Ketamine and propofol are two common intravenous anesthetics described, with ketamine having advantages for procedures where hemodynamic stability is important and propofol providing rapid induction and recovery. Both drugs are metabolized in the liver and have potential negative effects on respiratory and cardiovascular systems at higher doses if not carefully monitored. The document also outlines specific considerations for administration and potential complications like propofol infusion syndrome.
This document discusses the adrenergic system including adrenoceptor physiology, adrenergic agonists and antagonists. It describes the different types of adrenoceptors (alpha and beta), their locations and responses. It then discusses various adrenergic agonists like epinephrine, norepinephrine, phenylephrine, clonidine and dexmedetomidine and provides their mechanisms of action and dosages. Finally it covers various adrenergic antagonists like phentolamine, labetalol, esmolol, metoprolol and propranolol, describing their receptor selectivities, durations of action and dosages.
Ketamine produces dissociative anesthesia and has hypnotic, analgesic, and amnesic effects. It works by binding to NMDA receptors and other sites like opioid receptors. Ketamine has a rapid onset after IV or IM administration, with effects seen within 1-5 minutes. It causes increased blood pressure and heart rate by stimulating the sympathetic nervous system. Ketamine can also increase respiratory rate and salivation, dilate pupils, and has short-term side effects like confusion and out of body experiences. It has various indications like analgesia, anesthesia induction, and improving psychiatric disorders.
This document discusses the history and development of intravenous induction agents used in anesthesia. It describes key events such as the discovery of barbituric acid in 1864 and the development of thiopental as the first intravenous induction agent in 1934. The document then summarizes various intravenous induction agents that were introduced between 1956-1977 to replace or improve upon earlier agents, including etomidate, ketamine, benzodiazepines like diazepam and midazolam, and the discovery of propofol in 1977.
This document provides an overview of ketamine, including its history, pharmacology, effects, uses, and advantages for resource-poor settings. Some key points:
- Ketamine is a dissociative anesthetic and NMDA receptor antagonist first synthesized in 1962 and approved for use in 1970.
- It produces dissociative anesthesia while maintaining airway reflexes and cardiovascular stimulation.
- Ketamine has various uses including anesthesia, analgesia, and recently as a rapid-acting antidepressant at sub-anesthetic doses.
- Its safety profile and maintenance of airway reflexes make it advantageous for use in resource-poor settings without respiratory support.
1. Opium is one of the oldest known drugs, dating back over 30,000 years. Morphine was isolated from opium sap in the early 1800s and heroin was first synthesized in 1874. Since then, many natural, semisynthetic, and synthetic opioids have been developed to treat pain.
2. Opioids work by binding to and activating opioid receptors in the brain, spinal cord, and other organs. There are three main types of opioid receptors: mu, kappa, and delta.
3. Common opioids include morphine, codeine, oxycodone, fentanyl, hydromorphone, and methadone. They are classified based on their origin (natural
The document discusses ideal properties of intravenous anesthetics and summarizes the pharmacokinetics and pharmacodynamics of several commonly used IV anesthetics including barbiturates, propofol, etomidate, ketamine, benzodiazepines, and dexmedetomidine. It outlines desirable traits such as rapid onset and offset of action, minimal cardiovascular and respiratory depression, and lack of adverse effects. Each drug's mechanism of action, dosing, metabolism, indications, contraindications, and side effects are briefly described.
This document discusses various drugs used for anesthesia induction and maintenance. It describes common inducing agents like thiopentone sodium, methohexitone sodium, propofol, and etomidate. Slower acting drugs include benzodiazepines and ketamine. These drugs work by targeting GABA or NMDA receptors. Complications during and after anesthesia can include respiratory depression, arrhythmias, awareness, and organ toxicity.
This document discusses the adrenergic system including adrenoceptor physiology, adrenergic agonists and antagonists. It describes the different types of adrenoceptors (alpha and beta), their locations and responses. It then discusses various adrenergic agonists like epinephrine, norepinephrine, phenylephrine, clonidine and dexmedetomidine and provides their mechanisms of action and dosages. Finally it covers various adrenergic antagonists like phentolamine, labetalol, esmolol, metoprolol and propranolol, describing their receptor selectivities, durations of action and dosages.
Ketamine produces dissociative anesthesia and has hypnotic, analgesic, and amnesic effects. It works by binding to NMDA receptors and other sites like opioid receptors. Ketamine has a rapid onset after IV or IM administration, with effects seen within 1-5 minutes. It causes increased blood pressure and heart rate by stimulating the sympathetic nervous system. Ketamine can also increase respiratory rate and salivation, dilate pupils, and has short-term side effects like confusion and out of body experiences. It has various indications like analgesia, anesthesia induction, and improving psychiatric disorders.
This document discusses the history and development of intravenous induction agents used in anesthesia. It describes key events such as the discovery of barbituric acid in 1864 and the development of thiopental as the first intravenous induction agent in 1934. The document then summarizes various intravenous induction agents that were introduced between 1956-1977 to replace or improve upon earlier agents, including etomidate, ketamine, benzodiazepines like diazepam and midazolam, and the discovery of propofol in 1977.
This document provides an overview of ketamine, including its history, pharmacology, effects, uses, and advantages for resource-poor settings. Some key points:
- Ketamine is a dissociative anesthetic and NMDA receptor antagonist first synthesized in 1962 and approved for use in 1970.
- It produces dissociative anesthesia while maintaining airway reflexes and cardiovascular stimulation.
- Ketamine has various uses including anesthesia, analgesia, and recently as a rapid-acting antidepressant at sub-anesthetic doses.
- Its safety profile and maintenance of airway reflexes make it advantageous for use in resource-poor settings without respiratory support.
1. Opium is one of the oldest known drugs, dating back over 30,000 years. Morphine was isolated from opium sap in the early 1800s and heroin was first synthesized in 1874. Since then, many natural, semisynthetic, and synthetic opioids have been developed to treat pain.
2. Opioids work by binding to and activating opioid receptors in the brain, spinal cord, and other organs. There are three main types of opioid receptors: mu, kappa, and delta.
3. Common opioids include morphine, codeine, oxycodone, fentanyl, hydromorphone, and methadone. They are classified based on their origin (natural
The document discusses ideal properties of intravenous anesthetics and summarizes the pharmacokinetics and pharmacodynamics of several commonly used IV anesthetics including barbiturates, propofol, etomidate, ketamine, benzodiazepines, and dexmedetomidine. It outlines desirable traits such as rapid onset and offset of action, minimal cardiovascular and respiratory depression, and lack of adverse effects. Each drug's mechanism of action, dosing, metabolism, indications, contraindications, and side effects are briefly described.
This document discusses various drugs used for anesthesia induction and maintenance. It describes common inducing agents like thiopentone sodium, methohexitone sodium, propofol, and etomidate. Slower acting drugs include benzodiazepines and ketamine. These drugs work by targeting GABA or NMDA receptors. Complications during and after anesthesia can include respiratory depression, arrhythmias, awareness, and organ toxicity.
