Classification: Nonnarcotic analgesic; nonsteroidal anti-inflammatory drug

Indications: Mild to moderate analgesia for pain, antipyretic

Dose: The recommended dose of Ofirmev for patients 13 years old or older weighing 50 kg or more is 1000 mg every 6 hours or 650 mg every 4 hours intravenously; the maximum daily dose of acetaminophen by any route is 4000 mg. For patients older than 2 years old weighing less than 50 kg, the recommended dose is 15 mg/kg every 6 hours or 12.5 mg/kg every 4 hours intravenously.

Onset and duration: Onset: 5 to 15 minutes. Duration: 4 to 6 hours

Ofirmev can be given directly from the 100-mL vial (10 mg/mL) without further dilution and should be infused over 15 minutes.

Adverse effects: The antipyretic effect of acetaminophen may mask fever. In clinical trials of intravenous acetaminophen, adverse effects were minor and similar to those with placebo.

Precautions and contraindications: Avoid use in patients with liver disease. Overdose can cause serious or fatal hepatic injury, particularly in patients who are fasting. Hepatic toxicity after acetaminophen overdose can be treated with N-acetylcysteine.

Anesthetic considerations: Intravenous acetaminophen decreases pain and reduces fever in adults and children. It has an opioid-sparing effect. It is effective for mild to moderate pain.

Classification: Antiarrhythmic

Indications: Supraventricular tachycardia

Dose: 6-mg bolus administered over 1 to 2 seconds followed by normal saline line flush; may increase to 12-mg bolus if arrhythmia persists past 2 minutes. May repeat 12-mg bolus once.

Dosage forms: 3 mg/mL; 2- and 5-mL vials

Onset and duration: Onset: 10 to 20 seconds; duration: 1 minute

Adverse effects: Flushing, dyspnea, chest pain, headache, nausea, cough, malaise

Precautions and contraindications: Adenosine should not be used in patients receiving methylxanthine therapy (i.e., aminophylline, theophylline). Dipyridamole (Persantine) inhibits cellular uptake of adenosine. Use it with caution in patients with asthma. It is contraindicated in patients with second- or third-degree heart block.

Anesthetic considerations: This is an agent for use preoperatively and postoperatively. It is not used under anesthesia because it produces sinus arrest. It may be administered in lieu of or preceding administration of calcium channel blockers for long-term suppression.

Classification: β₂-adrenergic agonist, sympathomimetic, bronchodilator

Indications: Treatment of asthma and other forms of bronchospasm

Dose: Inhaler (metered dose): two deep inhalations 1 to 5 minutes apart; may be repeated every 4 to 6 hours (daily dose should not exceed 16 to 20 inhalations; each metered aerosol actuation delivers approximately 90 mcg/puff). Oral: 2 to 4 mg three to four times daily (total dose not to exceed 16 mg). Syrup: 2 mg/5 mL is available.

Onset and duration: Onset: inhalation: 5 to 15 minutes; oral: 15 to 30 minutes. Peak effect: inhalation: 0.5 to 2 hours; oral: 2 to 3 hours. Duration: inhalation: 3 to 6 hours; oral: 4 to 8 hours.

Adverse effects: Tachycardia, arrhythmias, hypertension, tremors, anxiety, headache, nausea, vomiting, hypokalemia

Precautions and contraindications: Safe use is not established during pregnancy. Use albuterol cautiously in patients with cardiovascular disease, hypertension, and hyperthyroidism. Monitor glucose and electrolyte levels.

Anesthetic considerations: Tolerance or tachyphylaxis can develop with long-term use. It has additive effects with epinephrine and other sympathomimetics. It is antagonized by β-receptor antagonists.

Classification: Opioid agonist; produces analgesia and anesthesia

Indications: Perioperative analgesia

Dose: Induction: intravenous: 50 to 150 mcg/kg; infusion: 0.1 to 3 mcg/kg/min.

