1. ANAESTHETICS 1.1.

General Anaesthetics KETAMINE General Information Drug Code 120 313 vial Description of the Drug Ketamine is a phencyclidine derivative used as an I.V. anaesthetic. It casuses dissociative anaesthesia (catatonia + amnesia + analgesia) Mode of Action It depresses the central nervous system by blocking the effects of the excitatory neurotransmitter, glutamic acid at the NMDA receptors. It is a cardiovascular stimulant, causing an increase in B.P, heart rate and cardic output due to sympathetic stimulation. It increases cerebral blood flow. Preparation Inj. Ketamine HCL Inj. Ketamine HCL Strength 50 mg / vial 10 mg /

Pharmacokinetics On I.V. administration, it crosses the blood brain barrier and reaches effective concentration in the brain rapidly. Onset of action is 1-3 minutes. Duration of analgesia is 40 minutes. Duration of anaesthesia is 15 minutes. Duration of amnesia is 1-2 hours. It is subsequently redistributed to other tissues. It is metabolized in the liver and is excreted in urine and bile. Clinical Information Indications For indication of anesthesia. To provide analgesia for painful procedures of short duration. Dosage I.V. 1-2 mg/kg. I.M. 5-10 mg/kg. Continuous infusion - 5-20 microgram/kg/min.

Routes of Administration I.V., I.M., Continuous infusion. Contraindications Patients with hypertension, ischaemic heart disease, aneurysms and hyperthyroidism (due to CVS stimulation). Patients with increased intracranial tension and psychotic disorders. Precautions / Practice points It can be used with advantage in patients with hypovolemia and shock. Administration Instructions: - Hive intravenous injections very slowly, not exceeding a Concentratim of 2mg/ml and rate not exceeding 0.5 mg/kg/min. - Do not mix with barbiturates and diazepam in the same syringe. - Always monitor the heart rate, B.P. respiratory rate and oxygen saturation Drug Interactions Barbiturates and narcotics may prolong the recovery time. Adverse Effects Common effects: Emergence phenomena during recovery from ketamine are common vivid, often unpleasant dreams, confusion, hallucinations, delirium, involuntary movement. Diazepam 0.2-0.3 mg/kg intravenously before giving ketamine reduces the incidence of these effects. Rare Effects: Increase in skeletal muscle tone and fasciculations. Drug Toxicity Increased cardiac stimulation, arrhythmias and respiratory depression. Treatment of Toxicity Ventilatory support, CVS monitoring and symptomatic treatment. Storage Store in airtight containers. Shelf Life 2 Years

THIOPENTONE SODIUM General Information Drug Code 121 Description of the Drug It is an ultra short acting Thiro barbiturate. Mode of Action It acts via the GABA receptors in the brain to decrease neuronal activity, rate of firing and synaptic transmission. It produces loss of consciousness and anaesthesia. It also reduces the arterial blood pressure, stroke volume and cardiac output. Cerebral blood flow is de creased and hence it is safe to use in increased intracranial tension. Pharmacokinetics It is highly lipid soluble and on IV administration, reaches effective blood concentration rapidly. Hence, onset of action is immediate (10-20 seconds). It is then redistributed to muscle, fat and solid organs. Hence, it is short acting (loss of consciousness lasts for only 10-15 minutes). It is metabolized in liver and is excreted by the kidney. Clinical Information Indications Induction of general anesthesia . Can be used alone for providing anesthesia for minor surgical procedures of short duration. Adjunct for intubation in head injury patients. Control of convulsive states. Treatment of elevated intracranial pressure. Dosage Adult 3-5 mg/kg as 2.5% solution Children 5-6 mg/kg Route of Administration IV. Preparation Inj. Thiopentone Sodium Strength 500 mg

Contraindications Thiopentone sodium is contraindicated inpatients with porphyria as it can precipitate attacks. Precaution / Practice points Poor analgesic and muscle relaxant. Hence, for adequate relaxation, a muscle relaxant should be used and analgesics should be given for postoperative pain. Use with caution in patients with hepatic and renal dysfunction. (For dose adjustments, see appendix) Cumulative toxicity can occur, so avoid repeated dosing. Administration Instructions: - Thiopentone is incompatible with the following drugs and MUST NOT be mixed with succinylcholine, atropine, amikacin, dimenhydrinate,diphenhydramine, codeine,morphine, pethidine, insulin, metaraminol, norepinephrine, penicilline G, - Always monitor the respiratory rate, heart rate and B.P. while administration. - Make sure administration is into the vein. Any intra-arterial injection or extravasation may produce intense vasoconstriction causing pain, gangrene and necrosis of limb. Drug Interactions Increases the CNS depressant effects of narcotic analgesics. Adverse Effects Laryngospasm may occur if respiratory secretions are present during induction. Preoperative atropine should be given to decrease secretions. Gastro-intestinal cramps. Pain on IM injection.

Drug Toxicity Respiratory depression, severe hypotension and cardio vascular collapse may occur. Treatment of Toxicity Continuous CVS monitoring, correction of hypovolemia with IV fluids, measures to combat shock - pressors such as norepinephrine and putting the patient in Trendelenburgs position.