This document provides an overview of intravenous anaesthetic agents. It discusses the uses of general anaesthesia including induction and maintenance. It describes the properties of ideal intravenous anaesthetics such as rapid onset and recovery, minimal side effects, and solubility. The document then covers the pharmacokinetics, metabolism, and effects of specific intravenous agents - barbiturates like thiopental, propofol, and ketamine. It provides details on their mechanisms of action, pharmacology, uses, and side effects.
Etomidate and ketamine are both commonly used induction agents. Etomidate acts via GABA receptors at a dose of 0.3 mg/kg IV, with rapid onset similar to thiopental but less cardiovascular and respiratory depression. However, it can cause adrenal suppression. Ketamine is a dissociative agent that acts via NMDA antagonism at doses of 1-2 mg/kg IV, providing profound analgesia while maintaining airway reflexes and spontaneous breathing. It increases blood pressure, heart rate and intracranial pressure but is useful for bronchospasm. Both drugs can cause emergence phenomena.
Ketamine is a dissociative anesthetic that was first used in humans in 1965. It acts as an NMDA receptor antagonist and also interacts with voltage gated sodium channels. Ketamine produces dissociative anesthesia and profound analgesia by inhibiting the cortex and thalamus while stimulating the limbic system. It has a rapid onset of action of 30-60 seconds and is metabolized primarily in the liver before being excreted by the kidneys. Common side effects include increased heart rate and blood pressure as well as emergence reactions like hallucinations. Ketamine can interact with other drugs to increase risks of seizures or potentiate muscle relaxants.
This document provides information about the drug etomidate. It discusses etomidate's history, mechanism of action, effects on body systems, pharmacokinetics, formulations, indications, contraindications, adverse effects, dosing, administration, safety, and relationship to adrenal suppression. The document also outlines cases for discussion and emphasizes that etomidate is the preferred induction agent for hemodynamically unstable patients.
This document discusses the use of midazolam for conscious sedation in emergency department procedures. It outlines midazolam's pharmacology, indications, administration techniques, monitoring equipment, and interactions. The key points are that midazolam provides rapid onset sedation and amnesia, has a short duration of action, and can be reversed with flumazenil. Proper administration via titration and monitoring are emphasized to safely sedate patients in the emergency department.
This document discusses several intravenous anesthetics, including their mechanisms of action, pharmacokinetics, effects on different organ systems, and clinical uses. It describes how propofol, thiopentone, midazolam, ketamine, and etomidate work by enhancing the inhibitory neurotransmitter GABA or by other receptor actions in the central nervous system. It outlines the distribution, metabolism and elimination of these drugs and compares their cardiovascular, respiratory and central nervous system effects.
Ketamine is being added to the formulary for use by paramedics. It provides sedation and analgesia while maintaining airway protection and respiratory drive. Ketamine works by disconnecting the brain from outside stimuli, resulting in analgesia, sedation and amnesia. It is ideal for situations where cardiovascular stability is important and for hypotensive patients as it may raise blood pressure. Paramedics can use it for RSI, excited delirium, pain management and facilitated extrication. Side effects may include apnea if given too rapidly by IV so it should be diluted and given slowly by IV. Emergence reactions are also possible.
The document discusses various sympathomimetic agents or adrenergic drugs. It defines them as medications that stimulate certain nerves in the body by mimicking or stimulating the release of epinephrine and norepinephrine. These drugs are used to treat life-threatening conditions like cardiac arrest, shock, asthma or allergic reactions. The document then classifies sympathomimetic drugs based on their chemical structure as catecholamines or non-catecholamines. It provides details on individual drugs like epinephrine, norepinephrine, phenylephrine, dopamine, isoproterenol, salbutamol and others including their properties, uses, doses and storage conditions. The drugs are further categorized based on their
Thiopentone is an ultra short-acting barbiturate used for induction of anesthesia. It works by enhancing the effect of the inhibitory neurotransmitter GABA at GABAA receptors in the brain, causing sedation, hypnosis and general anesthesia. It has a rapid onset of 10-20 seconds when given intravenously and is redistributed and metabolized quickly, typically causing awakening within 5-15 minutes. Common uses include induction of anesthesia and treatment of increased intracranial pressure. Side effects are generally mild and related to its cardiovascular and respiratory depressant effects.
This document summarizes the sympathomimetic system. It describes the synthesis, storage, release, reuptake and metabolism of catecholamines like norepinephrine and dopamine. It also discusses the pharmacological actions and therapeutic uses of endogenous catecholamines like epinephrine and norepinephrine. Additionally, it covers various classes of sympathomimetic drugs like alpha and beta agonists, their mechanisms and clinical applications.
Skeletal muscle relaxants can act peripherally at the neuromuscular junction, centrally in the central nervous system, or directly on muscle contractile mechanisms. Peripherally acting drugs include competitive blockers like tubocurarine and depolarizing agents like succinylcholine. Centrally acting drugs like diazepam and baclofen reduce muscle tone by depressing spinal reflexes. Dantrolene acts directly on muscle to inhibit calcium release and contraction. These drugs are used to reduce muscle spasms and tone in various neurological and orthopedic conditions as well as in anesthesia and electroconvulsive therapy.
General anesthetics were introduced in the 19th century with diethyl ether and chloroform. While effective, they had toxicity issues. In the 1840s-50s, William Morton, Pirogoff, and James Young Simpson successfully used ether and chloroform for surgeries and obstetrics. Modern balanced anesthesia uses combinations of inhaled and injectable anesthetics along with analgesics and muscle relaxants to reduce risks and side effects compared to single agents. Common inhaled agents include desflurane, isoflurane, sevoflurane, and nitrous oxide. Injectables include propofol, etomidate, ketamine, and barbiturates like thiopental.
This document discusses sympathomimetic drugs, which mimic the actions of epinephrine and norepinephrine. It describes the sympathetic and parasympathetic nervous systems, defines sympathomimetic drugs, and classifies them based on their mechanisms of action. The document also discusses the synthesis, storage, release, reuptake, and metabolism of catecholamines. It describes adrenergic receptors, where they are located, and provides examples of drugs that act on different receptor types. The actions and uses of epinephrine, norepinephrine, and dopamine are explained. Therapeutic classifications and examples of sympathomimetic drugs are also provided.
This document provides an overview of several intravenous anaesthetic agents including propofol, etomidate, ketamine, thiopental, midazolam, and dexmedetomidine. It describes the mechanism of action, pharmacokinetics, clinical uses, and effects on organ systems for each agent. The ideal properties of intravenous anaesthetics are discussed. Propofol, etomidate, ketamine and thiopental are described as rapid-acting induction agents while midazolam and dexmedetomidine provide sedation with minimal respiratory depression.
Define Muscle relaxants
Classification and pharmacology properties .
Toxicology of muscle relaxants
How to investigate muscle relaxant toxicity and managing.
This document provides an overview of parasympathomimetic agents or cholinergic drugs. It discusses the organization of the nervous system and types of cholinergic receptors. Cholinergic drugs are classified as directly acting or indirectly acting. Directly acting drugs like choline esters and pilocarpine directly bind to muscarinic and nicotinic receptors. Indirectly acting drugs like physostigmine and neostigmine inhibit acetylcholinesterase and prolong the action of acetylcholine. These drugs have therapeutic uses in conditions like myasthenia gravis and glaucoma. Organophosphate poisoning is also discussed which occurs due to inhibition of acetylcholinesterase.
