Continuous subcutaneous infusion

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.