BNF for Children 2011-2012

630 15.1.1 Intravenous anaesthetics BNFC 2011–201215 AnaesthesiaDrugs used for intravenous anaesthesia Propofol,the most widely used intravenous anaesthetic, canbe used for induction or maintenance of anaesthesia inchildren, but it is not commonly used in neonates.Propofol is associated with rapid recovery and lesshangover effect than other intravenous anaesthetics. Itcauses pain on intravenous injection which can bereduced by intravenous lidocaine. Significant extraneousmuscle movements can occur. Rarely, convulsions,anaphylaxis, and delayed recovery from anaesthesiacan occur after propofol administration; the onsetof convulsions can be delayed. Propofol is associatedwith bradycardia, occasionally profound; intravenousadministration of an antimuscarinic drug is used totreat this.Propofol can be used for sedation during diagnosticprocedures but is contra-indicated in children under16 years receiving intensive care because of the risk ofpropofol infusion syndrome (potentially fatal effects,including metabolic acidosis, cardiac failure, rhabdomyolysis,hyperlipidaemia, and hepatomegaly).Thiopental sodium is a barbiturate that is used forinduction of anaesthesia, but it has no analgesic properties.Induction is generally smooth and rapid, but doserelatedcardiorespiratory depression can occur. Awakeningfrom a moderate dose of thiopental is rapidbecause the drug redistributes into other tissues, particularlyfat. However, metabolism is slow and sedativeeffects can persist for 24 hours. Repeated doses have acumulative effect particularly in neonates, and recoveryis much slower.Etomidate is an intravenous agent associated with rapidrecovery without a hangover effect. Etomidate causesless hypotension than thiopental and propofol duringinduction. It produces a high incidence of extraneousmuscle movements, which can be minimised by anopioid analgesic or a short-acting benzodiazepinegiven just before induction. Pain on injection can bereduced by injecting into a larger vein or by giving anopioid analgesic just before induction. Etomidate suppressesadrenocortical function, particularly on continuousadministration, and it should not be used formaintenance of anaesthesia.Ketamine causes less hypotension than thiopental andpropofol during induction. It is sometimes used inchildren requiring repeat anaesthesia (such as for serialburns dressings), however recovery is relatively slowand there is a high incidence of extraneous musclemovements. Ketamine can cause hallucinations, nightmares,and other transient psychotic effects; these canbe reduced by a benzodiazepine, such as diazepam ormidazolam.ETOMIDATECautions see notes above; avoid in acute porphyria(section 9.8.2); interactions: Appendix 1 (anaesthetics,general)Contra-indications see notes aboveHepatic impairment reduce dose in liver cirrhosisPregnancy may depress neonatal respiration if usedduring deliveryBreast-feeding breast-feeding can be resumed assoon as mother has recovered sufficiently fromanaesthesiaSide-effects see notes above; also nausea, vomiting,hypotension, apnoea, hyperventilation, stridor, rash;less commonly hypersalivation, bradycardia, arrhythmias,hypertension, hiccups, cough, phlebitis; AVblock, cardiac arrest, respiratory depression, seizures,shivering, and Stevens-Johnson syndrome alsoreportedIndication and doseSee under preparationsEtomidate-Lipuro c (Braun) AInjection (emulsion), etomidate 2 mg/mL, net price10-mL amp = £1.53DoseInduction of anaesthesia. By slow intravenous injectionChild 1 month–18 years 150–300 micrograms/kg; childunder 10 years may need up to 400 micrograms/kgHypnomidate c (Janssen) AInjection, etomidate 2 mg/mL, net price 10-mL amp= £1.38Excipients include propylene glycol (see Excipients, p. 2)DoseInduction of anaesthesia. By slow intravenous injectionChild 1 month–18 years 300 micrograms/kg (max.total dose 60 mg)KETAMINECautions see notes above; dehydration; hypertension;respiratory tract infection; increased cerebrospinalfluid pressure; predisposition to seizures, hallucinations,or nightmares; psychotic disorders; head injuryor intracranial mass lesions; thyroid dysfunction;raised intraocular pressure; interactions: Appendix 1(anaesthetics, general)Contra-indications see notes above; hypertension,pre-eclampsia or eclampsia, severe cardiac disease,stroke; raised intracranial pressure; head trauma;acute porphyria (section 9.8.2)Hepatic impairment consider dose reductionPregnancy may depress neonatal respiration if usedduring deliveryBreast-feeding avoid for at least 12 hours after lastdoseSide-effects see notes above; also nausea, vomiting,tachycardia, hypertension, arrhythmias, hypotension,bradycardia, hypersalivation, laryngospasm, anxiety,insomnia, diplopia, nystagmus, raised intra-ocularpressure; rashes, apnoea, and respiratory depressionalso reportedIndication and doseSedation prior to invasive or painful procedures. By intravenous injectionChild 1 month–18 years 1–2 mg/kg as a singledoseInduction and maintenance of anaesthesia(short procedures). By intravenous injection over at least 60 secondsNeonate 1–2 mg/kg produces 5–10 minutes ofsurgical anaesthesia, adjusted according toresponse