Sympathomimetic drugs mimic the actions of norepinephrine and epinephrine. They can act directly on alpha and beta adrenoceptors or indirectly by releasing norepinephrine from neurons. These drugs have many therapeutic uses including treating hypotension, cardiogenic shock, congestive heart failure, bronchial asthma, glaucoma, and more. The most important classes are epinephrine, norepinephrine, dopamine, dobutamine, and selective beta-2 agonists. They work by various mechanisms like increasing cardiac output, relaxing bronchioles, and constricting blood vessels.
Intravenous anesthetic agents include barbiturates, benzodiazepines, opioids, and miscellaneous drugs. They are used for induction and maintenance of anesthesia, as well as sedation. Barbiturates like thiopental are used for induction but have cumulative effects. Benzodiazepines provide sedation and are used in regional anesthesia and intensive care. Opioids like fentanyl, alfentanil, and remifentanil provide analgesia before and after surgery. They can cause respiratory depression, nausea, and vomiting. Ketamine is used in shocked patients and where equipment is limited due to rapid onset and short duration.
Ketamine & its role in palliative careAnuja Bidkar
Ketamine has been used as an anesthetic since the 1960s and provides potent analgesia and amnesia. It exists as two stereoisomers and is metabolized in the liver by cytochrome P450 enzymes. At clinical doses, it works through multimodal action but can cause dissociative side effects like hallucinations. Long term use may affect memory, though studies are limited. Hepatic side effects like elevated liver enzymes are a concern, especially with repeated infusions close together. When used at subanesthetic doses for chronic pain, side effects like dizziness and nausea are common but usually mild and self-limiting. Recreational abuse can cause impaired consciousness, abdominal pain, and lower ur
Ketamine is a dissociative anesthetic that produces anesthesia by blocking NMDA receptors. It has analgesic, amnestic, and hypnotic effects. Ketamine causes mild increases in heart rate and blood pressure. While it preserves airway reflexes, respiration may be depressed initially. It crosses the placenta and increases secretions and intraocular pressure. Ketamine is used for analgesia, anesthesia induction, and reversing opioid tolerance, and may improve psychiatric conditions in small doses. Side effects include increased heart rate, confusion, out of body experiences, and sensory distortions.
Ketamine Injection USP 10mg/ml, 50mg/ml, 100mg/ml Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Ketamine Dosage & Rx Info | Ketamine Uses, Side Effects Ketamine: Indications, Side Effects, Warnings, Ketamine -Drug Information –Taj Pharma, Ketamine dose Taj pharmaceuticals Ketamine interactions, Taj Pharmaceutical Ketamine contraindications, Ketamine price, Ketamine Taj Pharma Ketamine SmPC-Taj Pharma Stay connected to all updated on Ketamine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
This document provides an overview of intravenous anaesthetic agents. It discusses the uses of general anaesthesia including induction and maintenance. It describes the properties of ideal intravenous anaesthetics such as rapid onset and recovery, minimal side effects, and solubility. The document then covers the pharmacokinetics, metabolism, and effects of specific intravenous agents - barbiturates like thiopental, propofol, and ketamine. It provides details on their mechanisms of action, pharmacology, uses, and side effects.
Etomidate and ketamine are both commonly used induction agents. Etomidate acts via GABA receptors at a dose of 0.3 mg/kg IV, with rapid onset similar to thiopental but less cardiovascular and respiratory depression. However, it can cause adrenal suppression. Ketamine is a dissociative agent that acts via NMDA antagonism at doses of 1-2 mg/kg IV, providing profound analgesia while maintaining airway reflexes and spontaneous breathing. It increases blood pressure, heart rate and intracranial pressure but is useful for bronchospasm. Both drugs can cause emergence phenomena.
Ketamine is a dissociative anesthetic that was first used in humans in 1965. It acts as an NMDA receptor antagonist and also interacts with voltage gated sodium channels. Ketamine produces dissociative anesthesia and profound analgesia by inhibiting the cortex and thalamus while stimulating the limbic system. It has a rapid onset of action of 30-60 seconds and is metabolized primarily in the liver before being excreted by the kidneys. Common side effects include increased heart rate and blood pressure as well as emergence reactions like hallucinations. Ketamine can interact with other drugs to increase risks of seizures or potentiate muscle relaxants.
This document provides information about the drug etomidate. It discusses etomidate's history, mechanism of action, effects on body systems, pharmacokinetics, formulations, indications, contraindications, adverse effects, dosing, administration, safety, and relationship to adrenal suppression. The document also outlines cases for discussion and emphasizes that etomidate is the preferred induction agent for hemodynamically unstable patients.
This document discusses the use of midazolam for conscious sedation in emergency department procedures. It outlines midazolam's pharmacology, indications, administration techniques, monitoring equipment, and interactions. The key points are that midazolam provides rapid onset sedation and amnesia, has a short duration of action, and can be reversed with flumazenil. Proper administration via titration and monitoring are emphasized to safely sedate patients in the emergency department.
This document discusses several intravenous anesthetics, including their mechanisms of action, pharmacokinetics, effects on different organ systems, and clinical uses. It describes how propofol, thiopentone, midazolam, ketamine, and etomidate work by enhancing the inhibitory neurotransmitter GABA or by other receptor actions in the central nervous system. It outlines the distribution, metabolism and elimination of these drugs and compares their cardiovascular, respiratory and central nervous system effects.
Ketamine is being added to the formulary for use by paramedics. It provides sedation and analgesia while maintaining airway protection and respiratory drive. Ketamine works by disconnecting the brain from outside stimuli, resulting in analgesia, sedation and amnesia. It is ideal for situations where cardiovascular stability is important and for hypotensive patients as it may raise blood pressure. Paramedics can use it for RSI, excited delirium, pain management and facilitated extrication. Side effects may include apnea if given too rapidly by IV so it should be diluted and given slowly by IV. Emergence reactions are also possible.
The document discusses various sympathomimetic agents or adrenergic drugs. It defines them as medications that stimulate certain nerves in the body by mimicking or stimulating the release of epinephrine and norepinephrine. These drugs are used to treat life-threatening conditions like cardiac arrest, shock, asthma or allergic reactions. The document then classifies sympathomimetic drugs based on their chemical structure as catecholamines or non-catecholamines. It provides details on individual drugs like epinephrine, norepinephrine, phenylephrine, dopamine, isoproterenol, salbutamol and others including their properties, uses, doses and storage conditions. The drugs are further categorized based on their
Thiopentone is an ultra short-acting barbiturate used for induction of anesthesia. It works by enhancing the effect of the inhibitory neurotransmitter GABA at GABAA receptors in the brain, causing sedation, hypnosis and general anesthesia. It has a rapid onset of 10-20 seconds when given intravenously and is redistributed and metabolized quickly, typically causing awakening within 5-15 minutes. Common uses include induction of anesthesia and treatment of increased intracranial pressure. Side effects are generally mild and related to its cardiovascular and respiratory depressant effects.
