An a Es Related Drugsmedical

8/13/2019 An a Es Related Drugsmedical

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Premedication Drugs

Premedication is defined as administration ofmedication prior to anaesthesia.

Aims:Anxiolysis

Analgesia

Antisialagogue (drying of airway secretions)

Anti-emetic

Acid aspiration prophylaxis


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Midazolam

It is a short acting benzodiazepine.

It is the most common drug used for sedation

and anxiolysis preoperatively

Perioperative indications are

sedative,anxiolysis,amnesic,anticonvulsant

Preoperatively midazolam can be given via

intravenous or orally.


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Midazolam (continued)

Dose : Oral - 0.2mg/kg

IV - 0.1-0.2mg/kg

* should be given 20-40 min preop

Side Effect:

hypotension, respiratory depression,

apnoea

Caution: reduce dose in elderly ( very sensitive )


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Diazepam

It is a long acting benzodiazepine

Perioperative indication are sedation,

termination of status epilepticus

For preoperatively diazepam normally be

given orally

Dose: oral 0.1-0.2mg/kg

Side effect : Sedation, circulatory depression


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Morphine

It is an opioid

It be given before op as an analgesia

Can be given via iv or scDose: 0.15-0.2mg/kg. Total dose 10 mg.

Side effect of morphine are histamine

release, hypotension, bronchospasm, nausea,

vomiting, pruritus, dysphoria

Should be used with caution as it can cause

prolonged risk of respiratory depression.


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Pethidine

It is an synthetic opioid

Used preoperatively as an analgesia (agent

of choice in asthma)Can be used postoperatively for

postoperative shivering

Analgesic dose 1-1.5mg/kg IV/IM


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Pethidine (continued)

Side effect :

Respiratory depression, hypotension,

dysphoriaShould be used with caution because it can

cause seizure in high dosage - maximum

daily dose 1 g/day ( 20 mg/kg/day)

Contraindication in pt on MAOI


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Atropine sulphate

Anticholinergic

Uses:

Preoperative: Antisialogogue, reduce incidence of

laryngospasm and reflex bradycardia arrythmiaduring general anaesthesia

Postoperative: Counteract muscurinic effects ofanticholinergic agents used for reversal of

neuromuscular blocking agents.Cardiac: Sinus bradycardia or asystole durigcardiopulmonary resuscitation or drug toxicity.


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Dosage:

Administered IV/IM at a dose of

0.015-0.02mg/kg

Antisialogogue:IV (0.3-0.6mg) 30 min before op .

Bradyarrythmias: adult IV/IM 0.5-1 mg max2mg. Child IV/IM 0.01-0.03 mg/kg max 0.6 mg


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Side effects:

Decrease secretions, decreses lower oesophagealsphincter tone, relaxes bronchial smooth muscle.

Confusion in elderly.Obstructive uropathy

Contraindications/Precautions: angle closure

glaucoma, obstructive uropathy, obstructivedisease of GIT.Caution in IHD, MI and fever.


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Glycopyrollate

It is an anticholinergic agent

Perioperative indication :

Blockade of muscurinic effects of

anticholinesterases,

Potent antisialogogue

Quaternary ammonium therefore

cannot cross blood brain barrierDose iv/im : 0.004-0.008mg/kg 30 min preop


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Glycopyrollate (continued)

Side effect : Paradoxical bradycardia in small

doses.

Reduces lower oesophageal

sphincter tone.

Caution in glaucoma and cardiovascular

disease.


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PromethazineIt is a phenothiazine group

It has an antihistamine with sedative and

antiemetic propertie

Commonly used as pediatric sedation

Dose 0.25-0.5mg/kg oral

Side effect extrapyramidal reactions


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Metoclopromide

A procainamide derivative.

It is a prokinetic drugs .

Act at the dopaminergc receptor.

Increases gastric emptying and lower

oesophageal sphinter tone .

Dopaminergic anti-emetic

Prescribes for premedication drug in patient

at risk of acid aspiration.

e.g: pregnancy, gastric outlet obstruction,

obese,etc


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Metoclopromide (continued)

Dose : Oral/IM/IV 5-20mg

Side effect: sedation,extrapyramidal/dystonic

reactions.Caution with concomitant usage with

neuroleptic and anticholinergic, patient with

abnormal renal or liver function, elderly ..


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Ranitidine

Gastric PH increasing drugs

Histamine (H2) receptor antagonistReduction in gastric acid secretion.

Use as premedication drug in patient at risk

of acid aspiration


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Ranitidine (continued)

Dose :- Adult : Oral - 150mg ON & morningIV - 50-100mg 1H preop

Child : Oral - 2 mg/kg/dose 12 hourly

or 4 mg/kg at night

IV - 1mg/kg/dose slowly 6-8hourly

Side effect : Generally infrequent. Headache,

malais, dizziness, thrombocytopenia (clinically

insignificant )

No known contraindication . Caution in renal and

hepatic dysfunction


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Omeprazole

Proton pump inhibitor.

Gastric PH increasing.

