LIGNOCAINE
Indications
Local anesthesia, topical, postherpetic neuralgia, burn, diabetic neuropathy.
Dose
Adult: Mouth/throat surface anesthesia. For pain—As 2% soln—300 mg, not more often than 3 hourly. Before procedures in the mouth and throat: As 4% soln—40–300 mg. For dentistry and otorhinolaryngology procedures: As 10% soln—10–50 mg. For laryngotracheal anesthesia— As 4% soln—160 mg as a single dose. Intravenous (IV) ventricular arrhythmias As HCl: In advanced cardiac life support—1–1.5 mg/kg, repeat if needed. Maximum total—3 mg/kg. In more stable patients: 50–100 mg. May repeat once or twice if needed, up to a max of 200–300 mg in 1 hour, then 1–4 mg/minute via continuous infusion. Regional anesthesia 50–300 mg (0.5% soln w/o adrenaline). Maximum—4 mg/dose. Intramuscular (IM) ventricular arrhythmia emergency—300 mg, repeat after 60–90 minutes if needed. Epidural anesthesia—2–3 mL soln for each dermatome to be anesthetized. Lumbar epidural—250–300 mg (1% soln) for analgesia and 225–300 mg (1.5% soln) or 200–300 mg (2% soln) for anesthetic and thoracic epidural—200–300 mg (1% soln). In obstetric caudal analgesia, up to 300 mg (0.5 or 1% soln). For surgical caudal analgesia—225–300 mg (1.5% soln).
Contraindication
Precautions
Aspiration when used as spray, bradycardia, cardiac failure, children over 12 years but weighing less than 25 kg, concomitant use of class 1 antiarrhythmics, concomitant use of other local anesthetics, risk of systemic absorption and toxicity, drug sensitivity, epilepsy.
Adverse Effects
Hypotension, nausea, methemoglobinemia, anaphylaxis.
Drug Interaction
Additive cardiac effects with IV phenytoin. Effects antagonized by hypokalemia caused by acetazolamide, loop diuretics and thiazides. Dose requirements may be increased with long-term use of phenytoin and other enzyme-inducers. Propranolol increase plasma concentration and toxicity. Increased risk of myocardial depression with β-blockers and other antiarrhythmics.
BUPIVACAINE
Indications
Analgesic (local and regional), anesthesia—for dental procedures, on eye, local, regional, pain.
Dose
In adult, intrapleurally 10–30 mL of bolus 0.25%, 0.375% or 0.5% every 4–8 hours. In pediatric, intrapleurally 0.25%.
Contraindications
Hypersensitivity, obstetrical paracervical block anesthesia.
Precautions
Obstetrical epidural anesthesia, cardiac rhythm disturbances, cardiovascular (CV) impairment, chondrolysis, concomitant use of monoamine oxidase (MAO) inhibitors or tricyclic antidepressants, debilitated, elderly or acutely ill, areas of compromised blood supply, epidural or caudal anesthesia, ergot-type oxytocic agents, familial malignant hyperthermia, head and neck area administration, hepatic disease, hypertensive vascular disease, intravenous regional anesthesia (Bier block), pediatric patients less than 12 years of age, repeated local administration, sulfite sensitivity.3
Adverse Effects
Bradycardia, heart block, ventricular arrhythmia, bacterial meningitis, immune hypersensitivity reaction, chondrolysis, central nervous system (CNS) depression or stimulation, cranial nerve disorder, paraplegia, seizure, respiratory arrest.
Drug Interactions
Decreased duration with hyaluronidase. Decreased clearance with cimetidine and ranitidine. Potentiates lidocaine and mepivacaine. Allergic-type reactions with formulations containing sodium metabisulfite. Potentially fatal—May potentiate systemic toxicity of other local amide anesthetics. Increased risk of myocardial depression with antiarrhythmics.
