ISMP Canada has developed the 5 questions that each patient should ask about medications? Of the 5 questions, I find that proper use is one that tends to be most difficult to communicate clearly and succinctly. How to take your medication? Do you take it with food? Without food? What does it mean to take it […]
CRITERIA FOR THROMBOLYSIS:
|#||Responsible Party||What should be done|
|1||Medical resident||While administering thrombolytic therapy attention to control chest pain is most important.|
|1) IV nitroglycerine — start at 5 mcg / minute and titrate for control of pain;|
|2) Avoid hypotension (systolic pressure less than 90 mmHg.) and sinus tachycardia if more than 110 bpm.|
|3) Morphine sulphate — give 2-4 mg IV and repeat every 5 -15 minutes until pain relieved|
|4) Beta-blockers should be given if there are no contraindications.|
|5) e) Follow ACLS algorhythms for the management of dysrhythmias.|
|· Complete the pre thrombolytic check list.|
|· Evaluate any case of chest pain / equivalent referred to him.|
|· Establish whether the patient fulfills the criteria of STEMI.|
|· Initiate Clinical Pathway for uncomplicated STEMI/ NSTEMI|
|· Decide if it is a case of acute STEMI, whether the patient is a candidate for thrombolytic therapy.|
|· Explain the risks and benefits of the therapy to the patient / patient representative and may obtain consent verbally and document in the medical record. The patient's signature on a consent form is not required.|
|· Fill the Intravenous "Thrombolytic Therapy Reperfusion Check List" and sign, date, time and stamp it.|
|2||consultant cardiologist Consultation||Consultant Cardiologist will be consulted when:|
|· The case is not typical|
|· Any contraindications are present.|
|· All the classic criteria are not met.|
|· When there is any doubt.|
|· For the choice of thrombolytic agent, follow the Thrombolytic Therapy Standing Order.|
|· Initiate and sign the appropriate adapted orders.|
|3||Assigned Nurse||· Assigned nurse will start Pre therapy management:|
|· Assess and record baseline data i.e. vital signs, skin color and temperature; CNS: orientation, reflexes; CVS: peripheral perfusion.|
|· Review medical history for existing or previous conditions that -|
|· Require cautious use of thrombolytic agents.|
|· Contraindicate use of thrombolytic agents.|
|· Ensure the establishment of Clinical Pathway for uncomplicated STEMI/ NSTEMI.|
|· Ensure that one- nurse remains at patient's bed side observing the patient during the administration of thrombolytic agent.|
|· Establish minimum two peripheral venous lines, with # 18 or # 20 gauge cannula prior the administration of thrombolytic agent.|
|· Ensure emergency trolley is at bedside and ready for use.|
|· Medication administration: follow thrombolytic therapy standing order.|
|· Follow thrombolytic therapy standing order once it is filled, signed, stamped and timed by the Medical resident on duty.|
|· Monitor patient for vital signs every 15 minutes during the therapy and then hourly.|
|· Monitor patient for any potential internal or external bleeding.|
|· Monitor patient for any signs of allergic reactions and inform doctor promptly.|
|· Avoid arterial invasive procedures and IM injections before and during the therapy.|
|· Maintain patient on bed rest during entire course of therapy and avoid handling patient unnecessarily because bruising occurs readily.|
|· Document appropriately.|
|4||Consultant in- charge / on call||· Respond promptly to the call of Medical resident.|
|· Refer the patient to Consultant Cardiology.|
HUMAN NORMAL IMMUNOGLOBULIN:
Indications: Replacement therapy in: Primary immunodeficiency syndromes such as: congenital agammaglobulinaemia and hypogammaglobulinaemia. common variable immunodeficiency. severe combined immunodeficiency. Wiskott Aldrich syndrome. Myeloma or chronic lymphatic leukaemia with severe secondary hypogammaglobulinaemia and recurrent infections. Children with congenital AIDS and recurrent infections. Immunomodulation. Idiopathic thrombocytopenic purpura (ITP) in children or adults at high risk of bleeding or prior to surgery to correct the platelet count. Guillain Barré syndrome. Kawasaki disease Allogeneic bone marrow transplantation.
Contraindications: Hypersensitivity to the active substance or to any of the excipients. Hypersensitivity to homologous immunoglobulins, especially in the very rare cases of IgA deficiency when the patient has antibodies against IgA.
Dose and Administration: The dose and dosage regimen is dependent on the indication. In replacement therapy the dosage may need to be individualised for each patient dependent on the pharmacokinetic and clinical response. The dosage regimen should achieve a trough level of IgG (measured before the next infusion) of at least 4 – 6 g/l. Three to six months are required after the initiation of therapy for equilibration to occur. The recommended starting dose is 0.4 – 0.8 g/kg, followed by at least 0.2 g/kg every three weeks. The dose required to achieve a trough level of 6 g/l is of the order of 0.2 – 0.8 g/kg/month. The dosage interval when steady state has been reached, varies from 2 to 4 weeks. Trough levels should be measured in order to adjust the dose and dosage interval. Guillain Barré syndrome: 0.4 g/kg/day for 3 to 7 days.
HEPATITIS B IMMUNOGLOBULIN:
Indications: indicated for post-exposure prophylaxis following either parenteral exposure (e.g. accidental “needle-stick”), direct mucous membrane contact, or oral ingestion of HBsAg-positive materials, such as blood, plasma or serum. Also indicated for the temporary protection of infants born to HBsAg-positive mothers (especially those who are HBeAg-positive), since these infants are at risk of acquiring hepatitis B infection. Infants born to HBsAg-positive mothers should receive hepatitis B immunoglobulin and the first dose of hepatitis B vaccine at the same time.
Contraindications: Intramuscular injections are not advocated for patients with bleeding disorders. The risk-benefit ratio in patients with a history of immunoglobulin A (IgA) deficiency or severe anaphylactic reactions to plasma
products should be considered. Is not appropriate for the treatment of any type of hepatitis B infection.
