l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
solution, solution for injection, spray
Ketamine (as Ketamine hydrochloride) 10 mg per 1 ml Ketamin 10
Curamed 50mg/5ml solution for injection ampoules | 10 ampoule P sb
Ketamine (as Ketamine hydrochloride) 50 mg per 1 ml Ketamine
10 ampoule P sb ▶ Ketalar (Pfizer Ltd)
Ketamine (as Ketamine hydrochloride) 10 mg per 1 ml Ketalar
200mg/20ml solution for injection vials | 1 vial P £5.06 (Hospital
Ketamine (as Ketamine hydrochloride) 50 mg per 1 ml Ketalar
500mg/10ml solution for injection vials | 1 vial P £8.77 (Hospital
HYPNOTICS, SEDATIVES AND ANXIOLYTICS ›
NON-BENZODIAZEPINE HYPNOTICS AND
Maintenance of sedation during intensive care
▶ Adult: 0.7 microgram/kg/hour, adjusted according to
response; usual dose 0.2–1.4 micrograms/kg/hour
Dexmedetomidine should only be administered by, or
under the direct supervision of, personnel experienced
in its use, with adequate training in anaesthesia and
fitted). uncontrolled hypotension
l CAUTIONS Abrupt withdrawal after prolonged use . bradycardia . ischaemic heart disease . malignant
hyperthermia . severe cerebrovascular disease (especially
at higher doses). severe neurological disorders . spinal
l INTERACTIONS → Appendix 1: dexmedetomidine
▶ Common or very common Agitation . arrhythmias . dry
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—toxicity in animal studies.
l BREAST FEEDING Manufacturer advises avoid unless
potential benefit outweighs risk—present in milk in animal
l HEPATIC IMPAIRMENT Manufacturer advises caution
(increased risk of toxicity due to decreased clearance).
Dose adjustments Manufacturer advises consider dose
▶ Monitor respiratory function in non-intubated patients.
l DIRECTIONS FOR ADMINISTRATION To be diluted before
use. For intravenous infusion given continuously in Glucose
5% or Sodium chloride 0.9%, dilute to a concentration of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Dexmedetomidine (Non-proprietary)
Dexmedetomidine (as Dexmedetomidine hydrochloride)
100 microgram per 1 ml Dexmedetomidine 1mg/10ml concentrate
for solution for infusion vials | 4 vial P £313.10 (Hospital only)
Dexmedetomidine 400micrograms/4ml concentrate for solution for
infusion vials | 4 vial P £125.30 (Hospital only)
Dexmedetomidine 200micrograms/2ml concentrate for solution for
infusion ampoules | 5 ampoule P £78.30 (Hospital only)
▶ Dexdor (Orion Pharma (UK) Ltd)
Dexmedetomidine (as Dexmedetomidine hydrochloride)
100 microgram per 1 ml Dexdor 1mg/10ml concentrate for solution
for infusion vials | 4 vial P £313.20 (Hospital only)
Dexdor 400micrograms/4ml concentrate for solution for infusion vials
| 4 vial P £125.28 (Hospital only)
Dexdor 200micrograms/2ml concentrate for solution for infusion
ampoules | 5 ampoule P £78.30 (Hospital only) | 25 ampoule P £391.50 (Hospital only)
MUSCLE RELAXANTS › DIRECTLY ACTING
l DRUG ACTION Acts on skeletal muscle cells by interfering
with calcium efflux, thereby stopping the contractile
▶ BY RAPID INTRAVENOUS INJECTION
▶ Adult: Initially 2–3 mg/kg, then 1 mg/kg, repeated if
necessary; maximum 10 mg/kg per course
Chronic severe spasticity of voluntary muscle
▶ Adult: Initially 25 mg daily, then increased to up to
100 mg 4 times a day, dose increased at weekly
intervals; usual dose 75 mg 3 times a day
Should only be administered by, or under the direct
supervision of, personnel experienced in the use of
dantrolene when used for malignant hyperthermia.
▶ With oral use Acute muscle spasm . avoid when spasticity is
useful, for example, locomotion
▶ With intravenous use Avoid extravasation (risk of tissue
▶ With oral use Females (hepatotoxicity). history of liver
disorders (hepatotoxicity). if doses greater than 400 mg
(hepatotoxicity).therapeutic effect may take a few weeks
to develop— discontinue if no response within 6–8 weeks
l INTERACTIONS → Appendix 1: dantrolene
1346 Malignant hyperthermia BNF 78
▶ Common or very common Abdominal pain . hepatic
disorders . nausea .respiratory disorders . skin reactions . speech disorder. vomiting
▶ Uncommon Crystalluria . hyperhidrosis
▶ Frequency not known Arrhythmias . dizziness . drowsiness
▶ With intravenous use Gastrointestinal haemorrhage . heart
failure . localised pain . pulmonary oedema . seizure . thrombophlebitis
▶ With oral use Asthenia . diarrhoea . dyspnoea . hypertension . malaise
▶ With intravenous use Use only if potential benefit outweighs
▶ With oral use Avoid use in chronic spasticity—embryotoxic
▶ With intravenous use Present in milk—use only if potential
▶ With oral use Present in milk—manufacturer advises avoid
▶ With oral use Manufacturer advises avoid in hepatic
▶ With oral use Test liver function before and at intervals
▶ With oral use Patients should be told how to recognise signs
of liver disorder and advised to seek prompt medical
attention if symptoms such as anorexia, nausea, vomiting,
fatigue, abdominal pain, dark urine, or pruritus develop.
