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Medicines used in general anaesthesia include the following pre-medications:
Sedation and Anxiolytics
A: diazepam (IV) 0.05 – 0.1mg/kg
OR
C: diazepam (PO) 0.5 – 0.75mg/kg
OR
C: lorazepam (IM) 0.05mg/kg or 0.04mg/kg (IV)
OR
D: midazolam (IV) 0.05–0.1mg/kg
If there is an overdose with benzodiazepines use the following antidote:
A: flumazenil (IV): 0.2mg stat over 30 seconds. Repeated dose of 0.2mg may be given at 1minute intervals until desired level of consciousness is achieved; do not exceed 4doses (1mg).
If there is bradycardia, salivary secretion or other muscarinic side effects give
A: atropine (IV) 0.01mg/kg
OR
S: glycopyrrolate (IV) 0.2–0.4mg (0.2mg for every 1mg of neostigmine). Alternatively, a dose of 10–15 µg/kg (0.01–0.015mg/kg) (IV) with 50 µg/kg (0.05mg/kg) neostigmine or equivalent dose of pyridostigmine
Antiemetics are indicated for prevention of Post-Operative Nausea and Vomiting (PONV)
B: dexamethasone sodium phosphate (IV) 4–5mg for PONV prevention
OR
C: metoclopramide (IV) 10mg
OR
S: ondansetron (IV)4mg administered over 2–5minutes
Antacids are given to patients at risk of aspiration, such as pregnant women, before Caesarean section.
B: sodium citrate (PO) 0.3moles, 30ml. Not more than 30 minutes pre–induction of anaesthesia
OR
C: pantoprazole (IV) 40 mg as soon as the possibility of surgery is known in cases of emergency procedures
General anaesthetics are used for induction of anaesthesia as boluses or for maintenance of anaesthesia as continuous infusions in Total Intravenous Anaesthesia (TIVA).
B: ketamine (IV) 1–2mg/kg (Forinduction, however can be used for maintenance under TIVA, but contraindicated in those who a significant rise in BP/IOP/ICP would constitute a serious hazard)
OR
C: thiopental (IV) 3–5mg/kg (For induction, however can be used for maintenance under TIVA)
OR
D: propofol (IV) 1.5–2.5mg/kg for induction of anaesthesia and 6–12mg/kg/hour infusion
for maintenance in TIVA.
propofol is contraindicted to Patients with risk of hypotension, use volatile agent for maintenance of anaesthesia
OR
S: etomidate (IV) 0.3mg/kg (between 0.2–0.6mg/kg) for induction (cardiostable, it affects cortisol production)
B: halothane 2–4% in air, oxygen or oxygen/nitrous oxide and maintenance 0.5–1.5%
(Nitrous oxide is delivered in a ratio of 70:30 Mix with oxygen, reduce the requirement of a more toxic anaesthetic/ potent agent)
OR
B: isoflurane1.2–2.5% titrates to desired effect
OR
S: sevoflurane 5–7%
Maintenance: 0.5–3% sevoflurane with or without the concomitant use of nitrous oxide.
B: suxamethonium (IV) 1–1.5mg/kg for induction
OR
C: pancuronium (IV) 0.04–0.1mg/kg for maintenance.
OR
S: atracurium (IV) 0.4–0.5mg/kg over 60 seconds followed by 0.08–0.1mg/kg 20–45minutes after initial dose for maintenance or infusion at 0.05–0.1 mg/kg/min (For patients with renal impairment)
OR
S: rocuronium (IV) 0.6 -1 mg/kg can be used for induction if sugammadex (reversal agent) is available, it has minimal side effects, can be used in case suxamethonium is contraindicated.
Contraindications: Suxamethonium is contraindicated in patients with risk for developing hyperkalaemia or with upper/lower motor neuron defect, prolonged chemical denervation, direct muscle trauma, tumour or inflammation, thermal trauma, disuse atrophy, severe infection
B: neostigmine (IV) 50µg/kg with atropine (IV), 20µg/kg (maximum 1.2mg)
OR
S: glycopyrrolate (IV)10 µg/kg
OR
S: sugammadex (IV) 2–4mg/kg
Non–Opiod Analgesics
B: paracetamol (IV) 15mg/kg 8hourly
Opioid analgesics
B: tramadol (IM/IV) 50mg 6hourly
OR
C: morphine (IV/IM) 3–5mg as a single dose, then further boluses of 1–2mg/minute.
Maximum dose of morphine 0.1–0.2mg/kg, and monitor vitals closely
OR
B: pethidine (IV/IM) 1–2mg/kg (used for analgesia during anaesthesia, and during labour)
OR
S: fentanyl (IV) 1–2µg/kg
For opioid over–dosage
B: naloxone (IV) 0.4mg–2mg, alternatively may be given intramuscularly or subcutaneously. For reversal of opioid sedation initial dose 0.1–0.2mg (IV) at 2–3 minutes’ intervals to the desired degree of reversal.
