o c Cc oO 8 € IT Wephine mm Emeses ont Fr a G f ex. Tm Cronthsel Ont ean oreo et verpt¢ { Table 5.1: IV Induction Agents “°C pate 2 Drugname | Dose] Onset] Distinct ‘Systemic effects Special poms = (induction) characteristics DZ oO cvs Respiratory [ens Ler te Fetet Seeky tone }) 30-70 api 18P Respiratory Powerful ~ |1. Canbe used in status & Bom ous Fee mgikg (one arm- brain | CO dopressant ‘anticonvulsant pllopticus and cerebral 9 —S /ty (cardiac ‘Transient apnoea protection n Gon Be eho wae depression) 2. Contraincicated in porphyria THR | and allergy o barbiturates ®en Swo Propofol 2oee} 2050 api ABP {Depresses the Minimat - — |1. Canbe used in TVA, ICU ( esi - gre HX mghkg LHR ryngeal refleKes> | hangover’ effect ‘or RA sedation, status _ Bronchodilation _ epilepticus, antiemetic >) Inuberte ~orcorP {Tension spnosa 2. Contraindicated in allergy to ~ a eggs, hypotension 5) Thee pe * Propofol infusion syndrome - Ketamine 1.0-2.0 TBP Maintains upper | Powerful PONV | 1. Used in patients with Pdeeunium mg/kg THR: airway tone and | analgesic and hypotension, severe a) oem or 1CcO reflexes amnesic _ asthma, analgesia in chron Arrythmias Bronchodilatic tICPIOP pain, short procedures: >, salivation: Visual/auditory (bums dressing etc). mass a) out hallucinations ‘casualties in the fld 2 por 2. Contraindicated in tICP, 8 laucoma, hypertension and ~ ave Dexa angina pref ‘Etomidate | 0202 | 10.85 |ndrono-corical [Reavy [GSdresrton Myodtene ne a eee Gee D ont mg/kg ‘secs | suppres lon — sion a ‘Single inducton can Ge morplone es rain durir ing ia leone | kee 2 coup nen mp Sers op Sam - hech Table 6.2: Sedative Orugs Type Dose/ route Effects ‘Special points ‘Midazolam Promedication: 0.07-0.1 mg/kg | Respiratory and CVS. 1. Used as part of premedication (Benzodiazepine) 0.5-1.0 mg boluses. : sion (especially elderly (anxiolysis), co-induction agent : 0.3 mg/kg, atients), dose have to (slow onset), sedative in ICU Infusion: 0.05-0.2 mg/kg/hr bo titrated accordingly 2. Effects can be reversed by flumazenil Lorazepam Sedative: IV, IM, oral 0.05 mg/kg | Onsetis 15 minutes in IV and | 4. Effects can be reversed by (Benzodiazepine) (max: 2.0-4.0 mg) 30-60 minutes in oral | flumazenit Lasts = 8-12 hrs | Dexmedetomidine Loading dose: IV 1.0 yg/kg (10-15 | With loading dose: sedative | 1. Used in MAC (AFOI, colonoscopy) (a-2 agonist) min) and ICU sedation Maintenance dose: 0.2-0.7 yg/kg/ min (according to manufacturer's table) 2. Lacks respiratory depression effects is beyond 15 mi 3. Dosage reduction in hepatic Mild amnesia and analg: ‘Sympatholysis property: hypotension and bradycardia difficulty in Naloxone Atropine Vasopressin Lignocaine Epinephrine (Aderenaline) - Drug administration via ETT route is an option if there is! ling IV or intraosseus access in crisis or 1 life threatening situation Doses are 2-2.5x of IV dose (diluted in 1-2 mi of saline) - Drugs that can be given via ETT (NAVEL): ct lc crt it Soni ousisamy suo) Scanned with CamScannervSL Volatile name Uses *MAC (%) Table 5.3: Inhalational Anaesthetics/ Volatile Agents Systemic Effects Major Advantages | cvs cr | Sevoflurane 2.0 Minimal effect on 1. Fast induction/ recovery BP/HR: (non-irritant) 2. Non pungent smell Bronchodilation 3. Bronchodilation Desflurane Maintenance of 6.0 THR with sudden Pungent smell (irritant | PONV 1. Fast onset/ recovery anaesthesia change in agent's | to airway) 2. Less metabolism concentration _| Bronchodilation 3. Bronchodilation Slight 1BP Isoflurane Maintenance of 1.15 