Dose and Administration: By intramuscular injection (as soon as possible after exposure; ideally within 12 hours, but no later than 7 days after exposure), adult and child over 10 years 500 units; child under 5 years 200 units, 5–9 years 300 units; neonate 200 units as soon as possible after birth
ANTI-D (RH0) IMMUNOGLOBULIN:
Indications: Rh (D) incompatibility.
Contraindications: Thrombocytopenia, coagulation disorders preventing intramuscular injection.
Dose and Administration: By intramuscular injection, to rhesus-negative woman for prevention of Rh0 (D) sensitisation: Following birth of rhesus-positive infant, 1000–1650 units immediately or within 72 hours; for large transplacental blood loss, 50–125 units per mL of fetal red cells. Antenatal prophylaxis, 1000– 1650 units given at weeks 28 and 34 of pregnancy; if infant rhesus-positive, further dose is needed immediately or within 72 hours of delivery.
Indications: It is an X-ray contrast medium for use in adults and children for cardioangiography, arteriography, urography, phlebography and CT-enhancement. Lumbar, thoracic, cervical myelography and computed tomography of the basal cisterns, following subarachnoid injection. It is also indicated for arthrography, endoscopic retrograde pancreatography (ERP), endoscopic retrograde cholangiopancreatography (ERCP), herniography, hysterosalpingography.
Contraindications: Manifest thyrotoxicosis. History of serious reaction to Iohexol.
Dose and Administration: The dosage varies depending on the type of examination, age, weight, cardiac output and general condition of the patient and the technique used. Usually the same iodine concentration and volume is used as with other iodinated X-ray contrast media in current use. Adequate hydration should be assured before and after administration as for other contrast media.
Indications: intravenous urography, computed tomography, intravenous digital subtraction angiography, arteriography, and angiocardiography.
Contraindications: Manifest thyrotoxicosis. History of serious reaction to Iohexol.
Dose and Administration: The doses must be adapted to the examination and the regions to be opacified, as well as to the body weight and renal function.
Indications: It is a contrast medium for cranial and spinal magnetic resonance imaging (MRI). It is also indicated for whole body MRI including head and neck region, thoracic space including the heart, extremities, abdomen and pelvis (prostate and bladder), female breast, abdomen (pancreas and liver), retroperitoneal space (kidney), musculosceletal system and vessels (angiography) by intravenous administration. Omniscan facilitates visualisation of abnormal structures or lesions and helps in the differentiation between healthy and pathological tissue.
Contraindications: Hypersensitivity to the active substance gadodiamide or to any of the excipients. Gadodiamide is contraindicated in patients with severe renal impairment (GFR <30 ml/min/1.73m2), and those who have had or are undergoing liver transplantation.
Dose and Administration: The recommended dosage to adults and children is 0.2-ml/kg body weight (b.w.) (0.1 mmol/kg b.w.) up to 100 kg. Above 100 kg body weight 20 ml is usually sufficient. When brain metastases are suspected, a dosage of 0.6 ml/kg b.w. (0.3 mmol/kg b.w.) can be administered to adults up to 100 kg. Above 100 kg bodyweight a total of 60 ml is usually sufficient. The dose of 0.6 ml/kg can be administered as a single injection. Alternatively a second bolus injection of 0.4 ml/kg b.w. (0.2 mmol/kg b.w.) may be administered within 20 minutes of the first injection of 0.2 ml/kg b.w. (0.1mmol/kg b.w.).
Indications: Magnetic Resonance Imaging for: cerebral and spinal disease; diseases of the vertebral column; other whole-body pathologies (including angiography).
Contraindications: Hypersensitivity to the active substance or to any of the excipients.
Dose and Administration: The recommended dose is 0.1 mmol/kg, i.e. 0.2 mL/kg in adults, children and infants.
In angiography, depending on the results of the examination being performed, a second injection may be administered during the same session if necessary. In some exceptional cases, as in the confirmation of isolated metastasis or the detection of leptomeningeal tumours, a second injection of 0.2 mmol/kg can be administered.
The product must be administered by strict intravenous injection.
Several different types of drug are given together during general anaesthesia. Anaesthesia is induced with either a volatile drug given by inhalation or with an intravenously administered drug; anaesthesia is maintained with an intravenous or inhalational anaesthetic. Analgesics, usually short-acting opioids, are also used. The use of neuromuscular blocking drugs necessitates intermittent positive-pressure ventilation. Following surgery, anticholinesterases can be given to reverse the effects of neuromuscular blocking drugs; specific antagonists can be used to reverse central and respiratory depression caused by some drugs used in surgery. A local anaesthetic can be used to reduce pain at the injection site. The required dose of induction agent may be less if the patient has been premedicated with a sedative agent or an opioid analgesic has been used.
Intravenous anaesthetics may be used either to induce anaesthesia or for maintenance of anaesthesia throughout surgery. Intravenous anaesthetics nearly all produce their effect in one arm-brain circulation time and can cause apnoea and hypotension, and so adequate resuscitative facilities must be available. They are contra-indicated if the anaesthetist is not confident of being able to maintain the airway (e.g. in the presence of a tumour in the pharynx or larynx). Extreme care is required in surgery of the mouth, pharynx, or larynx and in patients with acute circulatory failure (shock) or fixed cardiac output.
Indications: induction of general anaesthesia; anaesthesia of short duration; reduction of raised intracranial pressure if ventilation controlled; status epilepticus.
Contraindications: Respiratory obstruction, acute asthma, severe shock and dystrophia myotonica. Porphyria. Patients with hypersensitivity reactions to barbiturates. Breastfeeding should be temporarily suspended or breast milk expressed before induction of anaesthesia.
Dose and Administration: Induction of general anaesthesia, by slow intravenous injection usually as a 2.5% (25 mg/mL) solution, adult over 18 years, fit and premedicated, initially 100–150 mg (reduced in elderly or debilitated) over 10–15 seconds (longer in elderly or debilitated), followed by further quantity if necessary according to response after 30–60 seconds; or up to 4 mg/kg (max. 500 mg); child 1 month–18 years, initially up to 4 mg/kg, then 1 mg/kg repeated as necessary (max. total dose 7 mg/kg). Raised intracranial pressure, by slow intravenous injection, 1.5–3 mg/kg, repeated as required. Status epilepticus, by slow intravenous injection as a 2.5% (25 mg/mL) solution, adult over 18 years, 75–125 mg as a single dose; child 1 month–18 years,
initially up to 4 mg/kg by slow intravenous injection, then up to 8 mg/kg/hour by continuous intravenous infusion, adjusted according to
Other intravenous anaesthetics
Indications: As an anaesthetic agent for diagnostic and surgical procedures. When used by intravenous or intramuscular injection, Ketamine is best suited for short procedures. For the induction of anaesthesia prior to the administration of other general anaesthetic agents.