Driving and skilled tasks ▶ With oral use Drowsiness may
affect performance of skilled tasks (e.g. driving); effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
Powder for solution for injection
▶ Dantrium (Norgine Pharmaceuticals Ltd)
Dantrolene sodium 20 mg Dantrium Intravenous 20mg powder for
CAUTIONARY AND ADVISORY LABELS 2
▶ Dantrium (Norgine Pharmaceuticals Ltd)
Dantrolene sodium 25 mg Dantrium 25mg capsules | 100 capsule P £16.87 DT = £16.87
Dantrolene sodium 100 mg Dantrium 100mg capsules | 100 capsule P £43.07 DT = £43.07
The use of local anaesthetics by injection or by application to
mucous membranes to produce local analgesia is discussed
Local anaesthetic drugs act by causing a reversible block to
conduction along nerve fibres. They vary widely in their
potency, toxicity, duration of action, stability, solubility in
water, and ability to penetrate mucous membranes. These
factors determine their application, e.g. topical (surface),
infiltration, peripheral nerve block, intravenous regional
anaesthesia (Bier’s block), plexus, epidural (extradural), or
spinal (intrathecal or subarachnoid) block. Local
anaesthetics may also be used for postoperative pain relief,
thereby reducing the need for analgesics such as opioids.
Bupivacaine hydrochloride p. 1349 has a longer duration of
action than other local anaesthetics. It has a slow onset of
action, taking up to 30 minutes for full effect. It is often used
in lumbar epidural blockade and is particularly suitable for
continuous epidural analgesia in labour, or for postoperative
pain relief. It is the principal drug used for spinal
anaesthesia. Hyperbaric solutions containing glucose may be
Levobupivacaine p. 1351, an isomer of bupivacaine, has
anaesthetic and analgesic properties similar to bupivacaine
hydrochloride, but is thought to have fewer adverse effects.
Lidocaine hydrochloride p. 103 is effectively absorbed from
mucous membranes and is a useful surface anaesthetic in
concentrations up to 10%. Except for surface anaesthesia
and dental anaesthesia, solutions should not usually exceed
1% in strength. The duration of the block (with
adrenaline/epinephrine p. 1353) is about 90 minutes.
Prilocaine hydrochloride p. 1356 is a local anaesthetic of
low toxicity which is similar to lidocaine hydrochloride. A
hyperbaric solution of prilocaine hydrochloride (containing
glucose) may be used for spinal anaesthesia.
Ropivacaine hydrochloride p. 1357 is an amide-type local
anaesthetic agent similar to bupivacaine hydrochloride. It is
less cardiotoxic than bupivacaine hydrochloride, but also
Tetracaine p. 1358, a para-aminobenzoic acid ester, is an
effective local anaesthetic for topical application; a 4% gel is
indicated for anaesthesia before venepuncture or venous
cannulation. It is rapidly absorbed from mucous membranes
and should never be applied to inflamed, traumatised, or
highly vascular surfaces. It should never be used to provide
anaesthesia for bronchoscopy or cystoscopy because
lidocaine hydrochloride is a safer alternative.
The dose of local anaesthetic depends on the injection site
and the procedure used. In determining the safe dosage, it is
important to take account of the rate of absorption and
excretion, and of the potency. The patient’s age, weight,
physique, and clinical condition, and the vascularity of the
administration site and the duration of administration, must
Uptake of local anaesthetics into the systemic circulation
determines their duration of action and produces toxicity.
NHS Improvement has advised (September 2016) that,
prior to administration, all injectable medicines must be
drawn directly from their original ampoule or container into
a syringe and should never be decanted into gallipots or
open containers. This is to avoid the risk of medicines being
confused with other substances, e.g. skin disinfectants, and
to reduce the risk of contamination.
Great care must be taken to avoid accidental intravascular
injection; local anaesthetic injections should be given slowly
in order to detect inadvertent intravascular administration.
