PALLIMED EOLC

 A

Below is a UK-style palliative care syringe driver titration guide (continuous subcutaneous infusion, CSci), focusing on opioid + midazolam—the most commonly combined regimen in end-of-life symptom control.

This is aligned with typical NHS hospice / hospital palliative protocols (e.g., Liverpool Care Pathway successor guidance, local Trust guidelines, and palliative care formularies). Exact doses vary by Trust and patient factors.

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💉 SYRINGE DRIVER TITRATION GUIDE (UK PRACTICE)

Opioid + Midazolam (± antiemetic adjunct)

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1. BEFORE STARTING (CRITICAL CHECKS)

☐ Confirm indication: persistent pain, dyspnoea, agitation, or repeated PRN use
☐ Review 24-hour PRN usage (key for starting dose)
☐ Assess opioid tolerance
☐ Check renal function (important for morphine choice)
☐ Exclude opioid toxicity (myoclonus, pinpoint pupils + sedation)
☐ Decide drugs compatible in CSci (Trust syringe driver compatibility chart)

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2. OPIOID CONVERSION (STARTING POINT)

A. If patient already on regular opioid

Use total 24-hour opioid dose:

Step 1

• Convert all opioids → oral morphine equivalent (OME)

Step 2

• Calculate CSci dose:

CSci opioid dose = 50–100% of total 24h oral opioid

• Use 50% if frail/renal impairment

• Use 75–100% if uncontrolled symptoms

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B. If opioid-naïve patient

Typical starting:

• Morphine SC: 10–20 mg / 24 hours

• Lower end if elderly/frail

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C. Breakthrough dose

• 1/6th of total 24h opioid dose

• PRN SC every 1 hour (or Trust policy)

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3. MIDAZOLAM (ANXIETY / TERMINAL AGITATION)

Starting dose:

• 10–20 mg / 24 hours SC

Adjustments:

• Mild agitation: 10 mg/24h

• Moderate–severe agitation: 20–40 mg/24h

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PRN breakthrough:

• Midazolam 2.5–5 mg SC PRN hourly

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Escalation threshold:

If >2–3 PRN doses in 6–8 hours:
→ Increase CSci dose by 30–50%

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4. COMBINATION STARTING REGIMEN (COMMON NHS SETUP)

Typical first syringe driver:

Drug	Starting dose (24h CSci)
Opioid (morphine or equivalent)	10–60 mg (varies widely)
Midazolam	10–20 mg
Haloperidol OR Levomepromazine (optional antiemetic)	small adjunct dose if needed

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5. TITRATION RULES (CORE PRINCIPLES)

A. Pain / Dyspnoea not controlled

If persistent distress:

• Increase opioid by 30–50% every 24 hours

• If severe → 50–100% escalation acceptable

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B. Agitation not controlled

• Increase midazolam by 30–50%

• If severe terminal agitation:

  • escalate to 40–60 mg/24h or higher under specialist guidance

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C. Breakthrough pattern guide

PRN frequency	Action
0–1 doses/24h	No change
2–3 doses/24h	Increase CSci 30%
≥4 doses/24h	Increase CSci 50%
Persistent distress	Consider specialist review

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6. RENAL FAILURE ADJUSTMENTS (IMPORTANT)

If eGFR low / AKI:

Prefer:

• Oxycodone or alfentanil (if available)

Avoid / caution:

• Morphine (risk of metabolite accumulation → agitation, myoclonus)

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7. RESPIRATORY SECRETIONS / NAUSEA (OPTIONAL ADD-ONS)

Secretions:

• Glycopyrronium 600–1200 micrograms / 24h
  or

• Hyoscine butylbromide 20–60 mg / 24h

Nausea:

• Haloperidol 1.5–5 mg / 24h
  or

• Levomepromazine 6.25–25 mg / 24h

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8. REVIEW SCHEDULE (NHS STANDARD)

• Reassess within 4–6 hours if unstable

• Routine review every 24 hours minimum

• Always adjust based on:

  • PRN use

  • observed distress

  • nursing feedback (very important in practice)

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9. CLINICAL WARNING SIGNS (OVER-SEDATION / TOXICITY)

Watch for:

• Excess sedation with no distress relief

• Myoclonus

• Paradoxical agitation (especially benzodiazepines)

• Respiratory suppression not consistent with comfort goals

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⚠️ KEY NHS PRINCIPLE

“Titrate to comfort, not numbers.”

There is no fixed universal dose—only response-based escalation.

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If you want next step tools, I can generate:

• a Trust-style syringe driver prescription chart (blank fillable template)

• a full opioid conversion table (all routes → SC morphine equivalents)

• or a separate delirium vs pain vs dyspnoea titration algorithm (very exam-useful)