Contraindications: persons in whom an elevation of blood pressure would constitute a serious hazard and in those who have shown hypersensitivity to the drug. Ketalar should not be used in patients with eclampsia or pre-eclampsia, severe coronary or myocardial disease, cerebrovascular accident or cerebral trauma.
Dose and Administration: By intramuscular injection, short procedures, initially 6.5–13 mg/kg, adjusted according to response (10 mg/kg usually produces 12–25 minutes of surgical anaesthesia). Diagnostic manoeuvres and procedures not involving intense pain, initially 4 mg/kg. By intravenous injection over at least 60 seconds, short procedures, initially 1–4.5 mg/kg, adjusted according to response (2 mg/kg usually produces 5–10 minutes of surgical anaesthesia). By intravenous infusion of a solution containing 1 mg/mL, longer procedures, induction, total dose of 0.5–2 mg/kg; maintenance, 10– 45 micrograms/kg/minute, rate adjusted according to response.
Indications: For induction and maintenance of general anaesthesia. For sedation of artificially ventilated patients in the intensive care unit.
Contraindications: Hypersensitivity to propofol or to one of the excipients. Pregnancy (except in cases of abortion). Should not be used for general anaesthesia in children under the age of three years and for sedation of children under the age of 16 in the intensive care unit. Should not be used during lactation.
Dose and Administration: Induction of anaesthesia, by intravenous injection or infusion, 1.5–2.5 mg/kg (1–1.5 mg in those over 55 years) at a rate of 20– 40 mg every 10 seconds until response; child over 1 month, administer slowly until response (usual dose in child over 8 years 2.5 mg/kg, may need more in younger child e.g. 2.5–4 mg/kg). Maintenance of anaesthesia, by intravenous infusion, 4–12 mg/kg/hour or by intravenous injection, 25–50 mg repeated according to response; child over 3 years, by intravenous infusion, 9– 15 mg/kg/hour.
Inhalational anaesthetics may be gases or volatile liquids. They can be used both for induction and maintenance of anaesthesia and can also be used following induction with an intravenous anaesthetic. Volatile liquid anaesthetics are administered using calibrated vaporisers, using air, oxygen, or nitrous oxide– oxygen mixtures as the carrier gas; all can trigger malignant hyperthermia and are contra-indicated in those susceptible to malignant hyperthermia. To prevent hypoxia inhalational anaesthetics must be given with concentrations of oxygen greater than 21%.
Indications: Isoflurane may be used for induction and maintenance of general anesthesia. Adequate data have not been developed to establish its application in obstetrical anesthesia.
Contraindications: Known sensitivity to Isoflurane, USP or to other halogenated agents. Known or suspected genetic susceptibility to malignant hyperthermia.
Dose and Administration: Induction of anaesthesia, using specifically calibrated vaporiser, in oxygen or nitrous oxide–oxygen, increased gradually from 0.5% to 3%. Maintenance of anaesthesia, using specifically calibrated vaporiser, 1–2.5% in nitrous oxide–oxygen; an additional 0.5–1% may be required when given with oxygen alone; caesarean section, 0.5–0.75% in nitrous oxide–oxygen.
Indications: Sevoflurane is indicated for induction and maintenance of general anesthesia in adult and pediatric patients.
Contraindications: Sevoflurane can cause malignant hyperthermia. It should not be used in patients with known sensitivity to sevoflurane or to other halogenated agents nor in patients with known or suspected susceptibility to malignant hyperthermia.
Dose and Administration: Induction of anaesthesia, using a specifically calibrated vaporiser, in oxygen or nitrous oxide–oxygen, adjusted according to response, adult up to 5%; child 1 month–18 years up to 8%. Maintenance of anaesthesia, using a specifically calibrated vaporiser, in oxygen or nitrous oxide– oxygen, adjusted according to response, adult and child over 1 month 0.5–3%.
Antimuscarinic drugs are used as premedicants to dry bronchial and salivary secretions which are increased by intubation, by surgery to the upper airways, and by some inhalational anaesthetics. They are also used before or with neostigmine to prevent bradycardia, excessive salivation, and other muscarinic actions of neostigmine. They also prevent bradycardia and hypotension associated with drugs such as propofol and suxamethonium.
Atropine sulphate: used for premedication but still has an emergency role in the treatment of vagotonic side-effects. For its role in acute arrhythmias after myocardial infarction,
Hyoscine hydrobromide reduces secretions and also provides a degree of amnesia, sedation and anti-emesis. Unlike atropine it may produce bradycardia rather than tachycardia. In some patients, especially the elderly, hyoscine may cause the central anticholinergic syndrome (excitement, ataxia, hallucinations, behavioural abnormalities, and drowsiness)
GLYCOPYRRONIUM BROMIDE (Glycopyrrolate):
Indications: indicated for use as a preoperative antimuscarinic to reduce salivary, tracheobronchial, and pharyngeal secretions; to reduce the volume and free acidity of gastric secretions; and to block cardiac vagal inhibitory reflexes during induction of anesthesia and intubation. may be used intraoperatively to counteract surgically or drug- induced or vagal reflexes associated arrhythmias. Glycopyrrolate protects against the peripheral muscarinic effects (e.g., bradycardia and excessive secretions) of cholinergic agents such as neostigmine and pyridostigmine given to reverse the neuromuscular blockade due to non-depolarizing muscle relaxants.
Contraindications: Known hypersensitivity to glycopyrrolate or any of its inactive ingredients.