Storage Protect from Light. Shelf Life HALOTHANE General Information Drug Code 125 Description of the Drug Halothane is a volatile inhalational anaesthetic agent. noninflammable, nonirritant liquid. Mode of Action Halothane decreases the rate of firing and neuronal activity in the brain by altering the lipid layer of cell membranes, causing structural alterations in ion channels. This results in depression of CNS and anaesthesia. It depresses the respiratory center and is also a bronchodilator. It is a cardiac depressant and causes a decrease in cardiac output and heart rate. Also causes peripheral vasodilatation and hypotension. It sensitizes the myocardium to the effects of catecholamines. It increases cerebral blood flow and raises intracranial and CSF pressures. Pharmacokinetics It is absorbed by inhalation and being lipid soluble crosses the blood brain barrier. It is POTENT anaesthetic and minimum alveolar concentration is 0.75% to produce its effects. Excreted mainly by exhalation, though some detoxitication may occur in the liver. Clinical Information Indications For induction and maintenance of general anaesthesia. Dosage Inductions of anaesthesia: 2 to 4% v/v of halothane in oxygen or mixture of nitrous oxide and oxygen. Maintenance of anaesthesia 0.5% to 1.5% v/v. Routes of Administration It is a clear, colourless, Preparation Halothane Strength 200 ml 3 years.

Inhalation -nasal or endotracheal intubation. Contraindications History of unexplained jaundice following previous exposure to halothane. Patients who have developed malignant hyperthermia with prior use. Patients with increased intracranial pressure. Precaution / Practice points Halothane does not produce adequate analgesia and muscle relaxation. Advantage of halothane are: Induction and recovery is quick and pleasant with halothane. Vapour is nonirritant and incidence of coughing or breath holding is less. Not recommednded for obstetrical anaesthesia as it is a potent uterine muscle relaxant and may cause postpartum haemorrhage., Durg Interactions Potentially fatal: Catecholamine like adrenaline, theophylline, MAO inhibitors and tricyclic antidepressants should be avoided with halothane due to the risk of causing hypotehsive effects with betablockers, calcium channel blockersa and other antihypertensives and antipsychotics. Risk of hepatotoxicity increased by INH and other hepatotoxic drugs Nonfatal: The effects of competitive muscle relaxants like d-tubocurarine are enhanced by halothane. Adverse Effects Most significant adverse effects is hepatotoxicity. It can be mild,self limiting hepatic dysfunction, characterized by elevated serum SGOT and SGPT or a severe acute fulminant hepatitis. In susceptible individuals halothane may tigger off a syndrome of malignant hyperthermia tachycardia, tachypnoea, pyrexia, acidosis, arrhythmias, cyanosis, muscular rigidity and unstable blood pressure. Hyperkalemia may occur. Treatment consists of external cooling measures like icepacks, ventilatory support, CVS monitoring, correction of arrhythmias and blood pressure, maintenance of fluid and electrolyte balance. Durg Toxicity

Severe bradycardia, profound hypotension, respiratory depression and cardiac arrest may occur. Treatment of Toxicity Withdrawal of drug, ventilatory support with oxygen administration, maintenance of B.P.., fluid and electrolyte balance. Storage Below 25o C in airtight containers. Protect from light. Shelf Life 5 years.

ISOFLURANE General Information Drug Code 490 Description of the Drug Isoflurane is a halogenated volatile anaesthetic. It is an isomer of enflurane. It is nonirritant and non-inflammable. Its advantage over other inhalational anaesthetics are it is more potent, induction and recovery from anaesthesia is pleasant and there is less postoperative nausea and vomiting. Mode of Action General anaesthetics act by fluidizing the cell membrane and decreasing or altering the stucture of ion channels in the membrane, thereby decreasing the firing rate and potentials. Synaptic transmission is also decreased. It causes a decrease in arterial pressure and hypotension, but heart rate is increased. It also does not sensitize the myocardium to circulating catecholamines. It causes respiratory depression. Pharmacokinetics It is absorbed by inhalation and only 0.2% is metabolized to inorganic Fluoride. Excretion is mainly by exhalation. Its minimum alveolar concentration is 1.2%. Clinical Information. Indications Induction and maintenance of general anaesthesia. Dosage For induction: Starting with 0.5% upto 3%, given mixed with oxygen alone or mixture of nitrous oxide and oxygen. Preparation Isoflurane

 For maintenance: 1.5 2.5%. Routes of Administration IV. Inhalation only - nasal or endotracheal intubation. Contraindications Patients known to have malignant hyperpyrexia. Patients with increased intracranial pressure, as isoflurane increases the intracranial pressure. Precaution / Practice points Usually used only in maintenance, induction being done by an intravenous induction agent. Analgesic and muscle relaxant is necessary. When compared to halothane it has a higher incidence of coughing, laryngospasm (due to its pungency) but less tendency to cause cardiac depression and arrhythmias. It also does not sensitize the heart to circulating catecholamines like halothane. Drug Interactions Enhancement of action of competitive muscle relaxants like d-tubocurarine. Adverse Effects . Common Effects: Coughing, laryngospasm, salivation, etc., during induction. Increases intracranial pressure. Rare Effects : In susceptible individuals, malignant hyperpyrexia can occur. Drug Toxicity Hypotension, cardiac and respiratory arrest may occur. Treatment of Toxicity Withdrawal of the drug, CVS monitoring, ventilatory support and maintenance of B.P. Storage It is volatile hence, store in airtight containers away from light. Shelf Life 4 years.