Onset and duration: Onset: intravenous: 1 to 2 minutes; intramuscular: less than 5 minutes; epidural: 5 to 15 minutes. Duration: intravenous: 1 to 15 minutes; intramuscular: 10 to 60 minutes; epidural: 30 minutes.

Adverse effects: Bradycardia, hypotension, arrhythmias, respiratory depression; euphoria, dysphoria, convulsions, nausea and vomiting, biliary tract spasm, delayed gastric emptying, muscle rigidity, pruritus

Precautions and contraindications: Reduce the alfentanil dose in elderly, hypovolemic, or high-risk surgical patients and with the concomitant use of sedatives and other narcotics.

It crosses the placental barrier, and use in labor may produce respiratory depression in neonates. Resuscitation may be required; have naloxone available.

Anesthetic considerations: Circulatory and ventilatory depressant effects are potentiated by narcotics, sedatives, volatile anesthetics, and nitrous oxide. Analgesia is enhanced by α₂-agonists. Muscle rigidity in the higher dose range can be sufficient to interfere with ventilation.

Classification: Prostaglandin E

Indications: Neonates: to maintain temporary patency of the ductus arteriosus until corrective or palliative surgery can be performed

Dose: Children: continuous infusion into large vein: 0.05 to 0.1 mcg/kg/min initially; when a therapeutic response occurs, decrease to lowest possible dose to maintain response (maximum dose: 0.4 mcg/kg/min).

Dosage forms: 500 mcg/mL, 1-mL ampules (refrigerate at 2° to 8° C). Must be diluted in 5% dextrose in water (D₅W) or normal saline for continuous infusion to a final concentration of 5 to 20 mcg/mL.

Onset and duration: Onset: 30 minutes; elimination half-life: 5 to 10 minutes; duration: 30 minutes to 2 hours

Adverse effects: Apnea (10%-12%), fever (14%), flushing (10%), bradycardia and seizures (4%), thrombocytopenia (less than 1%), disseminated intravascular coagulation (1%), anemia, tachycardia, hypotension (4%), diarrhea (2%), gastric outlet obstruction secondary to antral hyperplasia (related to cumulative dose)

Precautions and contraindications: Apnea is most frequent in infants weighing less than 2 kg within the first hour of alprostadil administration; ventilatory assistance may be required. It is contraindicated in neonates with respiratory distress syndrome. Use it with caution in patients with bleeding tendencies because of alprostadil’s ability to inhibit platelet aggregation. In all neonates, monitor arterial pressure; if arterial pressure falls significantly, decrease the rate of infusion.

Anesthetic considerations: Alprostadil is used to maintain a patent ductus arteriosus in newborns.

Classification: Hemostatic agent; prevents the conversion of plasminogen to plasmin

Indications: Control of clinical bleeding in which hyperfibrinolysis is a contributing factor (hyperfibrinolysis should be confirmed by laboratory values such as prolonged thrombin time, prolonged prothrombin time, hypofibrinogenemia, or decreased plasminogen levels); also: open heart surgery; postoperative hematuria after transurethral prostatic resection, suprapubic prostatectomy, and nephrectomy; hematologic disorders such as aplastic anemia, abruptio placentae, cirrhosis, neoplastic diseases, and prophylaxis in patients with hemophilia before and after tooth extraction and other bleeding in the mouth and nasopharynx; reduction of blood loss in trauma and shock; possible prevention of ocular hemorrhaging and bleeding in subarachnoid hemorrhage

Dose: Acute bleeding: 5 g infused during the first hour followed by a continuous infusion of 1 g/hr for 8 hours or until bleeding is controlled

Chronic bleeding: 5 g preoperatively by intravenous piggyback over 1 hour; then 5 g by intravenous piggyback every 6 hours. Do not exceed 30 g in 24 hours. Decrease dose by 15% to 25% in patients with renal disease.

Children: 100 mg/kg intravenous piggyback over 1 hour; then 30 mg/kg/hr until bleeding is controlled (maximum dose: 18 g/m²/day).