Dose and Administration: Premedication, by intramuscular or intravenous injection, 200–400 micrograms or 4–5 micrograms/kg (max. 400 micrograms); child by intramuscular or by intravenous injection, 4–8 micrograms/kg (max. 200 micrograms). Intra-operative use, by intravenous injection, 200– 400 micrograms or 4–5 micrograms/kg (max. 400 micrograms), repeated if necessary; child under 18 years 4–8 micrograms/kg (max. 200 micrograms), repeated if necessary. Control of muscarinic side-effects of neostigmine in reversal of non-depolarising neuromuscular block, by intravenous injection, 200 micrograms per 1 mg of neostigmine, or 10–15 micrograms/kg; child 10 micrograms/kg.
Sedative and analgesic peri-operative drugs
These drugs are given to allay fear and anxiety in the pre-operative period (including the night before an operation), to relieve pain and discomfort when present, and to augment the action of subsequent anaesthetic agents. A number of the drugs used also provide some degree of pre-operative amnesia. The choice will vary with the individual patient, the nature of the operative procedure, the anaesthetic to be used, and other prevailing circumstances such as outpatients, obstetrics, and recovery facilities. The choice also varies between elective and emergency operations.
Anxiolytics and neuroleptics
Benzodiazepines possess useful properties for premedication including relief of anxiety, sedation, and amnesia; short-acting benzodiazepines taken by mouth are the most common premedicants. They have no analgesic effect so an opioid analgesic may sometimes be required for pain.
Benzodiazepines can alleviate anxiety at doses that do not necessarily cause excessive sedation and they are of particular value during short procedures or during operations under local anaesthesia (including dentistry). Amnesia reduces the likelihood of any unpleasant memories of the procedure (although benzodiazepines, particularly when used for more profound sedation, can sometimes induce sexual fantasies). Benzodiazepines are also used in intensive care units for sedation, particularly in those receiving assisted ventilation
Opioid analgesics given in small doses before or with induction reduce the dose requirement of some drugs used during anaesthesia. Alfentanil, fentanyl, and remifentanil are particularly useful because they act within 1–2 minutes and have short durations of action. The initial doses of alfentanil or fentanyl are followed either by successive intravenous injections or by an intravenous infusion; prolonged infusions increase the duration of effect. Repeated intra-operative doses of alfentanil or fentanyl should be given with care since the resulting respiratory depression can persist postoperatively and occasionally it may become apparent for the first time postoperatively when monitoring of the patient might be less intensive. Alfentanil, fentanyl, and remifentanil can cause muscle rigidity, particularly of the chest wall or jaw; this can be managed by the use of neuromuscular blocking drugs
Neuromuscular blocking drugs
Neuromuscular blocking drugs used in anaesthesia are also known as muscle relaxants. By specific blockade of the neuromuscular junction they enable light levels of anaesthesia to be employed with adequate relaxation of the muscles of the abdomen and diaphragm. They also relax the vocal cords and allow the passage of a tracheal tube. Their action differs from the muscle relaxants acting on the spinal cord or brain which are used in musculoskeletal disorders. Patients
who have received a neuromuscular blocking drug should always have their respiration assisted or controlled until the drug has been inactivated or antagonised. They should also receive sufficient concomitant inhalational or intravenous anaesthetic, or sedative drugs to prevent awareness.
Non-depolarising neuromuscular blocking drugs
Non-depolarising neuromuscular blocking drugs (also known as competitive muscle relaxants) compete with acetylcholine for receptor sites at the neuromuscular junction and their action may be reversed with anticholinesterases such as neostigmine. Non-depolarising neuromuscular blocking drugs have a slower onset of action than suxamethonium. These drugs can be classified by their duration of action as short-acting (15–30 minutes), intermediate-acting (30–40 minutes) and long-acting (60–120 minutes), although duration of action is dose-dependent. Drugs with a shorter or intermediate duration of action, such as atracurium and vecuronium, are more widely employed than those with a longer duration of action such as pancuronium.
ATRACURIUM BESILATE (Atracurium besylate):
Indications: highly selective, competitive or non-depolarising neuromuscular blocking agent (short to intermediate duration). It is used as an adjunct to general anaesthesia or sedation in the intensive care unit (ICU), to relax skeletal muscles, and to facilitate tracheal intubation and mechanical ventilation.
Contraindications: Atracurium is contraindicated in patients’ known to be hypersensitive to atracurium, cisatracurium or benzenesulfonic acid.
Dose and Administration: Surgery or intubation, adult and child over 1 month, by intravenous injection, initially 300–600 micrograms/kg; maintenance, by intravenous injection, 100–200 micrograms/kg as required or by intravenous infusion, 5–10 micrograms/kg/minute (300–600 micrograms/kg/hour). Intensive care, adult and child over 1 month, by intravenous injection, initially 300–
600 micrograms/kg (optional) then by intravenous infusion 4.5–
29.5 micrograms/kg/minute (usual dose 11–13 micrograms/kg/minute).
Indications: indicated for use during surgical and other procedures and in intensive care. It can be used as an adjunct to general anaesthesia, or sedation in the Intensive Care Unit (ICU) to relax skeletal muscles, and to facilitate tracheal intubation and mechanical ventilation (intermediate duration).
Contraindications: Cisatracurium is contraindicated in patients’ known to be hypersensitive to atracurium, cisatracurium or benzenesulfonic acid.
Dose and Administration: Intubation, by intravenous injection, adult and child over 1 month, initially 150 micrograms/kg; maintenance, by intravenous injection, 30 micrograms/kg approx. every 20 minutes; child 2–12 years, 20 micrograms/kg approx. every 9 minutes; or maintenance, by intravenous
infusion, adult and child over 2 years, initially, 3 micrograms/kg/minute, then after stabilisation, 1–2 micrograms/kg/minute; dose reduced by up to 40% if used with isoflurane. Intensive care, by intravenous infusion, adult 0.5– 10.2 micrograms/kg/minute (usual dose 3 micrograms/kg/minute).
Indications: Mivacurium is a highly selective, short-acting, non-depolarising neuromuscular blocking agent with a fast recovery profile. Mivacurium is used as an adjunct to general anaesthesia to relax skeletal muscles and to facilitate tracheal intubation and mechanical ventilation.
