Synopsis
Use a continuous subcutaneous infusion only for a clear route or symptom indication, calculate each 24-hour dose from assessed need, verify compatibility and device programming, and monitor the patient, site, pump and breakthrough response through every handover.
- Use a continuous subcutaneous infusion when oral or transdermal delivery is unreliable and a reasonably stable 24-hour medicine requirement exists.
- First-line preparation reconciles the last 24 hours of scheduled and rescue medicines, symptoms, renal and hepatic function, allergies and current route.
- Calculate the infusion from actual effective need and route conversion; do not place all anticipatory medicines into the pump simply because they are available.
Key red flags
A syringe pump is a route, not a diagnosis, sedation order or automatic indication that death is imminent.
New sedation, respiratory slowing, hallucination or myoclonus after starting or changing a pump requires immediate dose and device review.
Investigation priorities
Confirm the indication, symptom mechanism, oral or patch failure, expected duration and whether needs are stable enough for continuous delivery.
Management branches
An established symptom medicine is needed continuously and the oral route is no longer reliable.
- Assess symptoms and route, reconcile actual 24-hour exposure, check organ function and calculate each medicine and rescue through the local palliative protocol.
- Verify compatibility, diluent and concentration with an approved source or pharmacy and complete an independent prescription and device check.
Key medicines
Morphine by continuous subcutaneous infusionCalculate the total 24-hour subcutaneous morphine from actual prior opioid exposure using the current local conversion table; many formularies approximate it as half the 24-hour oral morphine dose, then adjust for toxicity, frailty and renal function with an independent check.
Midazolam for selected agitation or anxietyIn the last days a common specialist starting continuous subcutaneous dose is 5 to 10 mg over 24 hours, with 2.5 mg subcutaneous rescue when prescribed under the local protocol and after reversible causes are assessed.