A. Apfel,C et al. 2005. PONV: a problem of inhalational anaesthesia? Best Practice & Research Clinical Anaesthesiology. 19(3):485‐500.
B. AUSTRALIAN MEDICINES HANDBOOK 2006. Anaesthetics. In: Boucher, F (ed.) Australian Medicines Handbook. Adelaide (South Australia): Australian Medicines Handbook.
C. STACHNIK, J. and BONK, M. E. 2006. Inhaled anesthetic agents. American Journal of Health‐System Pharmacy, 63, 623‐634.
D. International drug price indicator guide: http://erc.msh.org/dmpguide/
E. BNF for children 2005. BNF Publishing Group Ltd: London
F. Sevoflurane product information
G. GUPTA, A et al. 2004. Comparison of Recovery Profile after Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review. Anesthesia and Analgesia, 98, 632‐641.
H. Enflurane product information
J. FENTON, P. Volatile anaesthetic agents [Online]. Available: http://update.anaesthesiologists.org/wp‐content/uploads/2009/08/Volatile‐Anaesthetic‐Agents‐
Update‐11.pdf [Accessed 01/12/2009 2009].
K. WHO model prescribing information: drugs used in anaesthesia
L. WHO model formulary 2004. WHO: Geneva
Table 4b: Effects of inhaled anaesthetics
Halothane Isoflurane Enflurane Desflurane Sevoflurane Cardiovascular effects:
Contractility ↓↓↓ ↓ ↓↓ minimal ↓
Heart rate ↓↓ ↑↑ ↑ ↑↑ nil
Systemic vascular
resistance ↓ ↓↓ ↓ ↓↓ ↓
Blood pressure ↓↓ ↓↓ ↓↓ ↓↓ ↓
Coronary steal no possibly no no no
Splanchnic blood flow ↓ unchanged ↓ unchanged unchanged
Sensitization to
catecholamines ↑↑↑ nil ↑ nil nil
Respiratory effects:
Respiratory rate ↑ ↑↑ ↑↑ ↑↑ ↑↑
Tidal volume ↓ ↓↓ ↓↓↓ ↓↓ ↓
PaCO2 unchanged ↑↑ ↑↑↑ ↑↑ ↑
Other effects:
Cerebral blood flow ↑↑↑ ↑ ↑ ↑ ↑
Cerebral O2 requirement ↓ ↓ ↓ ↓ ↓
EEG burst
suppression burst suppression epileptiform activity burst suppression burst suppression Effect on uterus some relaxation some relaxation some relaxation some relaxation some relaxation Potentiation of muscle
relaxation some significant significant significant significant
Analgesia some some some some some
Drug Sedation for short
procedures Induction Maintenance Recovery Physiological
effects PONV Adverse
outcomes/ Ketamine Safe (Level A
recommendation)1
Used - IV or
IM Widely used in developing nations. Often used without endotracheal intubation, and for sole operator
10-20% of useful in shock/
impared cardiovascular function, can raise BP (although these effects are dependant on endogenous noradrenaline).
Airway reflexes and
spontaneous ventilation
Infrequent4 Emergence hallucinations, hypertension, pain on injection, rarely laryngospasm, arrhythmias4
category A4 Not suitale if raised blood pressure or intraocular pressure.
Contraindicated in stroke/ myocardial infarction/ valvular heart disease4
IV
1-4.5mg/kg GBP 4.22/200mg
7
Thiopentone Not commonly used - causes hangover, prolonged somnolence
Used Not commonly
used - causes hangover, prolonged somnolence
Rapid after single dose, becomes prolonged after multiple doses, some hangover effect4
Negative inotropic effect, decreases blood pressure (but less than propofol).
Respiratory depression2
Uncommon Prolonged somnolence with repeated doses, cardiorespiratory depression, infrequently laryngospasm, bronchospasm4
category A4 Not suited for use with LMA.6 Porphyria4
IV 3-5mg/kg GBP 3.06/500mg
7
Propofol Safe (Level B recommmendation )1
Used Widely used in developed from general anaesthesia3
Least often of anaesthetic agents
Pain on injection, bradycardia, is at injection site, rarely seizure, pancreatitis, propofol infusion
category C4 Allergy to soya oil, egg lecithin4
IV
2-2.5mg/kg GBP 2.33/200mg
7
Etomidate Safe (Level C recommendation)1
Used Not commonly used7
Frequently unpleasant due to nausea and vomiting6
Particularly useful in shock/
impared cardiovascular function.