Contraindications: Mivacurium is contraindicated in patients’ known to be hypersensitive. Also contraindicated in pregnancy since there is no information on the use of Mivacron in pregnant women and in patients known or suspected of being homozygous for the atypical plasma cholinesterase gene.
Dose and Administration: By intravenous injection, 70–250 micrograms/kg; maintenance 100 micrograms/kg every 15 minutes; child 2–6 months initially 150 micrograms/kg, 7 months–12 years initially 200 micrograms/kg; maintenance (child 2 months–12 years) 100 micrograms/kg every 6–9 minutes. Doses up to 150 micrograms/kg may be given over 5–15 seconds, higher doses should be given over 30 seconds. In patients with asthma, cardiovascular disease or those who are sensitive to falls in arterial blood pressure give over 60 seconds. By intravenous infusion, maintenance of block, 8–10 micrograms/kg/minute, adjusted if necessary every 3 minutes by 1 microgram/kg/minute to usual dose of 6–7 micrograms/kg/minute; child 2 months–12 years, usual dose 11– 14 micrograms/kg/minute.
Indications: Rocuronium is indicated as an adjunct to general anaesthesia to facilitate tracheal intubation during routine and rapid sequence induction, and to provide skeletal muscle relaxation (intermediate duration) during surgery. Rocuronium is also indicated as an adjunct in the intensive care unit (ICU) to facilitate intubation and mechanical ventilation.
Contraindications: Hypersensitivity to rocuronium or to the bromide ion or to any of the excipients.
Dose and Administration: Intubation, adult and child over 1 month, by intravenous injection, initially 600 micrograms/kg; maintenance by intravenous injection, 150 micrograms/kg (elderly 75–100 micrograms/kg) or maintenance by
intravenous infusion, 300–600 micrograms/kg/hour (elderly up to
400 micrograms/kg/hour). Intensive care, by intravenous injection, adult initially
600 micrograms/kg; maintenance by intravenous infusion, 300–
600 micrograms/kg/hour for first hour, then adjusted according to response.
Depolarising neuromuscular blocking drugs
SUXAMETHONIUM CHLORIDE (Succinylcholine chloride):
Indications: Depolarising muscle relaxant of short duration. neuromuscular blockade (rapid onset, short duration)
Contraindications: family history of malignant hyperthermia, hyperkalaemia; major trauma, severe burns, neurological disease involving acute wasting of major muscle, prolonged immobilisation—risk of hyperkalaemia, personal or family history of congenital myotonic disease, Duchenne muscular dystrophy, low plasma-cholinesterase activity (including severe liver disease)
Dose and Administration: By intravenous injection, initially 1 mg/kg; maintenance, usually 0.5–1 mg/kg at 5–10 minute intervals; max. 500 mg/hour; neonate and infant under 1 year, 2 mg/kg; child over 1 year, 1 mg/kg. By intravenous infusion of a solution containing 1–2 mg/mL (0.1–0.2%), 2.5– 4 mg/minute; max. 500 mg/hour; child reduce infusion rate according to body-weight. By intramuscular injection, infant under 1 year, up to 4–5 mg/kg; child over 1 year, up to 4 mg/kg; max. 150 mg.
Anticholinesterases used in anaesthesia
Anticholinesterases reverse the effects of the non-depolarising (competitive) neuromuscular blocking drugs such as pancuronium but they prolong the action of the depolarising neuromuscular blocking drug suxamethonium.
Neostigmine: has a long duration of action. It is the specific drug for reversal of non-depolarising (competitive) blockade. It acts within one minute of intravenous injection and its effects last for 20 to 30 minutes; a second dose may then be necessary. Glycopyrronium or alternatively atropine, given before or with neostigmine, prevent bradycardia, excessive salivation, and other muscarinic effects of neostigmine
Antagonists for central and respiratory depression
Respiratory depression is a major concern with opioid analgesics and it may be treated by artificial ventilation or be reversed by Naloxone. Naloxone will immediately reverse opioid-induced respiratory depression but the dose may have to be repeated because of the short duration of action of naloxone; however, naloxone will also antagonise the analgesic effect.
Indications: reversal of opioid-induced respiratory depression; reversal of neonatal respiratory depression resulting from opioid administration to mother during labour; overdosage with opioids.
Contraindications: contraindicated in patients with hypersensitivity to naloxone hydrochloride or to any of the excipients of this medicinal product.
Dose and Administration: By intravenous injection, 100–200 micrograms (1.5–3 micrograms/kg); if response inadequate, increments of 100 micrograms every 2 minutes; further doses by intramuscular injection after 1–2 hours if required; child by intravenous injection, 10 micrograms/kg; subsequent dose of 100 micrograms/kg if no response; if intravenous route not possible, may be given in divided doses by intramuscular or subcutaneous injection. neonate, reversal of respiratory and CNS depression resulting from opioid administration to mother during labour, by subcutaneous, intramuscular, or intravenous injection, 10 micrograms/kg, repeated every 2–3 minutes; alternatively by intramuscular injection, 200 micrograms (60 micrograms/kg) as a single dose at birth.
Indications: indicated for the complete or partial reversal of the central sedative effects of benzodiazepines. It may therefore be used in anaesthesia and intensive care in the following situations: Termination of general anaesthesia induced and/or maintained with benzodiazepines. Reversal of benzodiazepine sedation in short diagnostic and therapeutic procedures. For the specific reversal of the central effects of benzodiazepines, to allow return to spontaneous respiration and consciousness, in patients in intensive care.
Contraindications: life-threatening condition (e.g. raised intracranial pressure, status epilepticus) controlled by benzodiazepines.
Dose and Administration: By intravenous injection, 200 micrograms over 15 seconds, then 100 micrograms at 60-second intervals if required; usual dose range, 300–600 micrograms; max. total dose 1 mg (2 mg in intensive care); question aetiology if no response to repeated doses. By intravenous infusion, if drowsiness recurs after injection, 100–400 micrograms/hour, adjusted according
to level of arousal.