Dosage forms: 250 mg/mL, 20 mL parenteral vial (5 g)

Administration: Dilute each dose in a proper volume of D₅W normal saline or lactated Ringer’s solution.

Onset and duration: Onset: 1 to 72 hours; half-life 1 to 2 hours in patients with normal renal function. No single concentration fits all. It must be diluted. Consult the package insert, an intravenous reference, or the pharmacy. Duration: 8 to 12 hours.

Adverse effects: Convulsions; myopathy; rarely muscle necrosis, nausea, vomiting; rapid infusion associated with hypotension, bradycardia, arrhythmias

Precautions and contraindications: A definitive diagnosis of hyperfibrinolysis must be made before aminocaproic acid administration. Use caution in patients with cardiac, renal, or hepatic disease. Administration in the presence of renal or ureteral bleeding is not recommended because of ureteral clot formation and the possible risk of obstruction. Owing to the substantial risk of serious or fatal thrombus formation, aminocaproic acid is contraindicated in patients with disseminated intravascular coagulation unless heparin is administered concurrently.

Anesthetic considerations: Do not administer without a definite diagnosis of laboratory findings indicative of hyperfibrinolysis.

Classification: Bronchodilator

Indications: Long-term therapy for bronchial asthma; reversal of bronchospasm associated with chronic obstructive pulmonary disease

Dose: Loading dose: for patients not already receiving a theophylline preparation, intravenous: 5 to 6 mg/kg (administered over 20-30 minutes). Oral or rectal: 6 mg/kg. Maintenance: intravenous: 0.5 mg/kg/hr; oral: 2 to 4 mg/kg every 6 to 12 hours. Therapeutic range: 10 to 20 mcg/mL.

Dilution for infusion loading dose: dilute 500 mg in 500 mL D₅W or normal saline (1 mg/mL)

Children 9 to 16 years: 1 mg/kg/hr for 12 hours; then 0.8 mg/kg/hr; children 6 months to 9 years: 1.2 mg/kg/hr for 12 hours; then 1 mg/kg/hr

Dosage forms: injection: 25 mg/mL; tablets: 100, 200 mg; tablets (sustained release): 225 mg; oral solution: 105 mg/5 mL; rectal solution: 60 mg/mL (rectal solution not marketed in the United States); rectal suppositories: 250, 500 mg

Onset and duration: Onset: intravenous: 2 to 5 minutes; oral: within 30 minutes. Duration: oral: 4 to 8 hours

Adverse effects: Palpitations, sinus tachycardia, supraventricular and ventricular tachycardia, flushing, tachypnea, seizures, headache, irritability, nausea, vomiting, hyperglycemia

Elevated serum levels are noted in patients receiving cimetidine, quinolone antibiotics, and macrolide antibiotics and in patients with cardiac failure or liver insufficiency. Decreased serum levels are seen with phenobarbital, phenytoin, rifampin, and smokers. Toxicity occurs with plasma levels greater than 20 mcg/mL. Avoid rapid infusions, which may cause hypotension, arrhythmias, and possibly death.

Precautions and considerations: Caution when used in patients with seizure disorders, hypertension, or ischemic heart disease.

Anesthetic considerations: Aminophylline potentiates the pressor effects of sympathomimetics and may produce seizures, cardiac arrhythmias, cardiorespiratory arrest, and ventricular arrhythmias with excessive plasma levels or in patients receiving volatile anesthetics. Use isoflurane or sevoflurane in patients who must be administered aminophylline or other exogenous sympathomimetic drugs before or during surgery. Use of halothane may potentiate cardiac dysrhythmia.