Potent vasodilator Pungent ‘smell ‘Small 1. Stable cardiac rhythm anaesthesia ISVR = [BP risk of | 2. Fast onset! recovery THR hepatitis | 3. Excellent muscle relaxant 4. Bronchodilation Nitrous Oxide | Adjunct 104 | Minimal Respiratory par] 1. No odor, cheap (N,0) inhalational (< potent) | myocardial depression (when 2. Fast onset and recovery (refer below for depression combined with 3. Minimal cardiopulmonary adverse effects) Mild sympathetic ‘sedatives and opioids) depression ‘stimulatory effect “Diffusion hypoxia 4. Mild analgesic * Refer pg. 147 Fenjews Po pregnennce ; 50 used Adverse effects of NO administration; ~_ Expansion of air‘illed spaces: pneumothorax, bowel obstruction, middle ear if the eustachian tube is obstructed - Nv N30 ~ Shronic exposure: Vitamin B12 deficiency, infertility, teratogenicity (if exposed durina 1 trimester) anc home marrow ssinnemesinn Scannéd with CamScannerinner Table 6.4: Analgesic Agents Scanned with CamScai Analgesic type Dose/ route of administration — Fentanyl IV 1.0-446 pg/kg (80 pg/kg for cardiac Morphine g Pethidine IV 1.0-1.5 mg/kg tds (meperidine) | 1M 0.8-1.0 mg/kg tds ‘Tramadol PONV 1.0-2.0 mgikgtds |, MaKe PPP ner Be) gcse Tt N80 mh For FOREcoo vs ond x Scanned with CamScanner ‘Analgesic type Dose/ route of ‘Onset | Duration Effects ‘Special points administration (min) | (hours) —l Non-Opioid NSAIDS 1. Diclofenac | PO 25-75 mg bd/tds c 7 (Voltaren) 2. Mefanamic | PO 250-500 mg tds S - Acid (Ponstan) PO 400 mg tds/qid ° - 1. Renal insufficiency Caution in: 3. Ibuprofen 2. Gastric ulcer/erosion asthma (Brufen) 3. Concurrent anticoagulant ‘stomach (gastric) ulcer or bleeding therapy kidney impairment Selective COX-2 4. Reactive airway disease previous problems with anti- inhibitor - - inflammatories 1. Parecoxib | IV 40-80 mg/day . platelet dysfunction (Dynastat) 2. Etoricoxib | PO 60-120 mg/day (Arcoxia) 3. Celecoxib —_| PO 200-400 mg OD (Celebrax) Acetaminophen | Adult: Oral, rectal, IV dose | - - Renal/ hepatic impairment —_| 1. Absorption of drug will be altered (paracetamol) | 1.0.9 6 hourly or 5-15 mg/ in those with altered gastric kg (max 4.0 g/day) emptying _|Peees: supp 30-40 mg/kg 2. Rectal administration produces delayed and variable uptake Adjuvant ‘Dexamethasone | IV 4.0-8.0 mg tds \ - = ‘Analgesia (through inhibition 1. A glucocorticoid (conlcosteroia) of prostaglandins) 2) Less mineralocorticoid property Antiinnamrmatory hence lees water retontorTable 5.5: Neuromuscular Blocking (NMB) Agent/ Muscle Relaxant Drug e/name Intubating Maintenance | Onset Dur type Eee pins fe uration Side Effects ‘Special points: (25% twitch height 1. Depolarising agent | Us (a) Suxamethonium/ | IV 1.0-2¢ mg/ - 30-60 4-6 min Myalgia, histamine 1. Fast onset and offset Succinylcholine kg secs release, transient increase muscle paralysis. IM3.0 mg/kg in ICPY IOP, 1K* level (fatal | 2. Prolonged block in (max 150 mg) repeated doses (> crush injuries, upper 8mgikg),"pseudo- motor neurones), trigger cholinesterase ‘malignant hyperthermia, | — deficiency bradycardiar> cautious HO *suxamethonium apnoea 2. Non-depolarizing Non organ dependent agent metabolism (a) Tracrium 1V0.4@5)ng/ | 0.1 mg/kg | 3-5 | 20-35 min | Bronchospasm secondary | 1. Non organ dependent kg min | (variable) | to histamine release metabolism (b)Cis-atracrium —|1v0.15-0.4 | 0.02mgikg | 3-5 | 20-35 min | Hypotension and 2. Less histamine release mg/kg min | (variable) | bradycardia (broncho- spasm uncommon) 0.6-0.9 mg! | 0.1m 1-2. | 20-95 min | Large doses cause Can be used in modified (¢) Rocuronium ie sce ela (variable) | mild vagolytic effect RSI (pg. 117) (tachycardia) * Refer pg. 148 - 150 Scanned with CamScanner8st Table 5.6: Local Anaesthetic Agent ‘Onset (min! Duration of | ‘Special points Type Dose (route) (min) eetion thes) i : 5-10 48 4. Do not use in IVRA (pg. 141) pet ttas to rere (depends on route, 2. More cardiotoxic (except in levo-bupivacaine) (ern 0.5% concentration, volume 3. 