This document summarizes the sympathomimetic system. It describes the synthesis, storage, release, reuptake and metabolism of catecholamines like norepinephrine and dopamine. It also discusses the pharmacological actions and therapeutic uses of endogenous catecholamines like epinephrine and norepinephrine. Additionally, it covers various classes of sympathomimetic drugs like alpha and beta agonists, their mechanisms and clinical applications.
Skeletal muscle relaxants can act peripherally at the neuromuscular junction, centrally in the central nervous system, or directly on muscle contractile mechanisms. Peripherally acting drugs include competitive blockers like tubocurarine and depolarizing agents like succinylcholine. Centrally acting drugs like diazepam and baclofen reduce muscle tone by depressing spinal reflexes. Dantrolene acts directly on muscle to inhibit calcium release and contraction. These drugs are used to reduce muscle spasms and tone in various neurological and orthopedic conditions as well as in anesthesia and electroconvulsive therapy.
General anesthetics were introduced in the 19th century with diethyl ether and chloroform. While effective, they had toxicity issues. In the 1840s-50s, William Morton, Pirogoff, and James Young Simpson successfully used ether and chloroform for surgeries and obstetrics. Modern balanced anesthesia uses combinations of inhaled and injectable anesthetics along with analgesics and muscle relaxants to reduce risks and side effects compared to single agents. Common inhaled agents include desflurane, isoflurane, sevoflurane, and nitrous oxide. Injectables include propofol, etomidate, ketamine, and barbiturates like thiopental.
This document discusses sympathomimetic drugs, which mimic the actions of epinephrine and norepinephrine. It describes the sympathetic and parasympathetic nervous systems, defines sympathomimetic drugs, and classifies them based on their mechanisms of action. The document also discusses the synthesis, storage, release, reuptake, and metabolism of catecholamines. It describes adrenergic receptors, where they are located, and provides examples of drugs that act on different receptor types. The actions and uses of epinephrine, norepinephrine, and dopamine are explained. Therapeutic classifications and examples of sympathomimetic drugs are also provided.
This document provides an overview of several intravenous anaesthetic agents including propofol, etomidate, ketamine, thiopental, midazolam, and dexmedetomidine. It describes the mechanism of action, pharmacokinetics, clinical uses, and effects on organ systems for each agent. The ideal properties of intravenous anaesthetics are discussed. Propofol, etomidate, ketamine and thiopental are described as rapid-acting induction agents while midazolam and dexmedetomidine provide sedation with minimal respiratory depression.
Define Muscle relaxants
Classification and pharmacology properties .
Toxicology of muscle relaxants
How to investigate muscle relaxant toxicity and managing.
This document provides an overview of parasympathomimetic agents or cholinergic drugs. It discusses the organization of the nervous system and types of cholinergic receptors. Cholinergic drugs are classified as directly acting or indirectly acting. Directly acting drugs like choline esters and pilocarpine directly bind to muscarinic and nicotinic receptors. Indirectly acting drugs like physostigmine and neostigmine inhibit acetylcholinesterase and prolong the action of acetylcholine. These drugs have therapeutic uses in conditions like myasthenia gravis and glaucoma. Organophosphate poisoning is also discussed which occurs due to inhibition of acetylcholinesterase.
Sympathomimetic drugs mimic the actions of norepinephrine and epinephrine. They can act directly on alpha and beta adrenoceptors or indirectly by releasing norepinephrine from neurons. These drugs have many therapeutic uses including treating hypotension, cardiogenic shock, congestive heart failure, bronchial asthma, glaucoma, and more. The most important classes are epinephrine, norepinephrine, dopamine, dobutamine, and selective beta-2 agonists. They work by various mechanisms like increasing cardiac output, relaxing bronchioles, and constricting blood vessels.
Intravenous anesthetic agents include barbiturates, benzodiazepines, opioids, and miscellaneous drugs. They are used for induction and maintenance of anesthesia, as well as sedation. Barbiturates like thiopental are used for induction but have cumulative effects. Benzodiazepines provide sedation and are used in regional anesthesia and intensive care. Opioids like fentanyl, alfentanil, and remifentanil provide analgesia before and after surgery. They can cause respiratory depression, nausea, and vomiting. Ketamine is used in shocked patients and where equipment is limited due to rapid onset and short duration.
Ketamine & its role in palliative careAnuja Bidkar
Ketamine has been used as an anesthetic since the 1960s and provides potent analgesia and amnesia. It exists as two stereoisomers and is metabolized in the liver by cytochrome P450 enzymes. At clinical doses, it works through multimodal action but can cause dissociative side effects like hallucinations. Long term use may affect memory, though studies are limited. Hepatic side effects like elevated liver enzymes are a concern, especially with repeated infusions close together. When used at subanesthetic doses for chronic pain, side effects like dizziness and nausea are common but usually mild and self-limiting. Recreational abuse can cause impaired consciousness, abdominal pain, and lower ur
Ketamine is a dissociative anesthetic that produces anesthesia by blocking NMDA receptors. It has analgesic, amnestic, and hypnotic effects. Ketamine causes mild increases in heart rate and blood pressure. While it preserves airway reflexes, respiration may be depressed initially. It crosses the placenta and increases secretions and intraocular pressure. Ketamine is used for analgesia, anesthesia induction, and reversing opioid tolerance, and may improve psychiatric conditions in small doses. Side effects include increased heart rate, confusion, out of body experiences, and sensory distortions.
Ketamine Injection USP 10mg/ml, 50mg/ml, 100mg/ml Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Ketamine Dosage & Rx Info | Ketamine Uses, Side Effects Ketamine: Indications, Side Effects, Warnings, Ketamine -Drug Information –Taj Pharma, Ketamine dose Taj pharmaceuticals Ketamine interactions, Taj Pharmaceutical Ketamine contraindications, Ketamine price, Ketamine Taj Pharma Ketamine SmPC-Taj Pharma Stay connected to all updated on Ketamine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
Ketamine produces dissociative anesthesia and has analgesic, amnesic, and hypnotic effects. It works by binding to NMDA receptors and other sites like opioid receptors. Ketamine has rapid onset after IV or IM administration, with effects seen within 1-5 minutes. It causes increased blood pressure and heart rate by stimulating the sympathetic nervous system. Ketamine can also increase respiratory rate and salivation, dilate pupils, and has short-term side effects like confusion and out of body experiences. It is used for analgesia, anesthesia induction, reversing opioid tolerance, and improving psychiatric conditions in small doses.
Intravenous Anaesthetics are a group of fast-acting
compounds that are used to induce a state of impaired
awareness of complete sedation.
These are drugs that, when given intravenously in an
appropriate dose, cause a rapid loss of consciousness.
This document discusses the assessment and treatment of acute asthma exacerbations in children. It outlines how to assess the severity of exacerbations using factors like respiratory rate, wheezing, and oxygen saturation. For mild exacerbations, inhaled albuterol is recommended every 20-30 minutes. Moderate exacerbations should also receive ipratropium bromide and systemic steroids. Severe exacerbations may require additional treatments like magnesium sulfate, IV steroids, and IV beta-agonists. The document provides dosing guidelines for recommended asthma medications in pediatric acute exacerbations.
