ventricular dysfunction . oedema .risk factors for
cardiovascular events . ulcerative colitis (may be
l INTERACTIONS → Appendix 1: NSAIDs
procedural complications .renal impairment.respiratory
disorders . skin reactions . vomiting
pain . embolism and thrombosis . hyperglycaemia . myocardial infarction .thrombocytopenia
▶ Rare or very rare Hypersensitivity . pancreatitis . perioral
patients with pre-existing renal impairment). severe
cutaneous adverse reactions (SCARs)
SIDE-EFFECTS, FURTHER INFORMATION For information
about cardiovascular and gastrointestinal side-effects, and
a possible exacerbation of symptoms in asthma, see Nonsteroidal anti-inflammatory drugs. p. 1130
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
reactions including sulfonamide hypersensitivity.
l CONCEPTION AND CONTRACEPTION Caution—long-term
use of some NSAIDs is associated with reduced female
fertility, which is reversible on stopping treatment.
l PREGNANCY Avoid unless the potential benefit outweighs
the risk. Avoid during the third trimester (risk of closure of
fetal ductus arteriosus in utero and possibly persistent
pulmonary hypertension of the newborn); onset of labour
may be delayed and duration may be increased.
l BREAST FEEDING Avoid—present in milk.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate impairment (risk of increased exposure); avoid
in severe impairment (no information available).
Dose adjustments Manufacturer advises dose reduction to
half the usual recommended dose in moderate
impairment; maximum 40 mg daily.
l RENAL IMPAIRMENT Avoid if possible or use with caution.
Dose adjustments The lowest effective dose should be used
for the shortest possible duration.
Monitoring In renal impairment monitor renal function;
sodium and water retention may occur and renal function
may deteriorate, possibly leading to renal failure.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (January
2003) that parecoxib is not recommended for use within
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder and solvent for solution for injection
Parecoxib (as Parecoxib sodium) 40 mg Dynastat 40mg powder
and solvent for solution for injection vials | 5 vial P £28.34
Powder for solution for injection
Parecoxib (as Parecoxib sodium) 40 mg Dynastat 40mg powder for
solution for injection vials | 10 vial P £49.60
Spontaneous respiration: analgesia and enhancement of
anaesthesia for short procedures
▶ Adult: Initially up to 500 micrograms, dose to be
administered over 30 seconds; supplemental doses
Assisted ventilation: analgesia and enhancement of
anaesthesia for short procedures
▶ Adult: Initially 30–50 micrograms/kg, supplemental
Assisted ventilation: analgesia and enhancement of
anaesthesia during maintenance of anaesthesia for
▶ Adult: Initially 50–100 micrograms/kg, dose to be
administered over 10 minutes or as a bolus, followed by
maintenance 30–60 micrograms/kg/hour
Assisted ventilation: analgesia and suppression of
respiratory activity during intensive care for up to
▶ Adult: Initially 2 mg/hour, adjusted according to
response; usual dose 0.5–10 mg/hour, alternatively
initially 5 mg in divided doses, to be administered over
10 minutes; dose used for more rapid initial control,
reduce rate of administration if hypotension or
bradycardia occur; additional doses of 0.5–1 mg may be
given by intravenous injection during short painful
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
▶ Repeated intra-operative doses Repeated intra-operative
doses of alfentanil 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.