Respiratory depression2
Frequent6 1. Adrenal suppression, pain on injection7 thrombophlebitis at injection site6
Depresses neonatal resp in 3rd trimester7
Not suited for use with LMA 6
IV 0.3mg/kg GBP 1.50/20mg7
KEY: PONV = Post
operative nausea and vomiting
IV =
Intravenous IM =
Intramuscular LMA = Laryngeal mask airway
GBP = Great Brittish Pound TCI =
Target
References for table 5: comparison of intravenous anaesthetic medicines:
1. Godwin, S. A et al. 2005. Clinical policy: Procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine, 45, 177‐196.
2. Nathan, N. and Odin, I. 2007. Induction of anaesthesia: A guide to drug choice. Drugs, 67, 701‐723.
3. Gupta, A et al. 2004. Comparison of Recovery Profile after Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review. Anesthesia and Analgesia, 98, 632‐641.
4. Australian Medicines Handbook 2006. Anaesthetics. In: Boucher, F (ed.) Australian Medicines Handbook. Adelaide (South Australia): Australian Medicines Handbook.
5. Strayer, R. J. & Nelson, L. S. 2008. Adverse events associated with ketamine for procedural sedation in adults. American Journal of Emergency Medicine, 26, 985‐1028.
6. Lupton, T. & Pratt, O. Intravenous drugs used for the induction of anaesthesia [Online].Available:
http://update.anaesthesiologists.org/wp‐content/uploads/2008/12/Induction‐Drugs‐used‐in‐Anaesthesia.pdf [Accessed 01/12/2009 2009].
7. BNF for children 2005. BNF publishing group Ltd: London
Table 6: Comparison of non-depolarizing neuromuscular blockers (AMH table)
Duration of action (minutes)1 Drug Onset
(minutes)1,2
initial
dose maintenance dose
Histamine
release3 Comments
1onset and duration of action are dose-related; times given are for recommended doses
2time to satisfactory intubating conditions
3can cause flushing, hypotension, tachycardia, bronchospasm and rarely anaphylactoid reactions
4will not counteract bradycardia produced by many anaesthetics or by vagal stimulation during surgery; bradycardia may be more common with these drugs
atracurium 1.5 30–40 15–25 yes • no effect on heart rate4
• can be used in renal or hepatic impairment
cisatracurium 2 30–40 20 no • no effect on heart rate4
• can be used in renal or hepatic impairment
mivacurium 2–2.5 15–30 15 yes • no effect on heart rate4
• metabolised by plasma cholinesterase; prolonged action in severe renal or hepatic impairment
pancuronium 1.5–2.5 60–120 25–60 no • vagolytic and
sympathomimetic effects (tachycardia,
hypertension)
• prolonged action in severe renal or hepatic impairment
rocuronium 1 30–40 15–20 no • may cause tachycardia at
high doses
• prolonged action in severe renal or hepatic impairment
vecuronium 2–3 20–40 20–40 no • no effect on heart rate4
• prolonged action in severe renal or hepatic impairment
Table 7: Comparison of medicines for neuromuscular blockade
Drug Dose : m g/kg
Tim e m ax im a l blocka de : m in utes
Recovery:
m in utes (25%
ba se line )
Re cove ry:
m in utes (75%
base line ) Com m e nts Cost (GBP )
Su ccynylch olin e 1 1.1 8 11
1. Considerable undesired effects 2. Agent with fas tes t onset, and shortest ac tion
£0.70/100m g (2m l)
Alcuro nium 0.2 7.1 47 (20% recovery) 90 (70% recovery)
1. Slow onset and very slow recovery 2. No longer widely used Atracu rium
See A MH
table See A M H table See A MH table See A M H table S ee AM H table
£1.66/25m g (2.5m l) Cisatracu rium
See A MH
table See A M H table See A MH table See A M H table S ee AM H table
£2.04/5m g (2.5m l) M iva curium
See A MH
table See A M H table See A MH table See A M H table S ee AM H table
£2.79/10m g (5m l) Pa ncuro nium
See A MH
table See A M H table See A MH table See A M H table S ee AM H table £0.65/4m g (2m l) Ve curon iu m
See A MH
table See A M H table See A MH table See A M H table S ee AM H table
£3.95/10m g (vial) Ro curon iu m
See A MH
table See A M H table See A MH table See A M H table S ee AM H table
£3.01/50m g
(5m l)