This document provides an overview of pharmacotherapeutics used in obstetrics, including oxytocics, tocolytics, antihypertensives, analgesics, and anticonvulsants. It summarizes the mechanisms of action, dosages, indications, contraindications and side effects of various drugs. Key drugs discussed include oxytocin, ergot alkaloids, prostaglandins, methyldopa, labetalol, nifedipine, magnesium sulfate, terbutaline, indomethacin, atosiban, diazepam, phenytoin, heparin, warfarin, and pethidine. The document is intended as a reference for nurses
2016 10 06 hartford hospital 2016 state protocol updatedinterlandi
This document summarizes key changes to the state EMS protocols that Hartford Hospital sponsored services must implement by December 31, 2016. It highlights several major protocol changes including updates to allergic reaction/anaphylaxis, asthma/bronchiolitis/croup, hypoglycemia, nausea/vomiting, pain management, and ketamine administration. It also reviews new guidance on orogastric tubes, bougie-assisted surgical cricothyrotomy, spinal motion restriction, and vasopressor administration. Providers are responsible for reading the full protocols and understanding all changes, and the hospital will continue providing support for medical decision making.
This document provides information on various local anaesthetics, including their classification, mechanisms of action, durations of effect, concentrations used, metabolism and side effects. It discusses aminoester and aminoamide local anaesthetics such as procaine, lignocaine, mepivacaine, prilocaine, bupivacaine, levobupivacaine, ropivacaine and etidocaine. It also briefly mentions dibucaine as having the longest duration of action of any local anaesthetic.
This document provides guidelines for using ketamine to treat pain in palliative care settings. It outlines that ketamine is effective for treating opioid-resistant pain from conditions like cancer and neuropathy. The guidelines recommend starting with intravenous ketamine to quickly determine dosage and monitor side effects before potentially switching to oral administration. Dosages are provided for both intravenous and oral ketamine use, along with guidance on monitoring patients, managing side effects, and adjusting dosages based on response to treatment. Contraindications and drug interactions are also reviewed.
I am professionally pharmacist. These slides for clinical subject. Especially for pharmacy department students. I hope these students get more benefits about it.
1. This document provides guidance on post-intubation care in the emergency department. It outlines steps to check tube placement and ensure patient safety and comfort.
2. Guidelines are given for oxygenation and ventilation management, including ventilator settings for different clinical scenarios. Signs to watch out for that could indicate issues are also listed.
3. Instructions are provided for ongoing sedation, analgesia, and paralysis as needed. Pretreatment options and push-dose inotropes/vasopressors for hemodynamically unstable patients are also outlined.
1. Antiplatelet drugs work by inhibiting platelet aggregation which is essential for forming blood clots. They are used to prevent thrombus formation in certain pathological conditions.
2. There are several classes of antiplatelet drugs including aspirin, clopidogrel, abciximab which work via different mechanisms such as inhibiting thromboxane A2, blocking ADP receptors, or inhibiting the glycoprotein IIb/IIIa receptor.
3. Fibrinolytics like streptokinase, alteplase work by activating plasminogen to plasmin to break down fibrin clots and are indicated for pulmonary embolism, myocardial infarction, and ischemic stroke. The major risks are bleeding complications.
Tocolytic drugs are used to suppress premature labor by postponing delivery long enough for glucocorticoids to increase fetal lung maturity. The main classes of tocolytic drugs are beta-adrenergic agonists like terbutaline, calcium channel blockers like nifedipine, magnesium sulfate, oxytocin receptor antagonists like atosiban, and prostaglandin inhibitors like indomethacin. Each drug has a different mechanism of action, dosage, administration route, contraindications, and side effects that must be monitored to safely delay premature birth.
Decontamination procedures should be undertaken simultaneously with initial stabilization and assessment. Skin decontamination involves removing contaminated clothing and washing skin with soap and water. For gastrointestinal decontamination, activated charcoal is usually sufficient to bind ingested poisons, though emesis or gastric lavage may also be used depending on the toxin. Specific antidotes are recommended for certain poisonings, such as acetylcysteine for acetaminophen overdose, atropine for organophosphate poisoning, sodium bicarbonate for certain cardiotoxic drugs, deferoxamine for iron poisoning, and naloxone for opioid overdoses. Enhanced elimination methods like hemodialysis, peritoneal dialysis
Oxytocin is a hormone that is used medically to induce and augment labor. It works by causing contractions of the uterus. It can be administered through intravenous infusion, with dosage protocols varying based on whether the patient is primigravid or multigravid. The hormone also acts in other areas like stimulating milk ejection and playing a role in social behaviors. While oxytocin induction and augmentation is widely used, it requires careful monitoring to avoid side effects from uterine hyperstimulation like fetal distress.
Common medication used for anesthesia, there action; dosage; adverse effect; duration of action.
They Include {inhalation + Induction + Muscle relaxant + Anticholinergic + Analgesic + Resuscitation}
This document discusses drugs and defibrillation for cardiac arrest. It states that ventricular fibrillation and ventricular tachycardia should be defibrillated at 200J, 300J, and 360J. Epinephrine and lidocaine are recommended drugs that may help restore spontaneous circulation. Defibrillation should be performed within the first few minutes, alternating with CPR and drug administration until spontaneous circulation returns or the patient progresses to another rhythm.
This document provides information on several medications including atropine, epinephrine, hydrocortisone, dopamine, furosemide, digoxin, digoxin immune fab, naloxone, phenytoin, phenobarbitone, and potassium chloride. For each medication, the document outlines indications, dosages, cautions, adverse effects, and monitoring as applicable. The document also provides treatment protocols for conditions like status asthmaticus and anaphylactic shock.
This document provides information on various medications including their indications, dosages, cautions, and adverse effects. It discusses drugs used to treat conditions like cardiac arrest, shock, seizures, and electrolyte abnormalities. The medications described include atropine, epinephrine, hydrocortisone, dopamine, furosemide, digoxin, phenytoin, phenobarbitone, potassium chloride, sodium bicarbonate, and calcium gluconate. Precise dosages are provided for neonatal and pediatric patients.
This document outlines treatment recommendations for mild, moderate, and severe allergic-like and physiologic reactions to contrast media. For mild reactions, observation and reassurance are usually sufficient, but antihistamines may be given. Moderate reactions require treatment with hydrocortisone, bronchodilators, or epinephrine for bronchospasm. Severe reactions are life-threatening and require immediate epinephrine via intravenous or intramuscular routes along with other interventions and emergency care.
1. The document provides guidelines for performing CPR on infants and children. It details how to open the airway, give rescue breaths, perform chest compressions, treat foreign body airway obstructions, and call for emergency assistance.
2. Key steps include tilting the head and lifting the chin to open the airway, giving 1 breath every 4 seconds for children or 1 breath every 3 seconds for infants, performing chest compressions at a rate of 100-120 per minute with a compression depth of at least one third the chest diameter.
3. For foreign body airway obstructions, back blows and chest thrusts are recommended for infants while abdominal thrusts are used for children over 1 year old.