l INTERACTIONS → Appendix 1: opioids
▶ Uncommon Coma . hiccups . hypercapnia . pain . post
procedural complications .respiratory disorders
▶ Rare or very rare Agitation . crying . epistaxis . vascular
▶ Frequency not known Cardiac arrest. cough . fever. loss of
SIDE-EFFECTS, FURTHER INFORMATION Alfentanil can
cause muscle rigidity, particularly of the chest wall or jaw;
this can be managed by the use of neuromuscular blocking
l BREAST FEEDING Present in milk—withhold breastfeeding for 24 hours.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Manufacturer advises dose reduction
l RENAL IMPAIRMENT Avoid use or reduce dose; opioid
effects increased and prolonged and increased cerebral
BNF 78 Peri-operative analgesia 1343
l DIRECTIONS FOR ADMINISTRATION 5 mg/mL injection to be
diluted before use. For continuous or intermittent
intravenous infusion dilute in Glucose 5% or Sodium
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: solution for
▶ Alfentanil (Non-proprietary)
Alfentanil (as Alfentanil hydrochloride) 500 microgram per
Alfentanil (as Alfentanil hydrochloride) 5 mg per 1 ml Alfentanil
5mg/1ml solution for injection ampoules | 10 ampoule P £21.95
DT = £23.19b ▶ Rapifen (Piramal Critical Care Ltd)
Alfentanil (as Alfentanil hydrochloride) 500 microgram per
1 ml Rapifen 5mg/10ml solution for injection ampoules | 5 ampoule P £14.50b
Rapifen 1mg/2ml solution for injection ampoules | 10 ampoule P £6.34 DT = £6.34b
Alfentanil (as Alfentanil hydrochloride) 5 mg per 1 ml Rapifen
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, papaveretum p. 469, hyoscine
▶ BY SUBCUTANEOUS INJECTION, OR BY INTRAMUSCULAR
l INTERACTIONS → Appendix 1: hyoscine . opioids
l LESS SUITABLE FOR PRESCRIBING Papaveretum with
hyoscine hydrobromide is less suitable for prescribing.
l MEDICINAL FORMS No licensed medicines listed.
Analgesia and enhancement of anaesthesia at induction
▶ Adult: Initially 0.25–1 microgram/kg, dose to be
administered over at least 30 seconds, if patient is to be
intubated more than 8 minutes after start of
intravenous infusion, initial bolus intravenous
injection dose is not necessary
Analgesia and enhancement of anaesthesia at induction
with or without initial bolus dose
▶ Adult: 30–60 micrograms/kg/hour, if patient is to be
intubated more than 8 minutes after start of
intravenous infusion, initial bolus intravenous
injection dose is not necessary
Assisted ventilation: analgesia and enhancement of
anaesthesia during maintenance of anaesthesia (initial
▶ Adult: Initially 0.25–1 microgram/kg, dose to be
administered over at least 30 seconds
Assisted ventilation: analgesia and enhancement of
anaesthesia during maintenance of anaesthesia with or
▶ Adult: 3–120 micrograms/kg/hour, dose to be
administered according to anaesthetic technique and
adjusted according to response, in light anaesthesia
additional doses can be given by intravenous injection
every 2–5 minutes during the intravenous infusion
Spontaneous respiration: analgesia and enhancement of
anaesthesia during maintenance of anaesthesia
▶ Adult: Initially 2.4 micrograms/kg/hour, adjusted
according to response; usual dose
Assisted ventilation: analgesia and sedation in intensivecare patients (for max 3 days)
▶ Adult: Initially 6–9 micrograms/kg/hour, then adjusted
in steps of 1.5 micrograms/kg/hour, allow at least
5 minutes between dose adjustments; usual dose
0.36–44.4 micrograms/kg/hour, if an infusion rate of
12 micrograms/kg/hour does not produce adequate
sedation add another sedative (consult product
Assisted ventilation: additional analgesia during
stimulating or painful procedures in intensive-care
▶ Adult: Usual dose 15–45 micrograms/kg/hour,
maintain infusion rate of at least 6 micrograms/kg/hour
for at least 5 minutes before procedure and adjust
every 2–5 minutes according to requirements
▶ Adult: (consult product literature)
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l UNLICENSED USE Remifentanil doses in BNF may differ
from those in product literature.
l CONTRA-INDICATIONS Analgesia in conscious patients
l INTERACTIONS → Appendix 1: opioids
▶ Common or very common Apnoea . muscle rigidity . post
▶ Rare or very rare Cardiac arrest
▶ Frequency not known Agitation . atrioventricular block . hypertension . seizure
SIDE-EFFECTS, FURTHER INFORMATION In contrast to other
opioids which are metabolised in the liver, remifentanil
undergoes rapid metabolism by plasma esterases; it has
short duration of action which is independent of dose and
Muscle rigidity Remifentanil can cause muscle rigidity
that can be managed by the use of neuromuscular blocking
l PREGNANCY No information available.
l BREAST FEEDING Avoid breast-feeding for 24 hours after
administration—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (limited information available).
