC (typically used as a stat dose rather than via CSCI)
  • Oxycodone: 10mg oral = 5mg SC (use as stat doses for break-through pain and via CSCI for background pain)
  • Ranitidine: 100mg oral = 50mg SC
  • Valproate: 200mg oral = 200mg SC (use as CSCI)

Combinations

Mixing mediations in subcutaneous infusions can cause problems if there are drug incompatibilities that cause reactions. Look for crystallization when mixing medications.

Some common compatible combinations include:

  • Morphine (or oxycodone) plus
    • Haloperidol
    • Levomepromazine
    • Metoclopramide
    • Haloperidol plus hyoscine butylbromide
    • Haloperidol plus midazolam
    • Haloperidol plus octreotide
    • Haloperidol plus midazolam plus hyoscine butylbromide
    • Haloperidol plus midazolam plus metoclopramide
    • Haloperidol plus midazolam plus hyoscine butylbromide
  • Fentanyl plus
    • Haloperidol
    • Hyoscine butylbromide
    • Metoclopramide
    • Haloperidol plus midazolam
    • Haloperidol plus midaozolam plus hyoscine butylbromide
  • Opioid-free combinations
    • Haloperidol plus ondansetron
    • Haloperidol plus hyoscine butylbromide plus octreotide plus ranitidine

See Also

References

  1. ↑ Gabriel J., The use of subcutaneous infusion in medication administration. Br J Nurs. 2013 Jul 25-Aug 7;22(14):S6, S8, S10 passim.
  2. ↑ Menahem S, Shvartzman P. Continuous subcutaneous delivery of medications for home care palliative patients-using an infusion set or a pump? Support Care Cancer. 2010 Sep;18(9):1165-70.
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