This document provides information on routine airway management techniques for general anesthesia. It discusses airway assessment, equipment, patient positioning, preoxygenation, intubation, tube placement confirmation, and extubation. Difficult airway management techniques are also reviewed, including use of video laryngoscopes, fiberoptic intubation, supraglottic airway devices, surgical airways, and cricothyroidotomy. Factors that increase airway difficulty and algorithms for managing difficult airways are described.
Local anesthetics work by blocking sodium channels and inhibiting nerve impulse conduction. The document discusses the mechanism of action, classification of nerve fibers, pharmacokinetics, pharmacodynamics, effects on organ systems, clinical profiles of various local anesthetics, and additives that are commonly used. Toxicity can occur if maximum doses are exceeded, if there is inadvertent intravascular injection, or in susceptible patients.
This document discusses neuromuscular blocking agents (NMBAs). It begins by explaining the physiological mechanism of NMBAs and how they interact with nicotinic cholinergic receptors. It then classifies NMBAs as either depolarizing (succinylcholine) or nondepolarizing drugs. Several nondepolarizing NMBAs are discussed in depth, including atracurium, cisatracurium, rocuronium, vecuronium, and pancuronium. The document also covers drug interactions, altered responses to NMBAs, reversal of neuromuscular blockade, and monitoring neuromuscular blockade. Reversal agents like neostigmine, pyridostig
PET-scan uses radioactive tracers to visualize and measure metabolic processes in the body. It is often used to diagnose cancer, prepare for epilepsy surgery, and evaluate neurological conditions like Alzheimer's, brain tumors, Parkinson's disease, Huntington's disease, and addiction disorders. PET scans provide information about the brain's chemical functioning that can help identify these conditions and distinguish between similar disorders.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
3. • Ketamine comes as a clear colourless liquid in an ampoule.
10mg/ml
50mg/ml
100mg/ml
Actions:
• Unconsiousness
• Analgesia
• Amnesia
4. • Intravenous (IV)- ind:1-2mg/kg main:0.5
mg/kg
• Intramuscular (IM)-ind:5-10mg/kg, main:3-
5mg/kg
• Oral (sedation)- children:15mg/kg max 500mg
It has a slower onset after an i.v. bolus (1-5 minutes).
The duration of action depends on the route of
administration (20-30 minutes for i.m. and 10-15
minutes for iv).
Route of administration
5. Using IV ketamine
• Premedicate with an antisialogogue (e.g.
atropine 10- 20mcg/kg)
• Anaesthesia: give 1-2mg/kg in small increments
initially to avoid episodes of apnoea. For
example 30mg boluses every 60 secs to a total of
100mg in a 70kg man. Onset is rapid (1-2 mins)
with a duration of 10 minutes. Anaesthesia can
be maintained by repeated boluses 0.5mg/kg
every 15-20 minutes or by continuous infusion
2-4 mg/kg/hr.
• (Add 500mg of ketamine to 500ml of a
crystalloid solution. Spontaneous ventilation = 1
drop/kg/min (4mg/kg/hr); Controlled ventilation
= 0.5 drop/kg min (2mg/kg/hr). The infusion is
stopped roughly 30 minutes prior to the end of
surgery.7
• Diazepam 0.1-0.2mg/kg helps to reduce
intraoperative movement and also limits
postoperative delirium.
• Analgesia - 0.5mg/kg produces rapid and
profound analgesia
Using IM ketamine
• Ideal for children and for
painful repeated procedures.
Atropine can be mixed with
ketamine for a single injection.
• Anaesthesia: 6-8mg/kg. Onset
is gradual over 5-10 minutes
and is preceded by intense
analgesia. IM titration of
maintenance doses is difficult
but 5 mg/kg every 30min is
usually adequate. An easier
technique is to prolong
anaesthesia using IV
supplements.
• Analgesia - 2-4mg/kg. Onset is
again 5-10 minutes
6. Pharmacokinetics of ketamine
Absorption Absorption Well absorbed orally, nasally, rectally and
intramuscularly Oral bioavailability 20%
Distribution Distribution 20-50% protein bound in plasma Volume
of distribution 3L/Kg Distribution half life is 11 mins
Recovery primarily due to redistribution from brain to
periphery
Metabolism Metabolism N-demethylation & hydroxylation of the
cyclohexylamine ring in the liver Some metabolites are
pharmacologically active
Excretion Excretion Urinary excretion of conjugated metabolites
Clearance 17ml/kg/min Elimination half life 2.5 hours
7. System Effect positive Effect negative
RS • preserves the laryngeal and
pharyngeal reflexes to some
degree
• ketamine is given slowly
respiration is usually well
maintained(Always have a self-
inflating bag and mask available)
• no oxygen or only limited
oxygen available
• Ketamine is an effective
bronchodilator.
• RR
• Saturation decreases when
airway obstruction
• after rapid i.v. injection the
breathing may stop for a short
while but usually restarts
within a minute.
CVS • increase in both blood
pressure and heart rate
• This is very useful in the
shocked patient but in patients
with a history of heart attack
or angina this can make their
heart disease worse.
• occasionally there can be a
large rise in blood pressure.
• patients with ischaemic heart
disease, Patients with diabetes
should have an ECG, if
available, to rule out “silent”
ischaemia (ischaemia without
chest pain)- avoided
Effect of Organ system
8. System Effect positive Effect negative
CNS • Ketamine provides very good
analgesia
• Co-administration of opiates or
tramadol intraoperatively can
reduce the amount of ketamine
required for maintenance of
anaesthesia and therefore reduce
the incidence and duration of
postoperative hallucinations.
• hallucinations can be reduced by
premedication with
benzodiazepines (usually
diazepam 0.15mg/kg orally 1
hour preoperatively or 0.1mg/kg)
• dissociative anaesthesia ( patient
may have their eyes open and
make reflex movements during
the operation)
• Patients can become tolerant of
ketamine. With frequent repeat
anaesthetics bigger doses are
needed, this tolerance usually
wears off over 3 days
• Co-administration (however increase the
risk of the breathing stopping during the
operation.)
• Ketamine increases the intracranial pressure
and for this reason should be avoided
wherever possible in those patients with
recent head injuries.
GIS /-/ • Ketamine increases salivation.
This can lead to airway problems
due to laryngeal spasm or
obstruction.
• It may also make the taping of
endotracheal tubes more difficult.
To reduce this salivation atropine
is usually given either as a premed
(20mcg/kg i.m.) 30 minutes
preoperatively, or at the time of
induction iv (10- 20mcg/kg).
9. System Effect positive Effect negative
Eyes /-/ Ketamine increases intraocular
pressure. The eyes also commonly
move continually during ketamine
anaesthesia (nystagmus). This
makes it an unsuitable anaesthetic
for eye surgery.
Skeletal Muscle /-/ Ketamine increases skeletal muscle
tone. This is most prominent after
the initial iv bolus and gradually
decreases. It is improved by
administration of benzodiazepines.
It is rarely a problem
intraoperatively.