1344 Anaesthesia adjuvants BNF 78
Dose adjustments No dose adjustment necessary in renal
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Ultiva ®), give continuously in Glucose 5% or Sodium
Chloride 0.9% or Water for Injections; reconstitute with
infusion fluid to a concentration of 1 mg/mL then dilute
further to a concentration of 20–250 micrograms/mL
(50 micrograms/mL recommended for general anaesthesia,
20–50 micrograms/mL recommended when used with
target controlled infusion (TCI) device).
l PRESCRIBING AND DISPENSING INFORMATION
Remifentanil should not be given by intravenous injection
intra-operatively, but it is well suited to continuous
infusion; a supplementary analgesic is given before
stopping the infusion of remifentanil.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
▶ Remifentanil (Non-proprietary)
Remifentanil (as Remifentanyl hydrochloride) 1 mg Remifentanil
1mg powder for concentrate for solution for injection vials | 5 vial P £25.60 (Hospital only)b
Remifentanil (as Remifentanyl hydrochloride) 2 mg Remifentanil
2mg powder for concentrate for solution for injection vials | 5 vial P £51.13 (Hospital only)b
Remifentanil (as Remifentanyl hydrochloride) 5 mg Remifentanil
Remifentanil (as Remifentanyl hydrochloride) 1 mg Ultiva 1mg
powder for solution for injection vials | 5 vial P £25.58 (Hospital
Remifentanil (as Remifentanyl hydrochloride) 2 mg Ultiva 2mg
powder for solution for injection vials | 5 vial P £51.15 (Hospital
Remifentanil (as Remifentanyl hydrochloride) 5 mg Ultiva 5mg
powder for solution for injection vials | 5 vial P £127.88 (Hospital
Conscious sedation for clinical
Sedation of patients during diagnostic and therapeutic
procedures is used to reduce fear and anxiety, to control
pain, and to minimise excessive movement. The choice of
sedative drug will depend upon the intended procedure;
some procedures are safer and more successful under
anaesthesia. The patient should be monitored carefully;
monitoring should begin as soon as the sedative is given or
when the patient becomes drowsy, and should be continued
ANAESTHETICS, GENERAL › NMDA RECEPTOR
Induction and maintenance of anaesthesia for short
▶ Adult: Initially 6.5–13 mg/kg, adjusted according to
response, a dose of 10 mg/kg usually produces
12–25 minutes of surgical anaesthesia
▶ Adult: Initially 1–4.5 mg/kg, adjusted according to
response, to be administered over at least 60 seconds, a
dose of 2 mg/kg usually produces 5–10 minutes of
Diagnostic manoeuvres and procedures not involving
Induction and maintenance of anaesthesia for long
▶ Adult: Initially 0.5–2 mg/kg, using an infusion solution
containing 1 mg/ml; maintenance
10–45 micrograms/kg/minute, adjusted according to
Ketamine should only be administered by, or under the
direct supervision of, personnel experienced in its use,
with adequate training in anaesthesia and airway
management, and when resuscitation equipment is
l INTERACTIONS → Appendix 1: ketamine
▶ Uncommon Appetite decreased . arrhythmias . hypotension .respiratory disorders
▶ Frequency not known Drug-induced liver injury
SIDE-EFFECTS, FURTHER INFORMATION Incidence of
hallucinations can be reduced by premedicaton with a
benzodiazepine (such as midazolam).
l PREGNANCY May depress neonatal respiration if used
l BREAST FEEDING Avoid for at least 12 hours after last
Dose adjustments Manufacturer advises consider dose
reduction—increased risk of accumulation.
l DIRECTIONS FOR ADMINISTRATION For continuous
intravenous infusion, dilute to a concentration of 1 mg/mL
with Glucose 5% or Sodium Chloride 0.9%; use microdrip
infusion for maintenance of anaesthesia. For intravenous
injection, dilute 100 mg/mL strength to a concentration of
not more than 50 mg/mL with Glucose 5% or Sodium
Chloride 0.9% or Water for Injections.
Driving and skilled tasks Patients given sedatives and
analgesics during minor outpatient procedures should be
very carefully warned about the risk of driving or
undertaking skilled tasks afterwards. For a short general
anaesthetic the risk extends to at least 24 hours after
administration. Responsible persons should be available to
BNF 78 Peri-operative sedation 1345
take patients home. The dangers of taking alcohol should
For information on 2015 legislation regarding driving
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