0.75% is contraindicated in obstetric patients 075%) Intrathecal: 8-12 mg and dose) ‘4. 0.5% (hyperbaric solution: addition of glucose (block up to T10) 8%) is used in spinal anaesthesia provi immediate onset Intrathecal: 14-20 mg 5. Addition of adrenaline lengthens the duration (block up to T4) of action Ropivacaine Infiltration/ epidural: 3.0- 10-15 48 1. Not intended for spinal anaesthesia (amide) 4.0 mg/kg (depends on route, 2. Less cardiotoxic compared to bupivacaine (0.2%, 0.5%, concentration, volume 3. Less motor blockade (beneficial in obstetric 0.75%, 1%) and dose) analgesia, chronic pain management and general post-op epidural infusion) Lignocaine infiltration, epidural: 12 1-2 1. Can be used to obtund sympathetic reflex amide) 3085 mglkg during laryngoscopy, anaesthesia of the (0.2%, 0.5%, 1%, airway via nebulizer, a content in EMLA. 2%, 4%, 5%) Topical ( in AFO! or with cream, IVRA and ventricular dysarrythmias adrenaline): 7.0 mg/kg 2. Addition of adrenaline lengthens the duration of action 3. If given via ETT — needs twice the dose 4. Antiarrhythmic agent (ventricular) EMLA 41. Cream applied - 1. Topical anaesthesia for minor procedures (IV (Eutectic on planned site cannulation in paediatrics) mixture of local and cover wil 2. Son as minimal amount as possible on intact > occlusive dressin skin Mnocainezs \AdueZSAG09 2. Srourlstorersant 3 Bane cause enythems, itching, blanching ‘and pritocaine Ts'wipe off and 2S) procedure can wooaanvH ¥53 yusarny O88 Scanned with CamScannerTable 5.7: Reversal Agent and Antichotinergics Scanned with CamScanner Enos ‘Special points De _f ae Bradycardia 1. Can prolong the duration of action of suxamethonium ee | ee increase bronchial secretions | 2. Roversai he wi non-depolarizing NMB agent leading to bronchosconstriction | 3. Ineffective in profound block crease salivation sis Routine reversal No data to suggest risk for 3, Specific reversal for rocuronium (aminosteroid group) — - mv 20 mgjkg (in TOF 2) | adverse effects on any target | 2. Effective in variable depth of block (including profound > 1V4.0 mg/kg (in PTC 2) | organ block SS a Immediate/ rescue 3. Can be used in “CICV" situation (if rocuronium is used) reversal: IV 16 mg/kg Naloxone | 0.002 mg/kg/dose or 0.1- | Opioid antagonist 1. Reverses opioid induced side effects (respiratory 02mg Onset within 2 minutes depression, pruritus) (every 2 minutes) Lasts = 45 minutes 2. Large quantity can be given without significant toxicity Flumazenil | 0.2 mg then 0.1 mg every | Benzodiazepine antagonist 1. Avoid rapid injection of flumazenil which can lead 1 minute Almost immediate onset to withdrawal symptoms such as agitation (tremor, (max: 1 mg) Palpitations, anxiety) and emotional lability (confusion, euphoria, depression) bas 2. Resedation may occur (need repeated dosing) : Anticholinergics (adjunct to neuromuscular blockade reversal ard counter the effects of neostigmine) Type Dose! route Effects Special points Atropine IV 0.01-0.02 Tachycardia Has a tertiary quat structur ic ir ie mglkg Bronchodilation