Pain on injection No No
10. Patients suitable for ketamine
• Children - nausea, vomiting
and hallucinations are less
common in children
• Burns (repeated painful
procedures), trauma,
radiotherapy
• Shocked patients
• Status asthmaticus
Patients unsuitable for ketamine
• Avoid ketamine with:
Hypertension
• Ischaemic heart disease
• Pre-eclampsia
• Raised intracranial pressure
• Open eye procedures
• Acute porphyrias
11. Case 1 A 22 year old man has been admitted with a gunshot wound to the
abdomen. He is shocked from major internal bleeding and requires a
laparotomy. You have a very small supply of inotropes and want to try and not
use them. What will you do for induction and maintenance of anaesthesia?
• This gunshot victim is shocked and requires a laparotomy, you have limited inotropes.
• Ketamine would be an ideal anaesthetic agent in this case due to its cardiovascular effects of
raising the blood pressure and heart rate, all other anaesthetic agents tend to have a cardiac
depressant effect.
• Inductioan can be performed with iv ketamine (1-2mg/kg), atropine (10-20mcg/kg) and
diazepam (0.1mg/kg). It is still possible to perform a modified rapid sequence intubation with
ketamine, despite its slower onset time.
• There are several options for maintenance:
• 1) intermittent boluses of iv ketamine (0.5mg/kg) given according to patient’s response - pupil
size, heart rate, blood pressure, movement etc
• 2) ketamine infusion. Put 500mg of ketamine in a 500ml bag of saline or dextrose. Run this
at 1-2mls/min (1-2mg/min). Some patients may require more and others less depending on
what other drugs have been given and the type of surgery. Generally the ketamine will need to
be discontinued 20-30 minutes before the end of the operation to avoid a long wait for the
patient to wake up. This technique for laparotomy is best used with non-depolarising muscle
relaxants (avoid pancuronium as combined with ketamine may have very high blood pressure
increases). It is however possible, although more difficult, to perform the laparotomy under
ketamine alone.
12. Case 2 Your laparotomy patient (case 1) is back on the ward. He has severe
postoperative pain but you have been unable to get any morphine this month.
How can you manage his postoperative pain?
• ketamine for postoperative analgesia
• Ketamine is a very good analgesic and can be a solution for severe pain
when morphine is not available. Its use postoperatively is limited by the
occurrence of hallucinations, however these are less of a problem when
relatively low doses are used.
• For adult patients in severe pain a loading dose of 0.5-1 mg/kg i.m. may be
given. This can then be followed by an infusion of 60-180mcg/kg/hr (4-12
mg/hr for a 70kg adult).
.
13. Case 3 A 37 year old woman is recovering from 45% burns, she needs dressing changes
every two days which are very painful. She has very few sites left for i.v. access and
you don’t want to use them as she has further surgery to come. She is also very scared
of needles. How will you manage the sedation she requires for her dressing changes?
• This woman requires recurrent sedation for painful burns dressings.
IV ketamine is possible but in burns patients there are often limited
sites for cannulation and these are best saved for trips to theatre.
• IM ketamine is also an option but requires relatively large painful
i.m. injections. Instead the intravenous preparation of ketamine can
be given orally. For an adult give 500mg of ketamine + diazepam
5mg. For a child use 15mg/kg ketamine + 0.2mg/kg diazepam (you
can use the i.v. preparation but it tastes very bad and may have to be
hidden in juice). The dressing change can usually start after 20-30
minutes. Responses can sometimes be unpredictable and onset time
may be slower.
• There should always be equipment for suction and face mask
ventilation available and if possible, oxygen and a pulse oximeter.
14. Case 6 An 18 year old girl has been admitted with severe asthma. You have
been asked to see her as she has not improved with subcutaneous injections of
salbutamol or intravenous aminophylline. She is getting tired and her oxygen
saturation is falling. Can you do anything to help?
• ketamine for the treatment of asthma
• Ketamine is an effective bronchodilator and can be used for the patient
who is not responding to conventional bronchodilators such as salbutamol
and aminophylline.
• The doses of ketamine required are very low and problems with
hallucinations rare. A loading dose of 0.2 mg/kg iv is given initially
followed by an infusion of 0.5mg/kg/hr for 3 hours. This may be continued
if necessary. Close monitoring of the patient is required and an anaesthetist
should be available if necessary.
15. • Propofol is slightly soluble
in water , oil-in-water
emulsion
• pH of 6 to 8.5
• In addition to the active
component, the formulation
also contains soybean oil
(100 mg/mL), glycerol (22.5
mg/mL), egg lecithin (12
mg/mL); and disodium
edetate (0.005%)
Propofol(2,6 di-isopropylphenol)
18. Pharmacokinetics of propofol
Absorption Following an IV bolus
Distribution there is rapid equilibration between the plasma and the
highly perfused tissue of the brain as described earlier.
Plasma levels decline rapidly as a result of
redistribution,
Metabolism followed by a more prolonged period of hepatic
metabolism and renal clearance. The initial
redistribution half-life is between 2 and 4 minutes
Excretion Excretion Urinary excretion of conjugated metabolites
Clearance 20-30ml/kg/min Elimination half life 14-23
hours
19. System Effect positive Effect negative
CVS /-/ • This is mainly due to systemic
vasodilatation
Blood pressure heart rate or
slighty
RR /-/ • Act on the respiratory centre to
cause respiratory depression.
This effect is the most profound
with propofol and a period of
apnoea is usually seen. (25-35%)
• Propofol also markedly reduces
airway and pharyngeal reflexes,
making it the ideal drug to use
with the laryngeal mask
CNS • Anticonvulsant in normal
doses.
• Most minimum vomitin g and
naussea
CMRO, CBF, ICP reduced
Effect of Organ system
20. • Propofol infusion syndrome (PRIS) is defined as acute bradycardia
progressing to asystole combined with lipemic plasma, fatty liver
enlargement, metabolic acidosis with negative base excess >10 mmol . l -1,
rhabdomyolysis or myoglobinuria associated with propofol infusion
Etiology & Risk factors
• airway infection,
• severe head injury,
• high-dose long-term propofol sedation
for more than 48 h at more than 5 mg.
kg-1. h-1, increased catecholamine and
glucocorticoid serum levels
• low energy supply
• poor oxygen delivery,
• sepsis
• lipemia,
• likely due to a failure of hepatic lipid
regulation, possibly related to poor
oxygenation or low glucose plasma
levels
Bradycardia has to be combined with
• lipemic plasma,
• fatty liver enlargement,
• metabolic acidosis with negative
base excess >10 mmol . l-1,
• rhabdomyolysis or myoglobinuria
Symptoms and signs are lactacidosis,
arrhythmia, hypotension, renal, cardiac and
circulatory failure, oliguria, rhabdomyolysis,
elevated serum creatine kinase, serum urea
and serum potassium, lipemic plasma, liver
enlargement, ketonuria, increased liver
enzymes and green or red coloured urine.
Propofol infusion syndrom(PRIS)
21. Death was more likely if the patients were younger than 19 yearsof age, males or
received a vasopressor. Other identified risk factors for death were cardiac
manifestations, metabolic acidosis, renal failure, hypotension, rhabdomyolysis or
dyslipidemia
Pathophysiology
• PRIS are cytolysis of skeletal and cardiac
muscle cells
• Muscle biopsies and fat metabolism
analyses of patients with PRIS resemble
these found in mitochondrial cytopathias
and acquired acyl-carnitine metabolism
deficiencies by inhibition of beta
oxidation.