Drugs for malignant hyperthermia
Malignant hyperthermia is a rare but potentially lethal complication of anaesthesia. It is characterised by a rapid rise in temperature, increased muscle rigidity, tachycardia, and acidosis. The most common triggers of malignant hyperthermia are the volatile anaesthetics. Suxamethonium has also been
implicated, but malignant hyperthermia is more likely if it is given following a volatile anaesthetic. Volatile anaesthetics and suxamethonium should be avoided during anaesthesia in patients at high risk of malignant hyperthermia. Dantrolene is used in the treatment of malignant hyperthermia. It acts on skeletal muscle cells by interfering with calcium efflux, thereby stopping the contractile process
Local anaesthetic drugs act by causing a reversible block to conduction along nerve fibres. The drugs used vary widely in their potency, toxicity, duration of action, stability, solubility in water, and ability to penetrate mucous membranes. These variations determine their suitability for use by various routes, e.g. topical (surface), infiltration, peripheral nerve block, intravenous regional anaesthesia (Bier’s block), plexus, epidural (extradural) or spinal block. Local anaesthetics may also be used for postoperative pain relief, thereby reducing the need for analgesics such as opioids.
LIDOCAINE HYDROCHLORIDE (Lignocaine hydrochloride):
Indications: Lignocaine is used as a local anaesthetic in infiltration field block, nerve block and spinal anaesthesia. As a local anaesthetic it has an action of intermediate duration, which can be increased by adding adrenaline.
Contraindications: Contra-indicated in patients that are hypersensitive to local anaesthetics. Lignocaine hydrochloride should not be given to patients with hypovolaemia, heartblock or other conduction disturbances, bradycardia, cardiac decompensation or hypotension unrelated to treatable tachyarrhythmias, myasthenia gravis.
Dose and Administration: Infiltration anaesthesia, by injection, according to patient’s weight and nature of procedure, max. 200 mg. Surface anaesthesia, usual strengths 2–4%.
Lidocaine hydrochloride 5% Ointment:
Dose: Dental practice, rub gently into dry gum, Sore nipples from breast-feeding, apply using gauze and wash off immediately before feed. Pain relief (in anal fissures, haemorrhoids, pruritus ani, pruritus vulvae, herpes zoster, or herpes labialis), 1–2 mL applied when necessary; avoid long-term use.
Lidocaine hydrochloride 10% Spray:
Dose: Dental practice, 1–5 doses. Maxillary sinus puncture, 3 doses. During delivery in obstetrics, up to 20 doses. Bronchoscopy, laryngoscopy, oesophagoscopy, endotracheal intubation, up to 20 doses; child up to 3 mg/kg.
Indications: indicated for local anaesthesia – on intact skin prior to minor dermatological procedures (e.g. needle insertion and surgical treatment of localised lesions) and prior to dermal procedures on larger areas e.g. split skin grafting. – on genital mucosa prior to surgical treatment of localised lesions. In term newborn infants and children under the age of 18 years, it is indicated for local anaesthesia on intact skin prior to minor dermatological procedures.
Contraindications: Known hypersensitivity to anaesthetics of the amide type or to any other component of the product.
Dose and Administration: Anaesthesia before minor skin procedures including venepuncture, apply thick layer under occlusive dressing 1–5 hours before procedure (2–5 hours before procedures on large areas e.g. split skin grafting); infant 1–12 months single application on intact skin under specialist supervision, under 1 month not recommended. Anaesthesia before removal of warts from genital mucosa in adults, apply up to 10 g 5–10 minutes before removal.
Indications: Intrathecal (subarachnoid) spinal anaesthesia for surgery (urological and lower limb surgery lasting 2–3 hours, abdominal surgery lasting 45–60 minutes). Bupivacaine is a long-acting anaesthetic agent of the amide type. Marcain Heavy has a rapid onset of action and long duration. The duration of analgesia in the T10–T12 segments is 2–3 hours.
Marcain Heavy produces a moderate muscular relaxation of the lower extremities lasting 2–2.5 hours. The motor blockade of the abdominal muscles makes the solution suitable for performance of abdominal surgery lasting 45–60 minutes. The duration of the motor blockade does not exceed the duration of analgesia. The cardiovascular effects of Marcain Heavy are similar or less than those seen with other spinal agents.
Contraindications: Hypersensitivity to local anaesthetics of the amide type or to any of the excipients. Intrathecal anaesthesia, regardless of the local anaesthetic used, has its own contraindications, which include: Active disease of the central nervous system such as meningitis, poliomyelitis, intracranial haemorrhage, sub-acute combined degeneration of the cord due to pernicious anaemia and cerebral and spinal tumours. Coagulation disorders or ongoing anticoagulation treatment.
Dose and Administration: Local infiltration, max. 60 mL, using a 2.5 mg/mL (0.25%) solution. Peripheral nerve block, max. 60 mL, using a 2.5 mg/mL (0.25%) solution; max. 30 mL, using a 5 mg/mL (0.5%) solution. Epidural block Surgery, lumbar, max. 20 mL, using a 5 mg/mL (0.5%) solution, Surgery, caudal, max. 30 mL, using a 5 mg/mL (0.5%) solution; child (up to 10 years) using a 2.5 mg/mL (0.25%) solution, up to lower-thoracic (T10) 0.3–0.4 mL/kg, up to mid-thoracic (T6) 0.4–0.8 mL/kg, Labour, lumbar, max. 12 mL using a
2.5 mg/mL (0.25%) or 5 mg/mL (0.5%) solution; caudal max. 20 mL using a 2.5 mg/mL (0.25%) or 5 mg/mL (0.5%) solution. Sympathetic block, max. 50 mL, using a 2.5 mg/mL (0.25%) solution. Marcain Heavy: Dose Intrathecal anaesthesia for surgery, 2–4 mL (dose may need to be reduced in elderly and in late pregnancy).
Indications: Surgical anaesthesia Epidural blocks for surgery, including Caesarean section. Major nerve blocks. Field blocks. Acute pain management Continuous epidural infusion or intermittent bolus administration during postoperative or labour pain. Field blocks.
Contraindications: Hypersensitivity to ropivacaine or to other local anaesthetics of the amide type. General contraindications related to epidural anaesthesia, regardless of the local anaesthetic used, should be taken into account. Obstetric paracervical anaesthesia. Hypovolaemia.