ROPIVACAINE
Indications
Cesarean section—local anesthetic lumbar epidural block; Epidural anesthesia—Surgical procedure, labor pain; Local anesthetic nerve block—Surgical procedure, postoperative pain, pain, peribulbar infiltration of local anesthetic; Spinal anesthesia—Surgical procedure.
Dose
In adult, 20–30 mL of 0.5% (100–150 mg) or 15–20 mL of 0.75% solution (113–150 mg.)
Contraindications
Hypersensitivity to ropivacaine.
Precautions
Cardiovascular impairment, chondrolysis, concomitant use of class 3 antiarrhythmics and local anesthetics, debilitated, elderly or acutely ill, emergency situations, head and neck area anesthesia, hepatic disease, hypotension, hypovolemia, or heart block, malignant hyperthermia, obstetrical paracervical block, peripheral nerve blocks, retrobulbar nerve blocks, supraclavicular brachial plexus blocks.
Adverse Effects
Fetal bradycardia, hypotension, pruritus, nausea, vomiting, backache, headache, paresthesia, fever, Horner's syndrome pupil.4
Drug Interactions
Itraconazole, ketoconazole or clarithromycin may reduce clearance of ropivacaine. Increased metabolism when used with rifampicin. Clearance is inhibited when used with fluvoxamine or ciprofloxacin. Increased risk of toxicity when used with other local anesthetics.
KETAMINE
Indications
General anesthesia; adjunct, procedural sedation, administration of analgesic—sedation, bronchospasm, rapid sequence intubation, induction.
Dose
In adult, 1–4.5 mg/kg IV single dose. In pediatric, 5–10 mg/kg IM.
Contraindications
Hypersensitivity to ketamine, elevations in blood pressure.
Precautions
Not to be injected IV without proper dilution in equal volume of sterile water for injection, alcohol intoxication, cerebrospinal fluid pressure, hypertension or cardiac decompensation, mechanical stimulation of the pharynx, postoperative confusional state, rapid rate of administration or overdose, vomiting, risk of aspiration.
Adverse Effects
Hypertension, tachycardia, emergence from anesthesia, psychiatric symptoms, anaphylaxis, apnea, laryngeal spasm, pulmonary edema, respiratory depression.
Drug Interactions
May increase effects of nondepolarizing muscle relaxants. May reduce hypnotic effect of thiopental. Prolonged recovery time with barbiturates/narcotics. Reduced cardiac output, BP and pulse rate with halothane. Increased risk of hypertension and tachycardia with thyroid hormones. Seizures and tachycardia may occur when used with theophyllines.5
HALOTHANE
Indications
Asthma with status asthmaticus, general anesthesia, malignant hyperthermia diagnosis.
Dose
In adult, 0.5–3% in oxygen or nitrous oxide. In pediatric, 0.5–2.5% in nitrous oxide or oxygen.
Contraindications
Hypersensitivity to halothane, obstetrical anesthesia, susceptibility to malignant hyperthermia, jaundice or other signs of acute hepatic damage.
Precautions
Obstetrical anesthesia, coronary heart disease or arrhythmias, increased intracranial pressure or intracranial lesions, myasthenia gravis, pheochromocytoma, previous liver dysfunction, hepatitis, elevations in serum bromide concentrations.
Adverse Effects
Cardiac dysrhythmia, CV finding, decreased cardiac finding, acute intermittent porphyria, body temperature finding, hypothermia due to anesthetic, metabolic finding, gastrointestinal tract (GIT) finding, nausea, vomiting, blood coagulation disorder, carboxyhemoglobinemia, hematology finding, immunosuppression, hepatotoxicity, liver finding, malignant hyperthermia, musculoskeletal finding, neurological effects, otic effects, acute renal failure, kidney disease, nephrotoxicity, respiratory effects, adverse reaction to bromide.
