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Rotherhamhospice.org.ukMetabolic or drug induced: Haloperidol
500micrograms to 5mg oral nocte, ( ), OR:
Good oral hygiene, and: Miconazole oral gel 24mg/ml Levomepromazine, oral or sc, from 6.25 mg od.
qds treatment should be continued for 48hours after lesions have healed. Fluconazole 50mg daily Intestinal obstruction - contact Specialist Palliative
ROTHERHAM PALLIATIVE CARE SERVICES
Adult Palliative Care Formulary – January 2011.
USEFUL TELEPHONE NUMBERS:
Review Date – January 2013.
Rotherham Hospice Ward.
Treat underlying cause: e.g. drugs/ hypercalcaemia/ his core formulary is a basic guide for prescribers
infection/ dehydration/ pain/ urinary retention, etc.
Has link to Palliative Medicine Drs & Consultant in hospital and primary care across the district. It is Midazolam - from 2.5 mg stat, every 2 - 4 hours, or: intended to be used in conjunction with the Palliative Haloperidol - 2.5 to 10 mg, oral or subcutaneous.
Care section of the current British National Formulary Palliative Medicine Consultants:
(B.N.F.). The listed medications are available from hospital and community pharmacies. The compilers believe that the majority of symptoms can be Midazolam – from 10mg to 30 mg subcutaneous over Community Hospice Team 24hr Advice line.
effectively managed within this formulary and that 24hrs via syringe driver. If still restless, seek specialist its acceptance and use will enhance the quality and palliative care advice.
consistency of palliative care for patients. Note: much RFT Macmillan CNSs:
of palliative care prescribing is by its nature outside of product licence.
RFT Medicines Information:
Consider when symptoms include dehydration, It is recommended that strong opioids are prescribed constipation, confusion, nausea & vomiting and in small total quantities (maximum one month's increased thirst. Treat symptomatic patients with treatment) in the community, as large quantities may an adjusted serum calcium > 2.6 mmol/L with not be used up when dosages change.
intravenous fluids and iv bisphosphonate – contact Specialist Palliative Care Team.
Specialist palliative care advice should be sought
early to avoid symptom crisis. Contact telephone
numbers are listed on the back page.
Hyoscine hydrobromide - 600 mcg subcutaneously stat, 600 micrograms – 2.4mg over 24 hours sc via Compiled by NHS Rotherham & The Rotherham NHS Analgesia should be prescribed and administered syringe driver. For specific symptom control advice Foundation Trust staff.
on a REGULAR basis 24 hours a day. If a step by step
in the last days of life, see the Liverpool Care approach is used there will be fewer side effects.
Pathway (LCP) STEP 1: Paracetamol tablets - 1g qds
NHS Rotherham is the Rotherham Primary Care Trust Creative Media Services NHS Rotherham Date of publication: 25.04.2012 STEP 2: Step 1 plus weak opioid, e.g.Codeine
Ref: HIEG3472_1112NHSR Phosphate 15mg to 60mg qds Intractable breathlessness due to end stage STEP 3: Replace Step 2 weak opioid, with regular
disease may respond to low dose opiates and/ 4 hourly immediate release strong opioid, (e.g. or benzodiazepines. These can be given orally or Oramorph liquid 10mg/5ml 2.5 – 10mg Oramorph 4 subcutaneously via syringe driver. hourly when required.) Titrate according to response.
Sub-cutaneous injection, via syringe driver over
Colic: Consider constipation. If acute spasm: Hyoscine
Patients should be pain free for 48 hours before 24hrs, and "rescue" doses of:- Diamorphine or
butyl-bromide (Buscopan) 10 - 20mg SIX hourly as conversion to12 hourly sustained release morphine required, oral or subcutaneous.
Oral morphine ratio to subcutaneous diamorphine:- Liver Capsule Pain: Dexamethasone 4 - 8mg mane,
Conversion: calculate the total daily dose of
If in pain, use: 2:1 ratio. If not in pain, use: 3:1 ratio.
and titrate down (do not give after 14.00hrs) immediate release morphine and divide by 2.
e.g. 10 mg oral morphine is equivalent to 3 - 5 mg e.g. 10mg (immediate release morphine) 4 hourly = Raised Intracranial Pressure: Dexamethasone 8 - 16mg
60mg in 24 hours = 30mg 12 hourly daily and titrate down (do not give after 14.00hrs) Oral oxycodone ratio to subcutaneous oxycodone: - Co-prescribe rescue doses of immediate release 3:2 ratio e.g. 30mg oral oxycodone is equivalent to morphine equivalent to 1/6 (one sixth) of total daily 20mg subcutaneous oxycodone.
dose of sustained release morphine. e.g. If: 30mg Consider the cause: e.g. Opiates.
