15: Anaesthesia
Approved: 1 Jan 2014. Last amended: 3 Jul 2020.
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15.1 General Anaesthesia
15.1.1 Intravenous anaesthetics
Recommended
Propofol 1%
(10mg/ml): 20ml, 50ml
Ketamine
(10mg/ml): 20ml
Ketamine
(50mg/ml): 10ml
Ketamine
(100mg/ml): 10ml
Thiopental sodium
Specific Indication
Propofol 1%
(10mg/ml): 50ml prefilled syringe – Target Controlled Infusion
Propofol 2%
(20mg/ml): 50ml – DCC only
Etomidate
(2mg/ml): 10ml – Where cardiovascular stability is a particular concern. Note: a single dose of supplemental hydrocortisone is recommended (Etomidate suppresses adrenocortical function).
15.1.2 Inhalational anaesthetics
15.1.2.1 Volatile liquid anaesthetics
Note: If high gas flows are needed during maintenance of anaesthesia (more than 500 ml/min) then isoflurane must be used due to the cost of desflurane and sevoflurane.
Recommended
Desflurane
Isoflurane
Methoxyflurane
Penthrox®
For use in ED only
Sevoflurane
15.1.2.2 Nitrous oxide
Recommended
Nitrous oxide
15.1.3 Antimuscarinic drugs
Recommended
Atropine
Injection
Glycopyrronium
Injection
Hyoscine hydrobromide
Injection
15.1.4 Sedative and analgesic peri-operative drugs
15.1.4.1 Benzodiazepines
The use of high strength midazolam (5ml/ml, in 2ml and 10ml ampoules, or 2mg/ml in 5ml ampoules) should be restricted to general anaesthesia, intensive care, palliative care or other situations where the risk has been assessed. It is advised that flumazenil is available when midazolam is used to reverse the effects if necessary. Please see the NPSA Rapid Response Report.
Recommended
Diazepam
Lorazepam
Midazolam
Temazepam
15.1.4.2 Non-opioid analgesics
Recommended
Ketorolac
10mg/ml, 30mg/ml injection: 1ml
15.1.4.3 Opioid analgesics
Recommended
Alfentanil
500mcg/ml injection: 2ml
Alfentanil
5mg/ml injection: 1ml
Fentanyl
50mcg/ml injection: 2ml, 10ml
Specific Indication
Remifentanil
2mg, 5mg injection – Often indicated where cardiovascular stability is critically important or rapid recovery forms an integral part of the surgical procedure. Also used in maternity for PCA when epidural analgesia is contra-indicated and in DCC for sedation (5mg).
15.1.4.4 Other drugs for sedation
Specific Indication
Clonidine
DCC, Post-op multimodal analgesia, Caudal use in orthopaedic surgery for children
Dexmedetomidine
DCC only; restricted for the sedation of patients who need to remain responsive to verbal stimulation and for patients failing to wean from invasive ventilation with traditional management due to agitation.
15.1.5 Neuromuscular blocking drugs
15.1.5.1 Non-depolarising neuromuscular blocking drugs
Recommended
Atracurium
Mivacurium
Rocuronium
15.1.5.2 Depolarising neuromuscular blocking drugs
Recommended
Suxamethonium
15.1.6 Drugs for reversal of neuromuscular blockade
15.1.6.1 Anticholinesterases
Recommended
Neostigmine
Neostigmine with glycopyrronium
15.1.6.2 Other drugs for reversal of neuromuscular blockade
Specific Indication
Sugammadex
Only to be used in the following circumstances:
- Emergency reversal of rocuronium after failed intubation in order to wake patient.
- Where there is concern about residual neuromuscular block (after rocuronium) post-operatively in patients with respiratory insufficiency who have already been reversed with a 5mg dose of neostigmine with glycopyrorronium. If possible discuss with a Consultant Anaesthetist.
- For prompt reversal that would otherwise waste 30 minutes of theatre time (e.g. where a large dose of rocuronium has been used for a short procedure). If possible discuss with a Consultant Anaesthetist.
15.1.7 Antagonists for central and respiratory depression
Recommended
Flumazenil
Naloxone
15.1.8 Drugs for malignant hyperthermia
Recommended
Dantrolene
15.2 Local Anaesthesia
15.2.1 Lidocaine
Recommended
Lidocaine 1% and 2%
Injection
Lidocaine with adrenaline 1% / 1 in 200,000
Injection
Lidocaine with adrenaline 2% / 1 in 200,000
Injection
Lidocaine with adrenaline 2% / 1 in 80,000
Cartridge – dental use
Lidocaine 2%
Gel
Lidocaine 5%
Ointment
Lidocaine 4%
Cream (LMX 4®)
Lidocaine 2.5% and prilocaine 2.5%
Cream (Emla®)
Lidocaine 2% and chlorhexidine 0.25%
Gel (Instillagel®)
Lidocaine 10% (10mg / dose)
Spray (Xylocaine®)
Lidocaine 4%
Topical solution
Lidocaine 5% with phenylephrine 0.5%
Topical solution
Lidocaine 4%, Adrenaline 0.1%, Tetracaine 0.5% gel (LAT gel: unlicensed)
Only for use in children or needle phobic adults
Lidocaine 5% medicated plaster (Ralvo®)
Pain Team initiation only
15.2.2 Bupivacaine
Recommended
Bupivacaine with adrenaline 0.25% / 1 in 200,000
Injection: 10ml
Bupivacaine with adrenaline 0.5% / 1 in 200,000
Injection: 10ml
Bupivacaine with glucose 5mg/80mg/ml
Injection (Marcain Heavy®): 4ml
15.2.3 Chloroprocaine
Recommended
Chloroprocaine 10 mg/ml solution for injection
Ampres®
15.2.4 Levobupivacaine
Recommended
Levobupivacaine 0.25% and 0.5%
Injection: 10ml
Levobupivacaine 0.125%
Infusion: 200ml
Levobupivacaine with fentanyl 0.1%/2mcg/ml
Infusion: 250ml, 500ml
Levobupivacaine with fentanyl 0.125%/4mcg/ml
Infusion: 500ml
15.2.5 Prilocaine
Recommended
Prilocaine 1%
Injection: 50ml
Prilocaine with felypressin 30mg/0.03 unit/ml
Cartridge: 2.2ml
Prilocaine with glucose 20mg/60mg/ml
Injection (Prilotekal®): 5ml
15.2.6 Ropivacaine
Recommended
Ropivacaine with adrenaline 400mg/1mg
Infusion: 201ml (unlicensed)
Ropivacaine with adrenaline and ketorolac
Infusion: 203ml (unlicensed)