Drug Interactions
Adrenaline, other sympathomimetics, and theophylline can produce cardiac arrhythmias. Morphine and chlorpromazine may increase depressant effects of halothane on respiration. Increased risk of phenytoin intoxication when used together. Midazolam may potentiate the anesthetic action of halothane. Dopaminergics increase the risk of ventricular arrhythmias. Neuromuscular blocking drugs are potentiated by halothane.6
PROPOFOL
Indications
General anesthesia, sedation, headache, procedural sedation, intubation.
Dose
In adult, 40 mg IV every 10 seconds until onset (2–2.5 mg/kg). In pediatric, 2.5–3.5 mg/kg IV over 20–30 seconds.
Contraindications
Hypersensitivity to propofol, fospropofol or its components, allergy to eggs, egg products, soybeans, or soy products, allergies to soy or peanut.
Precautions
Abrupt discontinuation, anaphylactic reactions, aseptic technique, failure, bolus administration rapid, burns, diarrhea, major sepsis patients, disorders of lipid metabolism, duration of infusion longer than 5 days, elderly, debilitated, or ASA III/IV patients, elderly, patients with recent fluid shift, epileptic patients, general anesthesia sedation, increased intracranial pressure, pediatric patients, postoperative unconsciousness, prolonged high dose infusions (greater than 5 mg/kg/hour for longer than 48 hours), sedation in the intensive care unit, upper respiratory tract infections.
Adverse Effects
Injection site pain, nausea and vomiting, involuntary movement of muscle, bradyarrhythmia, heart failure, hypertension, anaphylaxis, seizure, acute renal failure, priapism, apnea, respiratory acidosis, bacterial septicemia, infusion syndrome.
Drug Interactions
Reduce dose if given with nitrous oxide or halogenated anesthetics. Increased sedative, anesthetic and cardiorespiratory effects when used with other CNS depressants.7
PHENYLEPHRINE
Indications
Cardiomyopathy; diagnosis, glaucoma, hypotension, incontinence of feces, local anesthesia; adjunct, mydriasis induction, maintenance, myocardial infarction; diagnosis, nasal congestion, nasal formulation, nasal congestion, oral formulation, otitis media, paroxysmal supraventricular tachycardia, posterior synechiae—uveitis, priapism, ptosis of eyelid, regional anesthesia; adjunct shock.
Dose
In adult, 1 mg to every local anesthetic solution. In pediatric, 0.5–1 mg per 25 pounds of body weight.
Contraindications
Anatomical narrow-angle (ophthalmic), arteriosclerotic cardiovascular or cerebrovascular disease, hypersensitivity, hypertension, intraocular operative procedures, narrow angle glaucoma, pediatric use, ventricular tachycardia, breastfeeding mothers, hypersensitivity to phenylephrine, newborns.
Precautions
Anesthesia with agents that sensitize the myocardium to sympathomimetics, arteriosclerosis, bradycardia, cardiac block, cardio-vascular disease, ventricular arrhythmia, higher than recommended doses; increased risk of vasopressor response, hypertension, hyper-thyroidism, intraocular use, myocardial disease, rebound meiosis, reduced lacrimation during anesthesia; increased risk of vasopressor response.
Adverse Effects
Cardiovascular finding, hypertension, myocardial infarction, myocardial perfusion—finding, dermatologic effects, hematology finding, cell-mediated immune reaction, central nervous system finding, transient neurological symptoms, conjunctivitis, eye/vision finding, mydriasis, pulmonary edema, pulmonary embolism, respiratory finding, sense of smell altered.8
Drug Interactions
May increase hypertensive effect of β-blockers (nonselective); MAOI potentiate hypertension; methyldopa and tricyclic antidepressants (TCA) can increase the pressor response.
ISOFLURANE
Indication
General anesthesia.
Dose
In adult, 1.5–3% with oxygen or nitrous oxide.
Contraindications
Hypersensitivity to isoflurane, malignant hyperthermia.
Precautions
CO2 absorbents, dose-related hypotension and respiratory depression, coronary artery disease, obstetrical anesthesia, pediatric patients, sensitivity to halogenated anesthetics.