Classification: Class III antiarrhythmic

Indications: Treatment of life-threatening ventricular arrhythmias that do not respond to other antiarrhythmics (i.e., recurrent ventricular fibrillation and hemodynamically unstable ventricular tachycardia); selective treatment of supraventricular arrhythmias

Dose: Loading: oral: 800 to 1600 mg/day for 1 to 3 weeks; maintenance: oral: 200 to 600 mg/day; therapeutic level: 1 to 2.5 mcg/mL

Dosage forms: tablets: 200 mg; intravenous: 100 to 300 mg

The recommended starting dose of intravenous amiodarone HCl is about 1000 mg over the first 24 hours of therapy delivered by the following infusion:

Onset and duration: Onset: 2 to 4 days. Half-life: between 2 weeks and 2 months (including active metabolites). Duration: 45 days

Adverse effects: Arrhythmias, pulmonary fibrosis or inflammation, hepatitis or cirrhosis, corneal deposits, hyperthyroidism, hypothyroidism, peripheral neuropathy, cutaneous photosensitivity

Precautions and contraindications: Amiodarone increases serum levels of digoxin, warfarin, quinidine, procainamide, phenytoin, and diltiazem. The likelihood of bradycardia, sinus arrest, and atrioventricular block increases with concurrent β-adrenergic antagonist and calcium channel blocker therapy.

Anesthetic considerations: Antiadrenergic effects are enhanced in the presence of general anesthetics and manifest as sinus arrest, atrioventricular block, low cardiac output, or hypotension. Drugs that inhibit the automaticity of the sinus node such as halothane and lidocaine could accentuate the effects of amiodarone and increase the likelihood of sinus arrest. The potential need for a temporary artificial cardiac (ventricular) pacemaker and administration of sympathomimetics such as isoproterenol should be considered in patients receiving this drug.

Classification: Positive inotrope (phosphodiesterase inhibitor)

Indication: Short-term management of congestive heart failure

Dose: Loading dose: 0.75 mg/kg over 2 to 3 minutes. A second bolus may follow after 30 minutes. Maintenance is by continuous infusion of 5 to 10 mcg/kg/min (maximum dose: 10 mg/kg/day).

Dosage forms: injection: 5 mg/mL; dilution for infusion: 500 mg in 500 mL normal saline solution

Onset and duration: Onset: within 5 minutes; duration: 30 minutes to 2 hours

Adverse effects: Hypotension, arrhythmia, thrombocytopenia, abdominal pain, hepatic dysfunction

Precautions and contraindications: Use amrinone with caution in hypotensive patients. Avoid exposure of the ampule to light. Do not mix in solutions containing dextrose or furosemide. Use it with caution in patients with allergies to bisulfites. Fluid balance, electrolyte concentrations, and renal function should be monitored carefully during treatment. Monitor platelet counts on a long-term basis. Amrinone contains sodium metabisulfite, a sulfite that may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible patients. Sulfite sensitivity is seen more frequently in patients with asthma than in patients without asthma.

Anesthetic considerations: This drug is an alternative to conventional inotropes. It is useful when both inotropic and vasodilating properties are desired or to lower pulmonary vascular resistance. Milrinone, another phosphodiesterase-3 inhibitor, is more commonly used.

Classification: Antiemetic; neurokinin 1 (NK1) receptor antagonist

Indication: Postoperative nausea and vomiting

Dose: Oral 40-mg dose administered within 3 hours before the induction of anesthesia

Onset and duration: Onset: 1 to 3 hours. Duration: up to 24 hours when used in multimodal therapy

Adverse effects: The most frequent adverse events reported in clinical trials of aprepitant for postoperative nausea and vomiting were constipation, nausea, pruritus, pyrexia, hypotension, headache, and bradycardia.

Precautions and contraindications: Aprepitant produces a dose-dependent inhibition of CYP3A4 and should be used with caution in patients receiving drugs that are primarily metabolized through CYP3A4. Weak inhibition of CYP3A4 by a single 40-mg dose is not expected to alter the plasma concentrations of these products to a clinically significant degree.

The efficacy of hormonal contraceptives may be reduced during coadministration with aprepitant for up to 28 days after the last dose.

