• Drugs for controlling hypotension and arrhythmias are contained in Chapter 2.
• Surgery and routine medication:
  1. All routine medicines should normally be continued perioperatively with the exception of oral hypoglycaemics, MAOIs, oral anticoagulants.
  2. Oral contraceptives should be stopped for some forms of surgery.
  3. Patients on long-term corticosteroids should have steroid cover provided perioperatively. See intranet guidelines 0212, Peri-operative steroid supplementation and 0138, Guidelines for the taking of patient's medicines prior to surgery.
• Anaesthesia and driving: DVLA recommend that patients abstain from driving for 48 hours after a general anaesthetic.
• Acid aspiration prophylaxis: Should be considered for obstetric and emergency surgery. See intranet guideline 0254
• DVT prophylaxis in surgical patients: See intranet guideline 0130.
• Management of patients with suspected anaphylaxis during anaesthesia: See intranet guideline 0144. Anaesthetic and latex allergy investigations can be referred to the Anaphylaxis Testing Service in the Department of Anaesthesia.

Important: Drugs in this section should be used only by doctors with anaesthetic training and when resuscitation equipment is available.

Drugs used not listed here:

• Thiopental See section 4.8.2 Drugs used in status epilepticus

Propofol

• 1% injection 10mg in 1ml, 20ml ampoule
• 1% injection 10mg in 1ml, 50ml bottle
• 2% injection 20mg in 1ml, 50ml bottle

Notes

1. Propofol is used for induction of anaesthesia in adults and children (1% licensed for children over 1 month old, 2% licensed for children aged over 3 years), by infusion for total intravenous anaesthesia and short-term sedation on intensive care. It is not used for caesarean section. A sterile technique must be used for drawing up propofol to prevent bacterial contamination. Any unused propofol should be discarded.

Nitrous Oxide

Nitrous oxide diffuses into air containing closed spaces causing an increase in pressure. It should therefore not be used in patients with pneumothoraces; undergoing middle ear surgery and certain ophthalmic surgical procedures. It is contraindicated in bowel obstruction, facial fractures or if the patient's level of understanding /co-operation is low (intoxication).

Nitrous oxide

• Gas (piped / cylinder)

Entonox

(Nitrous oxide / oxygen)

• Gas (piped / cylinder)

Notes

1. Entonox is a pre-mixed gaseous product of 50:50 nitrous oxide and oxygen. It may be self-administered as an analgesic in obstetrics, or for pain relief during short painful procedures. Entonox is an excellent analgesic for children, providing pain relief, distraction and relaxation.

Volatile halogenated anaesthetics

Halothane

• 250ml

Notes

1. Halothane is available for use in management of the difficult airway. Halothane can cause hepatitis and malignant hyperthermia. It should be avoided where there is a history of previous adverse reactions, previous exposure within 3 months unless the indications are clinically overriding (the safe time interval is not known), history of unexplained jaundice/pyrexia after previous exposure.

Isoflurane

• 250ml

Sevoflurane

• 250ml

Notes

1. Sevoflurane is considered 1st line for inhalational induction of anaesthesia in children. Anaesthesia should then be maintained with isoflurane.

15.1.1 Anaesthetic adjuvants

Drugs used not listed here:

• Hyoscine hydrobromide, and Glycopyrronium bromide see section 1.2 Antispasmodics and other drugs altering gut motility

Antimuscarinic pre-medicant drugs may be used to dry secretions prior to awake fibre-optic intubation.

Atropine sulfate

• Injection 600micrograms/1ml ampoule (£1.17 = 1 ampoule)
• Injection 1mg/1ml ampoule (£16.81 = 1 ampoule)

Notes

1. Atropine may be used as an emergency treatment of vagotonic side effects.

15.1.2 Malignant hyperthermia

All inhalational anaesthetics and suxamethonium may trigger malignant hyperthermia.

Drugs used not listed here:

Dantrolene

• See section 10.2.2 Skeletal muscle relaxants

Notes

1. Dantrolene lowers intracellular ionic calcium and glucocorticoids and thereby stabilises cell membranes. The 20mg vial is reconstituted by adding 60ml water for injection. The resultant solution of pH 9-10 is irritant so should be given via a fast running drip into a central vein. An initial intravenous dose of 1mg/kg should be given rapidly into the vein. If the physiological and metabolic abnormalities persist or reappear, this dose may be repeated up to a cumulative dose of 10mg/kg. Clinical experience to date has shown that the average dose of dantrolene required to reverse the manifestations of malignant hyperthermia has been 2.5mg/kg. If a relapse or recurrence occurs, it should be re-administered at the last effect dose
2. For patients with a known susceptibility to malignant hyperthermia, dantrolene may be given during induction. These patients should be anaesthetised using propofol intravenous infusion and vapour free breathing circuits.

Full guidance may be obtained from the intranet guideline 0163, Malignant hyperthermia syndrome. A copy is located in recovery together with stocks of dantrolene.