When prolonged analgesia is required, a long-acting local
anaesthetic is preferred to minimise the likelihood of
cumulative systemic toxicity. Local anaesthesia around the
oral cavity may impair swallowing and therefore increases
Epidural anaesthesia is commonly used during surgery,
often combined with general anaesthesia, because of its
protective effect against the stress response of surgery. It is
often used when good postoperative pain relief is essential.
Vasoconstrictors in combination with local
Local anaesthetics cause dilatation of blood vessels. The
addition of a vasoconstrictor such as adrenaline/epinephrine
to the local anaesthetic preparation diminishes local blood
flow, slowing the rate of absorption and thereby prolonging
the anaesthetic effect. Great care should be taken to avoid
inadvertent intravenous administration of a preparation
containing adrenaline/epinephrine, and it is not advisable to
give adrenaline/epinephrine with a local anaesthetic
injection in digits or appendages because of the risk of
Adrenaline/epinephrine must be used in a low
concentration when administered with a local anaesthetic.
Care must also be taken to calculate a safe maximum dose of
local anaesthetic when using combination products.
In patients with severe hypertension or unstable cardiac
rhythm, the use of adrenaline/epinephrine with a local
anaesthetic may be hazardous. For these patients an
anaesthetic without adrenaline/epinephrine should be used.
Lidocaine hydrochloride is widely used in dental procedures;
it is most often used in combination with
adrenaline/epinephrine. Lidocaine hydrochloride 2%
combined with adrenaline/epinephrine 1 in 80 000
(12.5 micrograms/mL) is a safe and effective preparation;
there is no justification for using higher concentrations of
The amide-type local anaesthetics articaine and
mepivacaine hydrochloride p. 1355 are also used in
dentistry; they are available in cartridges suitable for dental
use. Mepivacaine hydrochloride is available with or without
adrenaline/epinephrine and articaine is available with
In patients with severe hypertension or unstable cardiac
rhythm, mepivacaine hydrochloride without
adrenaline/epinephrine may be used. Alternatively,
prilocaine hydrochloride with or without felypressin can be
used but there is no evidence that it is any safer. Felypressin
can cause coronary vasoconstriction when used at high
doses; limit dose in patients with coronary artery disease.
Toxicity induced by local anaesthesia
For management of toxicity see Severe local anaestheticinduced cardiovascular toxicity below.
Severe local anaesthetic-induced
After injection of a bolus of local anaesthetic, toxicity may
develop at any time in the following hour. In the event of
signs of toxicity during injection, the administration of the
local anaesthetic must be stopped immediately.
Cardiovascular status must be assessed and
cardiopulmonary resuscitation procedures must be followed.
In the event of local anaesthetic-induced cardiac arrest,
standard cardiopulmonary resuscitation should be initiated
immediately. Lidocaine must not be used as anti-arrhythmic
If the patient does not respond rapidly to standard
procedures, 20% lipid emulsion such as
Intralipid ®[unlicensed indication] should be given
intravenously at an initial bolus dose of 1.5 mL/kg over
1 minute, followed by an infusion of 15 mL/kg/hour. After
5 minutes, if cardiovascular stability has not been restored or
circulation deteriorates, give a maximum of two further
bolus doses of 1.5 mL/kg over 1 minute, 5 minutes apart, and
increase the infusion rate to 30 mL/kg/hour. Continue
infusion until cardiovascular stability and adequate
circulation are restored or maximum cumulative dose of
Standard cardiopulmonary resuscitation must be
maintained throughout lipid emulsion treatment.
Propofol is not a suitable alternative to lipid emulsion.
Further advice on ongoing treatment should be obtained
from the National Poisons Information Service.
Detailed treatment algorithms and accompanying notes
are available at www.toxbase.orgor can be found in the
Association of Anaesthetists of Great Britain and Ireland safety
guideline, Management of Severe Local Anaesthetic Toxicity and
Management of Severe Local Anaesthetic Toxicity – Accompanying
(Carticaine hydrochloride with epinephrine)
Infiltration anaesthesia in dentistry
▶ Adult: Consult expert dental sources
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
Should only be administered by, or under the direct
supervision of, personnel experienced in their use, with
adequate training in anaesthesia and airway
management, and should not be administered
parenterally unless adequate resuscitation equipment is
Adrenaline/epinephrine must be used in a low
concentration when administered with a local
anaesthetic. The total dose of adrenaline should not
exceed 500 micrograms and it is essential not to exceed a
concentration of 1 in 200 000 (5 micrograms/mL) if more
than 50 mL of the mixture is to be injected.
preservatives should not be used for caudal, epidural, or
spinal block, or for intravenous regional anaesthesia
CONTRA-INDICATIONS, FURTHER INFORMATION
▶ Injection site Local anaesthetics should not be injected into
inflamed or infected tissues nor should they be applied to
damaged skin. Increased absorption into the blood
increases the possibility of systemic side-effects, and the
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