Adverse Effects
Nausea, vomiting, cardiac arrest, myocardial infarction, myocardial ischemia, hyperkalemia, malignant hyperthermia, decreased liver function (rare), hepatic necrosis, liver failure, seizure, myoglobinuria, renal failure, respiratory depression.
Drug Interactions
Enhances effects of neuromuscular blockers. May sensitize the myocardium to adrenaline and other sympathomimetics. Enhances hypotensive effects of angiotensin converting enzyme (ACE) inhibitors, TCAs, MAOIs, antihypertensives, antipsychotics or β-blockers. May have synergistic effects with CNS depressants.
Preparation Available
SEVOFLURANE
Indication
General anesthesia.
Dose
0.5–3%.
Contraindications
Hypersensitivity to sevoflurane, malignant hyperthermia.
Precautions
Halogenated hydrocarbon anesthetics, hepatitis with or without jaundice, hyperkalemia and fatal cardiac arrhythmia, hypotension, KOH-containing CO2 absorbents, QT prolongation, renal injury, renal insufficiency, seizures.
Adverse Effects
Bradyarrhythmia, hypotension, nausea, vomiting, somnolence, agitation, cough, interrupted breathing, shivering, hepatic necrosis, liver failure, hypersensitivity reaction.
Drug Interactions
May enhance effect and duration of competitive neuromuscular blockers. Metabolism and toxicity increased by cytochrome P450 isoenzyme CYP2E1 inducers including isoniazid and alcohol. Increased risk of cardiac arrhythmias when used with epinephrine or norepinephrine.
THIOPENTONE
Indications
General anesthesia, narco-analysis, raised intracranial pressure, regional anesthesia; adjunct, seizure, intubation, procedure—sedation, pediatric patients, status epilepticus.
Dose
In adult, 50–75 mg (2–3 mL of 2.5% solution) slow IV, single dose at 20–40 second intervals. In pediatric, induction, (neonate) 3–4 mg/kg; (1–6 months) 5–8 mg/kg IV; (1–5 years) 5–6 mg/kg IV.10
Contraindications
Absence of suitable veins for intravenous administration, acute intermittent porphyria, hypersensitivity to thiopental products.
Precautions
Severe cardiovascular disease, hypotension or shock, conditions in which the hypnotic effect may be prolonged or potentiated, status asthmaticus, endocrine insufficiency, increased intracranial pressure, ophthalmoplegia, respiratory impairment.
Adverse Effects
Injection site reaction, myocardial dysfunction, hemolytic anemia, anaphylaxis, finding of intracranial pressure, radial neuropathy, apnea, laryngeal spasm, respiratory depression.
Drug Interactions
Possible increase in difficulty in producing anesthesia in patients taking alcohol or CNS depressants. Additive action with other CNS depressants including sedatives, hypnotics, nitrous oxide or alcohol.
Increased hypotension and excitatory effects with phenothiazine antipsychotics. Increased hypnotic effect with antipsychotic. Decreased requirement of thiopental sodium with metoclopramide, sulfisoxazole, aspirin, meprobamate, probenecid and other highly protein bound drugs. Increased respiratory depression with opioids.
ESMOLOL
Indications
Hypertension, intraoperative—tachyarrhythmia, intraoperative, hypertension, postoperative tachyarrhythmia, postoperative supraventricular arrhythmia, acute myocardial infarction, anesthesia—surgical procedure, aortic dissection—operation on aorta, atrial arrhythmia; adjunct electroconvulsive therapy; adjunct operation on heart, myocardial protection, pheochromocytoma, rapid sequence intubation, preinduction, thyroid storm, unstable angina.
Dose
Contraindications
AV block, second and third degree, bradycardia, sinus cardiac failure, cardiogenic shock.
Precautions
Bronchospastic disease, congestive heart failure, diabetes mellitus, hypertension, hypotension, renal impairment.