• PRIS may be aggravated by concomitant
diseases like cardiomyopathy.
• Low carbohydrate supply is a risk factor
for PRIS, because energy demand is
satisfied by lipolysis if carbohydrate
supply is low. Children are more prone to
the development of PRIS due to ow
glycogen storage and high dependence on
fat metabolism.43 Fat overload associated
with propofol infusion may also contribute
to increased plasma fatty acids
Therapy
• Propofol infusion must be stopped
immediately.
• Hemodynamic stabilization has to
be achieved by routine intensive
care procedures. Unfortunately,
bradycardia is often resistant to
catecholamines and external
pacing.
• Carbohydrate substitution is
recommended at 6-8 mg.kg.min
• Hemodialysis or hemofiltration is
recommended for elimination of
propofol and its potentially toxic
metabolites
22. • Sodium thiopentone (also known
as thiopental or pentothal) is
prepared by dissolving a
yellowish powder in sterile water
to provide a 2.5% solution (ie
25mg/ml).
• In this concentration 20mls of
solution will contain 500mg.
• Ph=10,8 alkaline
• Thiopentone can be used as the
sole anaesthetic agent for very
brief procedures.
Thiopentone (thiopentanyl sodium)
23. Acting Rapidly ,smooth barbiturates
Onset (arm-brain time ) 15—30 sec
Duration 5-10 min
Induction dose 3-7mg/kg
Pain injection 0/+ (Pain would suggest extravascular or intraarterial
injection)
Recovery time Rapidly
low incidence of nausea and vomiting.
• Following induction anaesthesia is usually maintained by breathing an anaesthetic
vapour such as halothane.
• Titrate the dose against effect; the loss of the eyelash reflex is a good guide to loss of
consciousness.
24. System Effect positive Effect negative
CNS • Thiopentone can also be used in
Intensive Care patients with head
injuries to control surges in
intracranial pressure.
• it posesses potent anticonvulsant
activity it may be given to treat
epileptic seizures
• CMRO, CBF
GIS and US • It does not have any direct toxic
effects on the liver or kidney, but
patients with liver or kidney
disease may require a lower dose
range than 3 to 7 mg/kg.
/-/
CVS • it increases heart rate, coronary
blood flow, and the oxygen demand
of the heart.
• Thiopentone directly depresses the
contractile force of the heart
• can cause hypotension in patients
who are hypovolaemic (eg
following haemorrhage).
• also causes a decrease in venous
tone, causing pooling of blood in
the peripheral veins;
Analgesic and muscle relaxant Thiopentone has no analgesic
properties, in fact in low doses it tends
to heighten sensitivity to pain. It has
poor muscle relaxant properties.
/-/
Effect of Organ system
25. • 1. Acute intermittent porphyria
• 2. Barbiturate allergy
• 3. Patients with a low circulating blood volume, such as after
haemorrhage, are prone to severe hypotension with thiopentone.
• 4. Patients with cardiac disease (particularly those with stenotic
heart valve lesions) are at risk from the cardiovascular depressant
effects of thiopentone. The drug must be carefully titrated against
effect.
• 5. Patients with partial airway obstruction should not be given an
intravenous anaesthetic agent in case total airway obstruction
develops.
• 6. In severe asthma it is thought that thiopentone may occasionally
cause bronchospasm.
Contraindications:
27. • Midazolam is a water
soluble benzodiazepine. It
comes as a clear solution.
1mg/ml
5mg/ml
• Actions: unconsiousness,
sedation , anxiolytic,
anticonvulant , amnesia
Benzodiazepines(Midazolam)
28. Acting
Sedation dose 0.05-0.1mg.kg(IV). Short duration
Oral dose (children) 0.5mg.kg Premedication 30min
preoperative
Induction dose 0.3mg.kg(0.2-0.4mg.kg
IV)
Onset time 30-90sec
Duration time 10-30min
Pain injection /-/
It undergoes hepatic metabolism (+glucorinide or oxidation)and renal elimination. In
the elderly, the lower hepatic blood flow and metabolic activity result in a significantly
prolonged half life.
Liver clearance rate : midazolam >lorazepam >diazepam
29. System Effect positive Effect negative
CvS /-/ Mild depressant*
RS /-/ Mild depressant *
CNS Anticonvulsant
,antiepileptic
CMRO2 and CBF
*-dose dependant (monitoring is important duration sedation)
When used as a sole induction drug, midazolam causes apnoea in up to 70% of
patients
The effects of midazolam can be reversed with flumazenil, a competitive
benzodiazepine antagonist. This should be given by intravenous injection in 100mcg
increments and should act with in 2 minutes. Flumazenil must be used cautiously, as it
can cause agitation and seizures
Effect of Organ system
30. • Diazepam is exclusively lipid
soluble, water insoluble due to its
carbon-containing ring structure.
• This property makes it a rapidly
absorbed by the oral route but also
means that it must be formulated
as a lipid emulsion (diazemuls)
for intravenous use
5mg/1ml
Diazepam
31. Diazepam
Induction dose 0.3-0.6mg.kg
Dose in children 0.2-0.3mg.kg
Onset time 45-60sec
Duration time 15-30min
Pain on injectin +++
Diazepam causes cardiorespiratory compromise, particularly when co-administered
with opioids.
32.
33. • Etomidate is an imidazole ester.
• It is usually presented as a lipid
emulsion or as a clear solution
containing propylene glycol at a
concentration of 2mg.ml
2mg/ml
Etomidate
34. Induction dose 0.2-0.3 mg.kg
Sedation dose 0.03-0.05mg.kg
Onset time 15-45sec
Duration time 3-12min
Pain on injectin +++
Recovery rapid (accompanied by nausea and
vomiting)
It is rapidly metabolized by hepatic and plasma esterases to yield inactive
metabolites. Excretion is predominantly urinary and the elimination half life varies
from 1 – 5 hours.
35. System Effect positive Effect negative
CVS • widely used to induce
anaesthesia in the shocked,
elderly or cardiovascularly
compromised patient
• Hemodynamic suitable
• Least cardiovascular
depression of the IV
anaesthetic drugs, with only a
small reduction in the cardiac
output and blood pressure.
• Deppressant trombocytes ,
prolonged bleeding time
RS /-/ • causes transient apnoea,
though less so than other
drugs, and can cause
cough or hiccups
Post operative nausea and vomiting is common after etomidate administration
MOST MINIMUM DEPRESSANT !!!!!
Effect of Organ system
36. • Etomidate inhibits 11-β-hydroxylase, an enzyme important in adrenal
steroid production.
• A single induction dose blocks the normal stress-induced increase in
adrenal cortisol production for 4-8 hours, and up to 24 hours in elderly and
debilitated patients.
• Continuous infusion of etomidate for sedation in critically ill patients has
been shown to increase mortality.
• Although no increase in mortality has been identified following a single
dose during induction of anesthesia, the use of etomidate has declined in
recent years due to a perceived potential morbidity
Etomidate