Zomorph 12 hourly then rescue dose = 10mg PRN (up Conversion table available in the Palliative Care to six doses in 24 hours.) section of the B.N.F.
Stimulants: If drug-induced: Senna 2 - 4 tablets nocte
or bd, or: Bisacodyl 5 - 20mg nocte
Remember to prescribe rescue doses. Pain control
must be titrated using immediate release morphine
Softener: Docusate 100 - 300mg nocte or bd.
For patients who are in renal or liver failure seek (or oxycodone) for breakthrough pain.
specialist palliative care advice.
Combined: Movicol/Laxido sachets, dose as
NB. If patient is on any other opioid, please inform
recommended, or: Co-danthramer 1 - 3 capsules Rotherham Specialist Palliative Care Team.
nocte, or: Co-danthrusate 5 - 15mls nocte or bd Stimulant laxatives should be considered from
Impaction: Rectal: Suppositories Bisacodyl 1 – 2
Step 2. The dose of the laxative should be titrated
SPECIFIC PAIN MANAGEMENT:
suppositories, or: Glycerin 4g 1 - 2 suppositories.
as the opiate dose increases.
Consider Gastric Protection: With: NSAIDs, &/or with
AND: Movicol sachets. Or Enemas: Microlax (sodium
corticosteroids. e.g. Lansoprazole 15mg od.
citrate), or Phosphate, or Arachis oil enema with An anti-emetic, for drug induced nausea and
overnight retention (NB. Avoid arachis oil in patients vomiting should be considered. e.g. Haloperidol 500
Musculo-Skeletal, Soft Tissue & Bone Pain: NSAIDs:
with peanut allergy) micrograms to 3mg nocte, or 1.5mg bd.
Ibuprofen – 400 mg tds, (maximum 2400 mg in 24 hours) or: Diclofenac - 50mg tds. (Avoid in severe ALTERNATIVE OPIATES, for when morphine is poorly
renal failure.) NAUSEA AND VOMITING:
tolerated - seek Specialist Palliative Care advice.
Consider the cause: obstruction/ constipation/
Bone Pain: Consider radiotherapy or bisphosphonates
hypercalcaemia / opiates, etc.
Oral Oxycodone MR (OxyContin) tablets –
- seek specialist advice.
dose equals HALF of the oral morphine sulphate dose.
Raised intra-cranial pressure: - Cyclizine 25 to 50mg
NB. Oxycodone prescription must state clearly Nerve Pain: Amitriptyline (check for contra-
tds oral, or subcutaneous (25 to 50 mg whether: Immediate release capsules or liquid, or indications first) 25 - 100mg nocte, increase every stat), (up to 150mg /24 hrs in syringe driver) modified release (MR) tablets, or injection.
3 days according to response. (Start at 10mg in the
elderly.) or: Gabapentin 300 – 1800mg CAPSULES,
Gastric stasis: - Metoclopramide 10 to 20mg qds oral
Transdermal: Fentanyl patch – Fentanyl patch takes
increasing as stated in BNF Pregabalin 50 – 600mg, or subcutaneous (10 mg stat) (40 to 80mg/24 hrs.) over 12 hours to reach its therapeutic effect.
increasing as stated in BNF. If partial response to NB. Fentanyl 25mcg/hr patch is equivalent to 90mg amitriptyline, may add gabapentin or pregabalin; morphine sulphate over 24 hours.
if NO response, replace.
Neuroscience in Anesthesiology and Perioperative Medicine Section Editor: Gregory J. Crosby Cerebral Oxygen Desaturation Events Assessed byNear-Infrared Spectroscopy During Shoulder Arthroscopyin the Beach Chair and Lateral Decubitus Positions Glenn S. Murphy, MD,* Joseph W. Szokol, MD,* Jesse H. Marymont, MD,* Steven B. Greenberg, MD,*Michael J. Avram, PhD,† Jeffery S. Vender, MD,* Jessica Vaughn, BA,* and Margarita Nisman, BA*
Katholische Fachhochschule Nordrhein-Westfalen, Abteilung Aachen Diplomarbeit im Fachbereich Sozialwesen Tiere als Therapeuten? Hunde als Helfer in der Sozialen Gruppenarbeit Vorgelegt von: Algenweg 1 Prof. Dr. theol. Rainer Krockauer Dipl.-Päd. Michael Ziemons Alsdorf, den 02. September 2008