Significantly reduces volume of gastric acidsecretion but no effect on gastric emptying.

Clinical usage: Treatment of peptic ulcer disease,peptic esophangitis , zollinger Ellison and canalso be use in patient at risk of gastric acidaspiration.


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Dosage:

Oral:40mg ON & 2-3h preop IV :40mg over 30 min

Side effect : In general well tolerated . Headache

and diarrhoea, myalgia, rash and abdominal pain.


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Na Citrate 0.3M

Gastric PH increasing drugs.

Uses: Given as premedication drug for patient atrisk of gastric acid aspiration in particularpregnancy

Dose : Oral 10-30mls


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Reversal Drugs

Includes reversal of :

Muscle relaxation

Drug action ( antagonist )


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Neostigmine

Anticholinesterase

reversal of non-depolarizing muscle relaxant

treatment of myasthenia gravis

Dose:

Reversal of muscle relaxant IV 0.04-0.05mg/kgin combination with anticholinergic agent


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Adverse/Side effects:

Muscurinic effects: nausea, vomiting, epigastricdiscomfort, abdominal cramps, increasesalivation and bronchial secretions, bradycardia,miosis, hypotension.

Nicotinic effects: Fasciculations, twitching,generalised weakness, respiratory depression,paralysis.

Overdosage: CNS stimulation, agitation , fear,death


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Naloxone

Opioid antagonist. Pure mu-receptor antagonist

Uses:

1. Reversal respiratory depression due to opiods.

2.the diagnosis of opioid overdose.

Dosage:

Reversal of opioid: adult IV 1.5mcg/kg IV 0.1 mgincrements at 2-3 minutes intervals to thedesired effect. Child IV 0.005-0.1 mg/kgrepeated every 2-3 min up to 3 doses ifnecessary


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Adverse/ side effects:

Abrupt reversal of analgesia may produce acatecholamine surge resulting in tachycardia,hypertension, pulmonary oedema and cardiacdysrhythmias

Remarks:

Beware of renarcotization if reversing long-actingopioid.

Caution in opiod addicts-may precipitate acutewithdrawal.


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Flumazenil

Benzodiazepine antagonist

Uses: reversal of centrally sedative effects ofbenzodiazepines.

Dose: IV 0.2 mg increments up to 1-2 mg

Contraindicated in patient known allergy. Mixed

intoxications with benzodiazepine and cyclicantidepressants since toxic effect of the lattermay emerge with the reversal of thebenzodiazepine effect.


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Caution in severe head injury or epileptic patient.

Side effects:

Arrythmias,seizures

Remarks:

Special precaution in benzodiazepine dependence

because can cause acute withdrawal.Beware of resedation if long-actingbenzodiazepine


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Miscellaneous:Other drugs that are commonly used inanaesthesia .

Vasopressor & inotropes

Electrolyte replacement

Antiarrythmias

Antihypertension


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Ephedrine

Direct and indirect sympathomimetic ( and adrenergic action ).

Uses: Treatment of hypotension particularlyfollowing general, spinal or epidural anaesthesia.

As a nasal decongestant.

Dose:3-6 mg repeated ( dilute 30 mg in 10 mlssaline)1 ml increments. IM: 30 mg


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Caution in elderly, hypertension and CVS disease.Can cause tachyphylaxis.

Avoid with MAOI and tricyclic antidepressantsmay increase alpha-adrenergic effects of

ephedrine.

Side effect: Increase heart rate and bloodpressure, acute urinary retention, anxiety,

palpitation.


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Phenylephrine

Selective direct-acting adrenergic agonist.Peripheral vasoconstriction

Uses: Treatment of hypotension.

Dose:

IV0.1-0.5 mg increments.

(10mg in 20 ml saline, 1 ml aliquots.)

IM: 2-5 mgInfusion: 30-60 /min


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Contraindication/precaution:

MAOI.

Caution in elderly or CVS disease

Side- effects:

Reflex Bradycardia, arryhmias


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Adrenaline

Endogenous cathecolamine with alpha and betaaction

Uses:1. Treatment of anaphylaxis

2. Bronchodilator

3. Positive inotrope

4. Given by nebulizer for croup


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Dose:

IV/IM/ETT:

1 ml aliquots of 1:10 000 up to 5-10 ml (0.5-1mg)

infusion: 2-20 mcg/min(0.04-0.4 mcg/kg/min)

nebulisation:5ml 1:1000max dose for infiltration:2 mcg/kg

Dilution: 3mg/50ml=1ml/hr=1g /min

Diluent: Normal saline / D5%

Infusion range: 1.2-12+ ml/hInitial rate: 5ml/h


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Caution in elderly.

Can cause arrythmias especially with halothane.

Side effects:Hypertension, tachycardia, anxiety,hyperglycaemia, arryhtmias.

Reduces uterine blood flow

Remarks: should be administered via centralcatheter whenever possible.


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Dopamine

Naturally occuring catecholamine with ,1, anddopaminergic activity.

Uses: Inotropic agent, treatment for hypotension.