Adverse Effects
Hypotension, injection site pain, nausea, heart block, anaphylaxis, seizure, bronchospasm, pulmonary edema.
Drug Interactions
Esmolol HCl may increase blood digoxin levels; it may prolong neuro-muscular blockade of succinylcholine. Morphine and warfarin may increase steady state blood esmolol levels. Bradycardia may occur when used concurrently with MAOIs. Esmolol may reduce elimination of theophylline. Potentially fatal—increased risk of bradycardia, AV block, hypotension and CHF with IV calcium channel blockers. Increased hypertensive risk with inotropes, adrenaline or noradrenaline. Hypotension or marked bradycardia with catecholamine depletors.
PAPAVERINE
Indications
Angina, cerebrovascular disease, ischemic heart disease, complicated by arrhythmias, peripheral vascular disease, with vasospasm, smooth muscle spasm, visceral, thromboembolic disorder, arterial catheter occlusion; prophylaxis, bypass transplantation with allogeneic transplant, graft preservation, erectile dysfunction.
Dose
In adult, 30 mg initially intracavernosal over 1–2 minutes, may increase up to 60 mg.
Contraindications
Precautions
Glaucoma, hepatic hypersensitivity.
Adverse Effects
Hypertension, tachyarrhythmia, pruritus, rash, abdominal discomfort, constipation, diarrhea, loss of appetite, nausea, vomiting, headache, somnolence, vertigo, acidosis, hepatotoxicity, priapism.
Drug Interactions
Use of Ginkgo biloba with papaverine may result in potentiation of papaverine therapeutic and adverse effects. Use with levodopa may result in decreased levodopa effectiveness. Papaverine may result in a false-positive urine opiate screen due to assay interference.
TRYPAN BLUE
Indications
Surgical procedure on eye, proper vitrectomy.
Dose
0.15% in vitrectomy and 0.5 mL in surgery.
Contraindications
Absorption of the dye by the lens.
Precautions
Excessive staining following injection.
Adverse Effects
Abnormal color of high water content hydrogen intraocular lenses, abnormal color of the posterior lens capsule and vitreous face, inadvertent.
DEXMEDETOMIDINE
Indications
Dose
In adult, initial, loading infusion of 1 µg/kg IV over 10 minutes; no loading dose required.
Contraindications
Specific contraindications have not been determined.
Precautions
Diabetes mellitus; hypotension and/or bradycardia, elderly patients, heart block, hepatic impairment, hypertension, chronic, hypertension, transient, hypovolemia, prolonged exposure (more than 24 hours), ventricular dysfunction, withdrawal symptoms (e.g. nausea, vomiting, agitation, hypertension, and tachycardia).
Adverse Effects
Hypertension, tachycardia, nausea, xerostomia, apnea, bronchospasm, pleural effusion, respiratory depression.
Drug Interactions
Use with meclizine, CNS depressants, oxycodone, sedatives, zolpidem and tapentadol may result in an increase in CNS depression or respiratory depression. With perampanel, loxapine and CNS depressants may result in potentiation of impaired cognitive function and motor skills and an increased risk of respiratory depression, hypotension, oversedation and syncope.
HYALURONIDASE
Indications
Injection of therapeutic agent, subcutaneous clysis of patient for fluid administration, urinary tract contrast procedure, cervical ripening procedure, injection site extravasation.
Dose
In adult, add 150 units (range 50–300 units) to the injection solution. In pediatric, add 150 units (range 50–300 units) to the injection solution.
Contraindications
Precautions
Concomitant use of dopamine or alpha agonists, corneal administration, infected or acutely inflamed area, intravenous administration, swelling due to bites or stings.
Adverse Effects
Injection site reaction, anaphylaxis.
Drug Interactions
Action potentiated by urokinase especially in the treatment of myocardial infarction (MI). May increase absorption and toxicity of local anesthetics. Heparin, salicylates and NSAIDs may inhibit the spreading action and efficacy of hyaluronidase.