Download 15: Anaesthesia - Gateshead Health NHS Foundation Trust

15: Anaesthesia
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15.1 General Anaesthesia
15.2 Local anaesthesia
Changes to the Formulary since previous version
(1.12.2012)
Section
Antimuscarinic drugs
Change
Reason for change
Atropine 1mg/10ml minijet
Product discontinued
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 1 of 11
Date: 10.10.2013
15.1 General Anaesthesia
Intravenous anaesthetics

Thiopental sodium 500mg injection

Etomidate Lipro 2mg/ml injection

Ketamine 10mg/ml, 50mg/ml and 100mg/ml injection

Propofol Lipuro 1% and 2% (2% ITU only)
Dose
- Propofol injection 1% (10mg/mL): induction of anaesthesia, by intravenous
injection or infusion, 1.5-2.5mg/kg (less in those over 55 years). Maintenance of
anaesthesia, by intravenous injection 25-50mg repeated according to response,
or by intravenous infusion 4-12mg/kg/hour.
- Thiopental injection 2.5% (25mg/mL): by intravenous injection, induction of
anaesthesia, 4-7mg/kg titrated to response.
- Etomidate injection 2mg/mL: by slow intravenous injection, 150300micrograms/kg (elderly, 150-200micrograms/kg).
Prescribing notes

Propofol is contra-indicated in patients allergic to eggs, nuts or soya, and
should be used with caution in patients with epilepsy due to increased risk
of convulsions.

Propofol is used in sub-anaesthetic doses by infusion for sedation.

Propofol is used for total intravenous anaesthesia.

Thiopental is used for rapid sequence induction of anaesthesia and may be
used in other patients who are allergic to propofol. It is contra-indicated in
patients allergic to barbiturates or with porphyria.

Whilst thiopental has good anti-epileptic properties, it has a very long halflife and as such its effects can take days to wear off. This may severely
delay assessment of neurological status in patients who have received it
for prolonged periods for status epilepticus.

Ketamine may be useful for sedation or induction of anaesthesia by the
intramuscular route as well as IV, and for refractory bronchospasm in
ventilated patients.

For further information on sedation on Critical Care, see Critical Care
Department Sedation Guideline.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 2 of 11
Date: 10.10.2013
Inhalational anaesthetics

Desflurane liquid

Isoflurane liquid

Sevoflurane liquid
Dose
- Dosage is variable and titrated to individual patient requirement. See BNF.
Prescribing notes

Isoflurane is less expensive than other agents.

Sevoflurane is associated with fewer adverse induction effects and can be
used for rapid inhalational induction in place of intravenous agents. When
used for maintenance of anaesthesia, sevoflurane is more economical
when used with low-flow fresh-gas settings.

All volatile anaesthetic agents (e.g. isoflurane, sevoflurane) can trigger
malignant hyperthermia; nitrous oxide does not trigger malignant
hyperthermia.

Adequate scavenging or external venting should be used.

Use of absorption breathing systems can permit use of low fresh gas flow
techniques which can result in significant economies with these agents.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 3 of 11
Date: 10.10.2013
Antimuscarinic drugs

Atropine 600 microgram/ml injection

Atropine 3mg/10ml injection pre-filled syringe

Atropine 1mg/5ml injection pre-filled syringe

Glycopyrronium 200 microgram/ml injection

Hyoscine hydrobromide 400 microgram/ml injection
Dose
- Atropine sulphate injection 600micrograms/mL: by intravenous injection,
prophylaxis or treatment of bradycardia, 300-600micrograms. During reversal of
neuromuscular blocking agent, 0.6-1.2mg in conjunction with neostigmine. In
accordance with UK Resuscitation Council Guidelines, asystolic cardiac arrest,
3mg intravenously as a single dose once only; electromechanical dissociation
(EMD) if heart rate less than 60/minute on monitor, 3mg intravenously.
- Glycopyrronium bromide injection 200micrograms/mL: by intravenous
injection, prophylaxis or treatment of bradycardia, 200-600micrograms. In
conjunction with neostigmine, up to 600micrograms.
Prescribing notes

Atropine and glycopyrronium are both suitable for reducing salivation prior
to upper airway endoscopy.

