b1 - medicine management

Syringe driver medications

A study of combinations and compatibilities

Derryn Gargiulo

Dr Jeff HarrisonDr Bruce FoggoEmma GriffithsLauren Doherty, Sana Khan, Kate Kilpatrick, Guangda Ma, Caitlin Renouf, Susan Wilson

Introduction

• Medicine combinations

• Physical and chemical compatibility

• Diluents and site reactions

• One previous NZ study (1995)1

1Lichter I, Hunt E. Drug combinations in syringe drivers. NZ Med J. 1995;108(1001):224-226.

Aims

• Medicines combinations

• Syringe driver demographics

• Medicine compatibility

Available literature

• Site reactions

• Change in practice

Methods

• Study design retrospective, observational, longitudinal 2006/7 and 2013

• Mercy Hospice Auckland in-patients

• Data collection and management• Comparison of data

Result 1: demographics

2006/7 2013

Time (months) 18 4

Number of syringes 1103 675

Non-cancer diagnoses (%) 5 12

Result 2: top five medicines

Medicine 2006/7Frequency of use (%)

Morphine (S or T)

67

Haloperidol 55

Midazolam 39

Metoclopramide 37

Dexamethasone 16

Result 3: most common combination

• Analgesic + anti-emetic +/- sedative

Pain, nausea/vomiting and delirium

• 3 medicines most commonly combined

Morphine + haloperidol + midazolam

Result 3: top five combinations 2006/7

1 2 3 D No. of

patients

(n)

Total syringes

administered

%

MS Haloperidol Midazolam WFI 34 7.5

MT Metoclopramide Midazolam WFI 20 6.8

MT Haloperidol Midazolam WFI 30 4.9

MT Metoclopramide Dexamethason

e

WFI 12 4.6

MT Haloperidol   WFI 18 4.4

Result 3: top five combinations 2013

1 2 3 D No. of

patients

(n)

Total syringes

administered

%

MT Haloperidol Midazolam NS 21 7.9

Oxy Haloperidol   NS 24 7.6

MT Levomepromazine Midazolam WFI 14 5.8

Oxy Levomepromazine Midazolam NS 19 5.6

MT Midazolam   NS 6 4.7

Result 4: medicine incompatibilities

• 2006/7

• No incompatibilities in 2013

1 2 3 Diluent Incompatibility

MT Metoclopramide

Midazolam WFI Crystallisation2,3

MT Cyclizine Hyoscine butylbromide WFI Crystallisation2,3

Result: medicine compatibility 2013

• 21 combinations with no data

• 30 combinations with clinical evidence

• 18 combinations with lab-based

evidence2,3,4

2Palliative Drugs http://www.palliativedrugs.com/index.html. 3Smith, S. Compatibility of syringe driver admixtures for continuous subcutaneous infusion. Auckland: Auckland District Health Board. 2002. 4Dickman A, Schneider J. The syringe driver: continuous subcutaneous infusions in palliative care. 3rd ed. Oxford: Oxford University Press. 2011.

Result 5: site reactions

1 2 3 4 5 6 7 80

5

10

15

20

25

30

2006/7 2013

Number of site reactions

Perc

en

tag

e o

f p

ati

en

ts

Result 6: drug in syringes where site reactions occurred

2006/7

Medicine

Site reaction (%)

Dexamethasone 18.3

Methadone 18.3

Cyclizine 15.1

Metoclopramide 13.6

Phenobarbitone 12.5

2013

Medicine

Site reaction (%)

Levomepromazine

12.8

Dexamethasone 12.1

Metoclopramide 10.4

Morphine 10

Oxycodone 8

Result 6: drug in syringes where site reactions occurred

2006/7

Medicine

Site reaction (%)

Dexamethasone 18.3

Methadone 18.3

Cyclizine 15.1

Metoclopramide 13.6

Phenobarbitone 12.5

2013

Medicine

Site reaction (%)

Levomepromazine

12.8

Dexamethasone 12.1

Metoclopramide 10.4

Morphine 10

Oxycodone 8

Key findings

• Increase in non-cancer patients with CSCI

• Medicines used and combinations same

• Top five combinations

• Lack of information about in-vitro testing

of compatibilities of combinations used

Implications and future research

• Collaborative approach in palliative care

• Need for in vitro compatibility studies

• Generation of national compatibility

guidelines

• Site reaction research

Acknowledgements

• Mercy Hospice Auckland

• Dr Bruce Foggo

• Mrs Emma Griffiths

Thank-you

Syringe driver medications

A study of combinations and compatibilities

Derryn Gargiulo

Dr Jeff HarrisonDr Bruce FoggoEmma GriffithsLauren Doherty, Sana Khan, Kate Kilpatrick, Guangda Ma, Caitlin Renouf, Susan Wilson

Pharmacy/Hospice PC research

• Nation-wide network– Gather data– Large amount of data– Compare regions and NZ internationally

• SoP at Auckland University– Ethics, funding applications – Data analysis, statistical help– Publication, dissemination

• Year 4 research project

Possible research topics

• Drug mixes with ranitidine, octreotide, lignocaine, phenobarbitone and furosemide

• An exploration of patient’s and families feelings regarding medicines management in palliative care and what would help them manage their medicines

• Alternative/complimentary therapies. What is used? Does it work? Does it interact?