Dose and Administration: Surgical anaesthesia: lumbar epidural, adult and child over 12 years, 15–20 mL of 10 mg/mL solution or 15–25 mL of 7.5 mg/mL solution (max. total dose 200 mg); caesarean section, 15–20 mL of 7.5 mg/mL solution in incremental doses (max. total dose 150 mg). thoracic epidural (to establish block for postoperative pain), adult and child over 12 years, 5–15 mL of 7.5 mg/mL solution. major nerve block (brachial plexus block), adult and child over 12 years, 30–40 mL of 7.5 mg/mL solution. field block, adult and child over 12 years, 1–30 mL of 7.5 mg/mL solution.
Indications: For the production of local anaesthesia for conservative and surgical interventions in the oral region (especially for dental work).
Contraindications: in patients with a known hypersensitivity to the amide type of local anaesthetic.
Dose and Administration: The dose varies and depends on the area to be anaesthetized, vascularity of the tissues, number of neuronal segments to be blocked, individual tolerances and the technique of anaesthesia. The lowest dose needed to provide effective anaesthesia should be administered. The average dose of one dental cartridge will usually suffice. This dose may be doubled if necessary to effect anaesthesia. The maximum adult dose should not exceed 400 mg mepivacaine hydrochloride, (approximately 7 mg/kg) at any one time and the total dose should not exceed 1 g in any twenty-four hour period.
Emergency treatment of poisoning
Prevention of absorption
Given by mouth, activated charcoal can bind many poisons in the gastrointestinal system, thereby reducing their absorption. The sooner it is given the more effective it is, but it may still be effective up to 1 hour after ingestion of the poison—longer in the case of modified-release preparations or of drugs with antimuscarinic (anticholinergic) properties. It is relatively safe and is particularly useful for the prevention of absorption of poisons that are toxic in small amounts, e.g. antidepressants.
Indications: adsorption of poisons in the gastro-intestinal system.
Contraindications: drowsy or comatose patient (risk of aspiration); reduced gastro-intestinal motility (risk of obstruction); not for poisoning with petroleum distillates, corrosive substances, alcohols, clofenotane (dicophane, DDT), Malathion, and metal salts including iron and lithium salts.
Dose and Administration: Reduction of absorption, adult and child over 12 years, 50 g; child under 12 years, 1 g/kg (max. 50 g).
Indications: To induce vomiting after ingesting something poisonous.
Contraindications: Do not administer ipecac when a patient has a decreased level of consciousness or has ingested either a corrosive substance or hydrocarbon with a high aspiration potential.
Dose and Administration: Ipecac syrup, which contains total alkaloids123 to 157 mg per 100 mL, has been used to induce vomiting. The usual dose range for the syrup is 10 to 30 mL, yielding a dose of alkaloids of 12 to 48 mg. Do not confuse the syrup with the fluid extract of ipecac, which is 14 times stronger. Cumulative toxicity requires administration of emetine for amebic dysentery in low doses for a short time with intervals of several weeks before further treatment.
Indications: Indicated For the treatment of paracetamol overdosage.
Contraindications: Hypersensitivity to any ingredient in the preparation.
Dose and Administration: By intravenous infusion, adult and child, initially 150 mg/kg (max. 16.5 g) over 15 minutes, then 50 mg/kg (max. 5.5 g) over 4 hours then 100 mg/kg (max. 11 g) over 16 hours.
Indications: Opioid-induced toxicity especially respiratory depression. Postoperative opioid depression. Neonatal respiratory depression secondary to the administration of opioids to the mother.
Contraindications: Known sensitivity to naloxone hydrochloride. Safety in pregnancy has not been established.
Dose and Administration: Doses used in acute opioid overdosage may not be appropriate for the management of opioid-induced respiratory depression and sedation in those receiving palliative care and in chronic opioid use. Opioid toxicity in Adults: 0,4 to 2 mg intravenously repeated if necessary at two to three
minute intervals as needed.
If no response has been observed after a total dose of 10 mg, then the diagnosis of overdosage with agents other than opioids should be considered. Children – Opioid toxicity: 0,01 mg/kg body mass intravenously followed, if necessary, by a larger dose of 0,1 mg/kg body mass.
Indications: Treatment for chronic iron overload, e.g. transfusional haemosiderosis in patients receiving regular transfusions (e.g. thalassaemia major). primary and secondary haemochromatosis in patients in whom concomitant disorders (e.g. severe anaemia, hypoproteinaemia, renal or cardiac failure) preclude phlebotomy. Treatment for acute iron poisoning. For the diagnosis of iron storage disease and certain anaemias. Aluminium overload – In patients on maintenance dialysis for end stage renal failure where preventative measures (e.g. reverse osmosis) have failed and with proven aluminium-related bone disease and/or anaemia, dialysis encephalopathy; and for diagnosis of aluminium overload.
Contraindications: Hypersensitivity to desferrioxamine mesilate unless the patients can be desensitised.
Dose and Administration: By continuous intravenous infusion, adult and child up to 15 mg/kg/hour, reduced after 4–6 hours; max. 80 mg/kg in 24 hours.
Indications: lead poisoning.
Contraindications: Hypersensitivity to penicillamine or any of the ingredients. Agranulocytosis or severe thrombocytopenia due to penicillamine. Lupus erythematosus. Moderate or severe renal impairment.
Dose and Administration: 1–2 g daily in 3 divided doses before food until urinary lead is stabilised at less than 500 micrograms/day; child 20 mg/kg daily in 3 divided doses before food.
Indicated for the complete or partial reversal of the central sedative effects of benzodiazepines. It may therefore be used in anaesthesia and intensive care in the following situations: Termination of general anaesthesia induced and/or maintained with benzodiazepines. Reversal of benzodiazepine sedation in short diagnostic and therapeutic procedures. For the specific reversal of the central effects of benzodiazepines, to allow return to spontaneous respiration and consciousness, in patients in intensive care see under (15.1.7).
Indications: Neutralisation of the anticoagulant effect of heparin therapy and the treatment of heparin overdose.