Glycopyrronium is first choice in older patients as it causes less
tachycardia than atropine.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 4 of 11
Date: 10.10.2013
Sedative and peri-operative drugs

Diazepam 5mg/ml injection

Midazolam 1mg/ml, 2mg/ml and 5mg/ml injection

Lorazepam 1mg tablets

Temazepam 10mg and 20mg tablets

Temazepam 10mg/5ml oral solution
Dose
- Diazepam tablets 5mg, 10mg; oral solution 2mg/5mL: 5-10mg 1-2 hours
before procedure.
- Temazepam tablets 10mg, 20mg; oral solution 10mg/5mL: pre-medication,
10-20mg (elderly, 10mg) 1 hour before operation.
- Lorazepam tablets 1mg: 2-3mg the night before operation, or 2-4mg 1-2
hours before operation.
- Midazolam injection 2mg/mL: by intravenous injection, 1mg (max 10mg)
titrated slowly to response.
Prescribing notes

Lorazepam may be preferred for pre-operative sedation because of its
amnesic effects.

Flumazenil can be used to reverse the effect of benzodiazepines.

Midazolam is the drug of choice for intravenous sedation but has no
analgesic effect.

For further information on sedation on Critical Care, see Critical Care
Department Sedation Guideline.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 5 of 11
Date: 10.10.2013
Non-opioid analgesics

Ketorolac 30mg/ml injection

Paracetamol 1g/100ml injection

Diclofenac 75mg/ml injection (Dyloject®) – Theatres only

Diclofenac suppositories 12.5mg, 25mg , 50mg, and 100mg
Opioid analgesics

Alfentanil 500 microgram/ml

Alfentanil 5mg/ml injection – ITU only

Fentanyl 100 microgram/2ml injection and 500 microgram/10ml injection

Remifentanil 1mg injection

Morphine sulphate injection 10mg/mL, 15mg/mL, 20mg/mL, 30mg/mL; intravenous
infusion 50mg/50mL

Diamorphine injection 5mg, 10mg, 30mg, 100mg, 500mg
Prescribing notes

Fentanyl, alfentanil, remifentanil, morphine and diamorphine are used
during anaesthesia under specialist supervision. Since there is a very wide
variation in dose requirements, dose should be adjusted to individual
patient needs and indication.

Opioid analgesics given in small doses before or with induction reduce the
dose requirement of some drugs used during anaesthesia.

Alfentanil, fentanyl and remifentanil are useful because of their rapid onset
and short duration of action.

Naloxone may be used to reverse the effects of opioids.

Older patients are particularly susceptible to respiratory depression and
constipation secondary to opiates.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 6 of 11
Date: 10.10.2013
Muscle relaxants

Atracurium 25mg/2.5ml, 50mg/5ml and 250mg/25ml injection

Pancuronium 4mg/2ml injection

Rocuronium 50mg/5ml injection

Vecuronium 10mg injection

Suxamethonium 100mg/2ml injection
Dose
- Atracurium besilate injection 10mg/mL: by intravenous injection, 20-50mg
for intubation followed by 5-10mg increments or infusion at 300-600
micrograms/kg/hour.
- Vecuronium bromide injection 10mg vial: by intravenous injection, 3-8mg for
intubation followed by 1-2mg increments.
- Suxamethonium chloride injection 50mg/mL: by intravenous injection,
1mg/kg (range 0.3-1.1mg/kg); usual range 20-100mg.
- Rocuronium bromide injection 10mg/mL: by intravenous injection, 30-80mg.
Prescribing notes

Repeated suxamethonium doses can cause intense bradycardia or cardiac
arrest and patients should be pretreated with an anticholinergic agent.

Suxamethonium is a depolarising agent causing rapid paralysis. Prolonged
paralysis occurs in 1:2400 patients following administration of
suxamethonium, as a genetically transmitted defect of metabolism.

Suxamethonium can trigger malignant hyperthermia.

Suxamethonium should be used with caution in patients with high
potassium levels, such as in renal failure or burns.

Vercuronium may be a preferred choice in patients with bronchospasm due
to minimal histamine-releasing properties.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 7 of 11
Date: 10.10.2013
Anticholinesterases used in anaesthesia

Neostigmine 2.5mg injection

Neostigmine 2.5mg plus glycopyrronium 500 microgram injection
Prescribing notes

Neostigmine is used for the reversal of neuromuscular blocking agents. It
requires concurrent antimuscarinic administration to prevent serious
bradycardia or cardiac arrest.
Other drugs for reversal of neuromuscular blockade

Sugammadex 200mg/2ml and 500mg/5ml injection
Antagonists for central and respiratory depression

Doxapram 100mg/5ml injection

Flumazenil 500 microgram/5ml injection

Naloxone 2mg/2ml syringe and 400 microgram/ml injection
Dose
Please note that the use and doses of these agents in anaesthesia are different
from those given for the treatment of poisoning/overdose. Chapter 16,
Appendix 2.
- Naloxone injection 400micrograms/mL: by intravenous injection, initially 100200micrograms (1.5-3micrograms/kg); if response inadequate, increments of
1OOmicrograms every 2 minutes; further doses may be required by intravenous
bolus or infusion. Higher doses are required for poisoning. Patients should be
observed and monitored until the risk of re-narcosis is over.
- Flumazenil injection 1OOmicrograms/mL: by intravenous injection, initially
200micrograms over 15 seconds, then 1OOmicrograms at 60-second intervals if
required; usual dose range, 300-600micrograms; max total dose 1mg (2mg in
intensive care); question aetiology if no response to repeated doses. By
intravenous infusion, if drowsiness recurs after injection, 1OO4OOmicrograms/hour, adjusted according to level of arousal.
Prescribing notes

The antagonist should be matched to the cause of the respiratory
depression. All doses should be titrated to the patient's response.