15.1.3 Neuromuscular blockade

Depolarising neuromuscular blocking drugs

Suxamethonium chloride

• Injection 50mg in 1ml, 2ml ampoule

Notes

1. Suxamethonium has a quicker onset of action than the non-depolarisers and may be used for rapid sequence induction in emergency cases and in obstetrics.
2. Suxamethonium is metabolised by plasma cholinesterases and has a short duration of action. Prolonged paralysis may occur in patients with low or atypical plasma cholinesterases.

Non-depolarising neuromuscular blocking drugs

Atracurium besilate

• Injection 10mg in 1ml, 2.5ml, 5ml, 25ml vials

Notes

1. Atracurium is currently the best value non-depolarising muscle relaxant.

Mivacurium

• Injection 2mg in 1ml, 5ml, 10ml ampoule

Notes

1. Mivacurium is metabolised by plasma cholinesterases and has a short duration of action. Prolonged paralysis may occur in patients with low or atypical plasma cholinesterases.

Rocuronium bromide

• Injection 10mg in 1ml, 5ml vial

Notes

1. Rocuronium has the fastest onset of action among the non-depolarising muscle relaxants.

15.1.4 Neuromuscular blockade reversal

Neostigmine metilsulphate

• Injection 2.5mg in 1ml, 1ml ampoule

Neostigmine with glycopyrronium bromide

• Injection neostigmine 2.5mg with glycopyrronium bromide 500 micrograms in 1ml

Sugammadex

• Injection 100mg in 1ml, 5ml vial

15.1.5 Peri-operative analgesia

Drugs used not listed here:

• Alfentanil, see section 4.7.2 Opioid analgesics
• Fentanyl, see section 4.7.2 Opioid analgesics

Oral diclofenac or ibuprofen may be used successfully as a pre-med. Please see section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs) for details. Where an NSAID is indicated perioperatively, then oral ibuprofen or oral / rectal diclofenac are considered as first line as they are reliable and inexpensive. NSAID's should be administered with caution in patients with atopic asthma. Prior to administration of rectal diclofenac (or paracetamol) under general anaesthesia, patient consent should be obtained.

Paracetamol is available for IV administration (see 4.7.1 Non-opioid analgesics and compound analgesic preparations for details).

See intranet guideline 0232: Acute Pain Management. Acute Pain Service Anaesthetists can be contacted for advice in situations where simple analgesia has failed Ext 55467.

Parecoxib

• Injection powder for reconstitution 40mg vial

Notes

1. Indicated only for the short term management of post-operative pain

Remifentanil

• Injection powder for reconstitution 1mg, 2mg, 5mg vials

Notes

1. Remifentanil is given as an infusion only under the supervision of a consultant anaesthetist. It is metabolised by systemic cholinesterases making accumulation extremely unlikely. The pharmacokinetics of remifentanil makes it particularly suitable for Day Surgery.

15.1.6 Peri-operative sedation

Drugs in this section may have primary care use, their inclusion here relates to use as pre-medication.

Drugs used not listed here

• Diazepam See section 4.1.2 Anxiolytics
• Lorazepam See section 4.8.2 Drugs used in status epilepticus
  • Lorazepam has a longer duration of action and may cause amnesia
• Midazolam See section 4.8.2 Drugs used in status epilepticus
  • There have been reports of overdose when high strength midazolam has been used for conscious sedation. Use should be restricted to general anaesthesia, intensive care, palliative care or other situations where the risk has been assessed.
  • Flumazenil must be kept in all departments that use IV or SC midazolam (NPSA/2008/RRR011).
  • Midazolam is a Schedule 3 CD and must be ordered in the CD order book.
• Temazepam See section 4.1.1 Hypnotics

Ketamine

• Injection 50mg in 5ml ampoule preservative free (unlicensed preparation)
• Injection 10mg in 1ml, 20ml vial
• Injection 50mg in 1ml, 10ml vial

Notes

1. Ketamine gives a high incidence of hallucination and this reduces its potential. It has analgesic properties (may be used in palliative care), and may sometimes be given intramuscularly. Rarely, it may be used orally in combination with midazolam as a premedication for disturbed children (unlicensed use).

Antagonists for central respiratory depression

Naloxone hydrochloride

•  Solution for injection ampoules 400micrograms/1ml (£4.05 = 1 ampoule)

Notes

1. Nalaxone reverses opioid-induced respiratory depression but has a short duration of action and doses may need to be repeated. Its action antagonises opioid mediated analgesia.

Flumazenil

• Injection 100mg in 1ml, 5ml ampoule

Notes

1. Flumazenil is a specific benzodiazepine antagonist with a short duration of action. Doses may need to be repeated.

Nyxoid

(Naloxone hydrochloride)

• 1.8mg in 0.1ml nasal spray, single use
• Each pack contains two nasal sprays

Prenoxad

(Naloxone hydrochloride)

• 2mg in 2ml solution for injection pre-filled syringe, for intramuscular injection
• Each pack contains one 2ml syringe (five 0.4ml doses) and two needles

Notes

1. CAS alert 10 November 2022: Prenoxad 1mg/ml Solution for Injection in a pre-filled syringe, Macarthys Laboratories, (Aurum Pharmaceuticals Ltd), caution due to potential needles in sealed kits.