ry quaternary si re which crosses the blood brain barrier and may present with central anticholinergic i Reduce s: tion (anti- sialagogue) | amnesia, a, ) ee on: and bronchial secretions Glycopyrrolate | 1V5.0-10 | Less tachycardia Has a quaternary structure, wem HO v9/kg | Better anti-sialagogue + Decrease GIT motility barrier hence devoid of any therefore it doesn't th e central effects ‘cross the blood brain ee ORE Cee i z i 5Table 5.8: Basic Resuscitation Drugs Scanned with CamScanner Drug type ‘Mechanism of action Dose route ‘Usage ‘Special points Adrenaline! T ‘Sympathomimetics IV 0.1 mg bolus: Anaphylaxis: Low doses gives the B-effects and Epinephrine (a and B-agonist) IV 1.0 mg bolus Cardiac arrest high doses gives a-effects 1V 0.01-0.1 yg/kg/min infusion | Low CO states . (via ETT need twice IV dose) _ | (as inotropic drug) 1: 1000 Cl aefaale = long) Nebulizer 0.4 ml/kg (max 5 ml) | Bronchospasm \ 10,000 C Lepwoule AME (Occ USD]. Croup Atropine Anticholinergic agent ‘As previously mentioned’ IV, | Bradycardias As previously mentioned above hay IMETT 4 Dose Wins /ios : Ephedrine 1. Indirect action: release | IV 3.0-6.0 mg bolusr 0.07 —_| Hypotension Increases the BP by increasing the S Lop of Noradrens mg/kg bolus (in spinal epidural) | heart rate and cardiac contraction 2. Direct action: a and a *Tachyphylaxis why He B-agonist CHR N/oreely Hl He eegeod Phenylephrine | Sympathomimetics 1V 25-100 meg bolus Hypotension Increases the BP by vasoconstriction ¥ (a1-agonist) (in obstetric RA) __| (have simultaneous bradycardia ‘Bp Plate im Me NS, = Chosen for obstetric RA due to Tye x Teo\ oi teats) the better fetal acid-base profile beesme (60 es to compared to using ephedrine (in large doses) Resembles adrenaline but more prolonged effect and less effect on ! the heart Vdoronrre Wrox: ZO MCYAaD - Sfe of Cecent max clOSe > Triehkycoretoe SSTable 5.9: Herbal and Dietary Supplements Affecting Anaesthesia Name of herb/ diet supplement ‘Common uses Pos: Je effects on anaesthesia Ephedra (Ma Huang) ‘Appetite suppressant Ashtma and bronchitis CNS stimulant (street name: “Cloud 9” and “Herbal Ecstasy") Predominant compound is ephedrine, hence the sympathomimetic property In the presence of other sympathomimetic drugs, it can cause erratic hypertension, arrhythmias and hyperthermia Garlic Lowering of cholesterol, triglyceride | Potent inhibitor of thromboxane synthetase enzyme and BP In the presence of anticoagulants or anticlotting agents, it increases the Anti-inflammatory risk of bleeding Anti-emetic Ginger Anti-emetic Inhibits prostaglandin and leukotriene biosynthesis In the presence of anticoagulants or anticlotting agents, it increases the > risk of bleeding Ginkgo biloba Peripheral vascular disease ‘Anti-oxidant property and inhibits platelet-activating factor (improves blood circulation) In the presence of anticoagulants or anticlotting agents, it increases the Dementia risk of bleeding Lowers blood glucose Ginseng Immunomodul Pharmacokinetic profile is partly understood Glucosamine Increases physical stamina and mental concentration Osteoarthritis In the presence of anticoagulants or anticlotting agents, it increases the risk of bleeding ‘Aids glycosaminoglycan synthesis May interact with insulin causing hypoglycaemia Herbal diuretics (green tea, saw palmetto) ‘Natural weight loss remedy Enlarged prostate and urinary inflammation Postulated renin-angiotensin-aldosterone pathway interference Leads to electrolyte imbalance Scanned with CamScanner