Since the duration of action of naloxone may be less than the duration of
the opioid causing respiratory depression, repeat doses may be required.
Naloxone also antagonises the analgesic effects of opioids.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 8 of 11
Date: 10.10.2013

Flumazenil is potentially hazardous in patients receiving central nervous
system drugs, and may precipitate withdrawal symptoms in patients who
are benzodiazepine dependent.
Drugs for malignant hyperthermia

Dantrolene 20 mg injection
Dose
- Dantrolene sodium injection 20mg vial: by rapid intravenous injection, 12mg/kg (3-6 x 20mg vials requiring 60mL sterile water per vial). Repeated as
required to a cumulative max. of 10mg/kg.
Prescribing notes

Advice regarding the treatment of hyperthermia induced by drugs other
than anaesthetics, such as MDMA or cocaine, can be obtained from the
National Poisons Information Service or TOXBASE.

Patient must be transferred to intensive care as soon as practicable.

Body temperature may be reduced by surface cooling with ice, or
administration of cooled intravenous infusions.

Treatment of malignant hyperthermia may also include :
o
sodium bicarbonate
o
mannitol (may need to melt precipitate first)
o
furosemide
o
dextrose/insulin infusion
o
intravenous beta-blocker
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 9 of 11
Date: 10.10.2013
15.2 Local Anaesthesia

Lidocaine 1% injection (10mg/ml)

Lidocaine 2% injection (20mg/ml)

Lidocaine 1%, 2% with adrenaline 1:200 000 injection

Lidocaine 2% with adrenaline 1:80 000 injection

Lidocaine 10% spray

Lidocaine 5% ointment

Lidocaine 4% topical ointment (LMX4®)

Lidocaine 0.2% Glucose 5% infusion 500ml

Bupivacaine 0.25%, 0.5% injection (10ml)

Bupivacaine 5mg in Glucose 80mg/ml injection

Bupivacaine 0.125% 250ml infusion

Bupivacaine 0.25%, 0.5% with adrenaline 1:200 000

Levo-bupivacaine 0.25% and 0.5% injection

Levobupivacaine 0.1% with fentanyl 500mg/250ml infusion

Prilocaine 1% injection

Prilocaine 20mg/ml Glucose 60mg/ml (Prilotekal 2%) injection

Mepivacaine 3% cartridges for dental use

Ropivacaine 75mg/10ml & 100mg/10ml injection
Prescribing notes

Local anaesthetics can be very toxic and therefore great care should be
taken to avoid inadvertent injection into a vein or accidental overdose.

Vasoconstrictors (adrenaline or octopressin) should not be injected into
extremities.

Choice of local anaesthetic, concentration and the presence of a
vasoconstrictor can depend on total dosage required, site of
insertion/application and intended surgical procedure.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 10 of 11
Date: 10.10.2013

Maximum doses of each agent also depend on total dose, site of injection,
presence of vasoconstrictor and vascular state of the tissues.

Levobupivacaine is less cardiotoxic than bupivacaine and can be used for
high dose blocks which have a significant potential for accidental
intravenous placement.

Lower concentrations of anaesthetics cause less stinging on injection;
irritation is reduced by warming anaesthetic solutions prior to injection.

The total dose of adrenaline should not exceed 500 microgram (i.e. 0.5ml
of a 1 in 1000 solution).

Lidocaine has a faster onset of action and less toxic than bupivacaine.
However bupivacaine has the advantage of a longer duration of action.
Drugs for local anaesthetic toxicity

Intralipid 20% injection
Dose
- Intralipid 20% injection: 1.5ml/kg over 1 minute then infusion of
0.25ml/kg/min. Repeat bolus every 3-5mins up to 3ml/kg total dose. Continue
infusion until haemodynamic stability is restored. Increase rate to 0.5ml/kg/min if
BP declines. Max total dose of 8ml/kg.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Green + are classified as
Green by default
Amber = Drugs with shared care agreement
Green + = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 11 of 11
Date: 10.10.2013