Dose: 2-10 mcg/kg/min

Dilution:200mg/50ml (4mg/ml)

alternative regime:

3mg/kg/50ml = 1ml/h = 1g/kg/min

Diluent: 0.9% saline, 5%dextroseInfusion rate: 2-9 ml/h


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Contraindicated in phaeochromocytoma (due tonoradrenaline release),tachyarrythmias and VF.Caution in patient with peripheral vasculardisease

Remarks:

Should be administered via central catheter.


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Dobutamine

1 adrenergic agonist, positive inotrope andchronotrope. Use in cardiac failure

Dose: 2.5-10 mcg/kg/min

Dilution:250mg/50ml (5mg/ml)


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Contraindicated in arrythmias and hypertension.

Side effects:

Tachycardia, decreased peripheral and pulmonaryvascular resistance.

Remarks:

Can cause phlebitis, but can beadministereed peripherally


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Noradrenaline

Potent cathecolamine adrenergic agonist.

Vasoconstriction.

Uses: Treatment of hypotensionDose:2-20 mcg/min (0.04-0.4 mcg/kg/min)

Dilution: 4 mg/40ml (100 mcg/ml)

Diluent: 5% dextrose


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Side effects: Reflex bradycardia, arrythmia,hypertension

Remark:Administered via central catheter only.

Potentiated by MAOI and tricyclic antidepressants


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Vasopressin

-ADH.

-vasoconstriction.Uses:

Treatment of hypotension

Treatment of diabetes insipidus

Dose: 20 unit/ml in 40 ml NS (0.5 unit/ml)

initial rate 2 ml/h ( diluent normal saline )

Extreme caution in coronary vascular disease

Side effects: Pallor, coronary vasoconstriction.


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Calcium gluconate

Uses:

1. Electrolyte replacement2. Positive inotrope.

3. Treatment for hyperkalemia and

hypermagnesaemia.

Description:

Calcium gluconate 10% contains Ca2+ 220mol/ml.

Calcium chloride contains Ca2+ 680mol/ml


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Dose:

2-5 ml 10% solution (10mg/kg, 0.07 mmol/kg)

Side effects:Arrythmias, hypertension, hypercalcaemia

Remarks:Less phlebitis than calcium chloride


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Potassium chloride

Uses: Electrolyte replacement

Dose:

10-20 mmol/h (max concentration 40 mmol/litreperipherally).

With ECG monitoring:

Up to 20-40 mmol/h via central line (Max 200mmol/day)

Dilution: 1 gm in 50mls run over 1 h


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Remarks:

Dilute solution before administration with 0.9%normal saline,Dextrose 5%.

Rapid administration can cause cardiac arrest.

High concentration can cause phlebitis.


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Magnesium sulphate

Essential mineral used to treat:1.Hypomagnesaemia

2.Eclamptic seizures.

3. Arrythmias

Magnesium sulphate

50%=500mg/ml=2mmol Mg2+/ml.

Normal plasma level Mg2+ 1.5-2.2mEq/litre.


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Uses:

1. Hypomagnesaemia: 10-15 mg/kg over 20 min,

then 1 g/h.

2. Arrythmias: 2g over 10 min.

3. Eclampsia: 4g over 10 min then 1 g/h for 24h.

Caution:

Potentiate muscle relaxants.

Monitoring of serum level essential during

treatment. Can cause heart block

Side effects: CNS depression, hypotension


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Sodium bicarbonate

Treatment for acidosis

Dose:

Wt(kg)x base deficit x 0.3) mmolNormally administered undiluted (8.4%

solution)

Remarks:8.4%=1000mmol/litre. Given via central line ifpossible


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Amiodarone

Mixed class IC and III antiarrhythmicuseful in treatment of supraventicular andventricular arrhythmias.

Dose:Should be diluted with 5% dextrose only

Loading infusion : 5 mg/kg over 1-2 H then15mg/kg over 24h

Maximum 1.2 g in 24H


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Contraindication:

CI in Sinoatrial heart block, thyroid dysfunctionand pregnancy

Side effects:

Commonly causes thyroid dysfunction, reversiblecorneal deposits, prolongation of QT interval.

Lung Fibrosis (rare)

Remarks: administered via central catheter.

l l


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Esmolol

Short acting cardioselective beta-blocker.Metabolized by red cell esterases.

Treatment of supraventricular tachycardia orintra-operative hypertension

Dose:

SVT: 0.5 mg/kg over 1 min, then 50-200g/kg/min.

Hypertension: 25-100 mg then 50-300g/kg/min

Dilution: 2.5g/50ml (50 mg/ml)


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Contraindication:

Asthma, heart failure, AV block

Side effects:Hypotension, bradycardia


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Labetolol

Combined (mild) and adrenergic receptorantagonist.

Blood pressure control without reflex tachycardia.

Duration 2-4 h

Dose:5 mg increments up to 100 mg.

Infusion: 20-160mg/h

Contraindicated in asthma,heart failure, AV block.

Side effects: Hypotension, bradycardia,bronchospasm


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