Contraindications: Previous life threatening reaction to protamine.
Dose and Administration: Adults: Protamine Sulphate Injection should be administered by slow intravenous injection (max rate 5 mg/min) over a period of 10 minutes. The dose is dependent on the amount of heparin to be neutralised. One mg of Protamine Sulphate will usually neutralise at least 100 IU of mucous heparin or 80 IU of lung heparin if given within 15 minutes of heparin administration. If more than 15 minutes has elapsed since heparin administration then less Protamine is required due to the rapid excretion of heparin. Not more than 50 milligrams of Protamine Sulphate should be administered in a ten minute period. To antagonise heparin infusion: 25-50mg after stopping infusion. To antagonise heparin subcutaneous injection: 1-1.5 mg/ 100 IU heparin. 25-50 mg can be given by slow IV injection and the remainder by slow IV infusion over 8- 16 hours (or the expected duration of absorption of heparin), or 2 hourly divided doses.
METHYLENE BLUE (Methylthioninium chloride):
Indications: Methemoglobinemia. large doses of methylene blue are sometimes used as an antidote to potassium cyanide poisoning.
Contraindications: Deficiency of Glucose-6-Phosphate Dehydrogenase, Hemolytic Anemia from Pyruvate Kinase and G6PD Deficiencies, Severe Renal Disease.
Dose and Administration: Adult Min/Max Dose: 1.0mg/kg/4.0mg/kg Pediatric Min/Max Dose: 1.0mg/kg/4.0mg/kg.
Indications: indicated for the treatment of known or strongly suspected digoxin or digitoxin toxicity, where measures beyond the withdrawal of the digitalis glycoside and correction of any serum electrolyte abnormality are felt to be necessary.
Contraindications: Allergy to ovine protein.
Dose and Administration: Acute ingestion of unknown amount of glycoside: Adults and children over 20 kg: If a patient presents with potentially life-threatening digitalis toxicity after acute ingestion of an unknown amount of digoxin or digitoxin, and neither a serum digoxin concentration nor an estimate of the ingested amount of glycoside is available, 20 vials of Digibind can be administered. This amount will be adequate to treat most life-threatening ingestions in adults and large children. Infants and children 20 kg: In infants and small children 20 kg) with potentially life- threatening digitalis toxicity after acute ingestion of an unknown amount of digoxin or digitoxin, when neither a serum concentration nor an estimate of the ingested amount is available, clinical judgement must be exercised to estimate an appropriate number of vials of Digibind to administer.
chlorhexidine gluconate 0.05% For cleansing and disinfecting wounds and burns and swabbing in obstetrics.
STERETS UNISEPT 0.05%
chlorhexidine gluconate 4% for the Use instead of soap for pre-operative hand and skin preparation and for general hand and skin disinfection.
SCRUB-STAT & HISCRUB 4%
chlorhexidine gluconate 0.5% in an alcoholic solution For pre-operative skin disinfection.
ULTRASEPT & HISOL HAND RUBB.
Indications: Disinfection of wounds, lacerations, abrasions and burns. Prophylaxis against infection in hospital and surgery procedures. Preparation of skin and mucous membranes prior to surgery. Post- operative application to protect against infection. Treatment of infected skin conditions.
Contraindications: preterm neonate gestational age under 32 weeks; avoid regular use in patients with thyroid disorders or those receiving lithium therapy.
Dose and Administration: Apply full strength, as paint, or soak or spray as often as needed.
Sunscreens and camouflagers
Indications: indicated for the gradual bleaching of hyperpigmented skin such as chloasma, melasma, freckles and other unwanted areas of melanin hyperpigmentation.
Contraindications: history of sensitivity or allergic reaction to any of the ingredients.
Dose and Administration: a thin application should be applied to the affected area twice daily.
Indications: indicated for the gradual bleaching of hyperpigmented skin such as chloasma, melasma, freckles and other unwanted areas of melanin hyperpigmentation.
Contraindications: history of sensitivity or allergic reaction to any of the ingredients.
Dose and Administration: a thin application should be applied to the affected area twice daily.
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Shampoos and other preparations for scalp and hair conditions
Dandruff is considered to be a mild form of seborrhoeic dermatitis. Shampoos containing antimicrobial agents may have beneficial effects. Shampoos containing tar extracts may be useful and they are also used in psoriasis. Ketoconazole shampoo should be considered for more persistent or severe dandruff or for seborrhoeic dermatitis of the scalp.
Indications: used for the prevention and treatment of dandruff caused by fungal infections of the scalp, as well as for the relief of associated symptoms such as flaking, scaling and itching.
Contraindications: Known hypersensitivity to ketoconazole or any of the other ingredients, which may be recognised by severe itching and redskin after application of the shampoo.
Dose and Administration: Wet hair. Apply sufficient shampoo to produce a generous lather. Gently massage over the entire scalp. Allow the shampoo to
Soak in for 3 to 5 minutes before rinsing.
Use regularly, at least twice a week for 8 weeks to treat the infection. To prevent the infection reappearing, use once a week or once every two weeks.
Indications: Treatment of dandruff, seborrhoeic dermatitis & pruritus associated w/ these conditions.
Contraindications: Pregnancy & lactation. Known hypersensitivity to Ciclopirox or any of the other ingredients.
Dose and Administration: Use as shampoo for the hair & scalp 2-3 times/week.
Topical application of minoxidil may stimulate limited hair growth in a small proportion of adults but only for as long as it is used.
Indications: treatment of alopecia androgenetica in men aged between 18 and 65. Onset and degree of hair regrowth may be variable among users. Although trends in the data suggest that those users who are younger, who have been balding for a shorter period of time or who have a smaller area of baldness on
the vertex are more likely to respond to Regaine for Men Gel, individual responses cannot be predicted.
Contraindications: in users with a history of sensitivity to minoxidil, ethanol, propylene glycol, carbomer and diisopropanolamine, in users with treated or untreated hypertension, in users with any scalp abnormality (including psoriasis and sunburn).
Dose and Administration: Apply 1 mL twice daily to dry hair and scalp (discontinue if no improvement after 1 year); 5% strength for use in men only.