Anesthetic considerations: Aprepitant is most effective when used as a component of multimodal prophylaxis with a serotonin receptor blocker.

Classification: Nondepolarizing skeletal muscle relaxant

Indications: Relaxation of skeletal muscles during surgery; adjunct to general anesthesia or mechanical ventilation; facilitation of endotracheal intubation

Dose: Initially for paralyzing: intravenous: 0.3 to 0.5 mg/kg; maintenance: intravenous: 0.08 to 0.1 mg/kg

Dosage forms: injection: 10 mg/mL

Onset and duration: Onset: less than 3 minutes. Duration: 30 to 45 minutes. Elimination: plasma (Hofmann elimination, ester hydrolysis). The primary metabolite is laudanosine (a cerebral stimulant) produced in low doses, excreted primarily in the urine.

Adverse effects: Primarily resulting from histamine release: vasodilation, hypotension, sinus tachycardia, sinus bradycardia, hypoventilation, apnea, bronchospasm, laryngospasm, dyspnea, inadequate block, prolonged block, rash, and urticaria

Precautions and contraindications: Use atracurium with caution in patients with conditions in which histamine release may prove hazardous, in patients with myasthenia gravis or other muscle disorders, and in patients with electrolyte disturbances.

Anesthetic considerations: Monitor the patient’s response with a peripheral nerve stimulator. Reverse the effects with anticholinesterase. Pretreatment doses may induce sufficient neuromuscular blockade to cause hypoventilation in some patients.

Classification: Competitive acetylcholine antagonist at muscarinic receptor

Indications: Symptomatic bradycardia, asystole, cardiopulmonary resuscitation (CPR); antisialagogue; for vagolytic effects to block bradycardia during surgery from stimulation of the carotid sinus, traction on abdominal viscera, or extraocular muscles; blockade of muscarinic effects of anticholinesterases; adjunctive therapy in the treatment of bronchospasm, peptic ulcer disease

Dose: Adults: sinus bradycardia. CPR: intravenous, intramuscular, subcutaneous, via endotracheal tube (diluted in 10 mL of sterile water or normal saline): 0.5 to 1 mg every 3 to 5 minutes as indicated (maximum dose: 40 mcg/kg/event). Preoperative: 0.4 mg intramuscular, subcutaneous, or oral: 30 to 60 minutes preinduction.

Blockade of muscarinic effects of anticholinesterases: 7 to 10 mcg/kg with edrophonium, 15 to 30 mcg/kg with neostigmine, 15 to 20 mcg/kg with pyridostigmine

Bronchodilation: inhalation: 0.025 mg/kg every 4 to 6 hours. Dilute to 2 to 3 mL in normal saline and deliver by compressed air nebulizer (maximum dose: 2.5 mg/dose). Pediatric bronchodilatory dose: 0.05 mg/kg diluted in normal saline three or four times daily.

Children: sinus bradycardia, CPR: intravenous, intramuscular, subcutaneous, or via endotracheal tube: 0.02 mg/kg every 5 minutes up to a maximum of 1 mg in children and 2 mg in adolescents (minimum dose, 0.1 mg).Preoperative: oral, intramuscular, subcutaneous: 0.02 mg/kg for neonates, 0.1 mg for children weighing 3 kg, 0.2 mg for those weighing 7 to 9 kg, and 0.3 mg for those weighing 12 to 16 kg.

Dosage forms: injection: 0.05, 0.1, 0.3, 0.4, 0.5, 0.8, and 1 mg/mL; inhalation solution: 0.2%, 0.5%; tablets: 0.4 mg, 0.6 mg

Onset and duration: Inhibition of salivation occurs within 30 minutes to 1 hour and peaks in 1 to 2 hours after oral or intramuscular atropine administration. Increase in heart rate occurs within 3 to 10 minutes after intravenous or intramuscular administration. Duration: 15 to 45 minutes after intravenous administration and 2 to 4 hours after intramuscular administration.

Adverse effects: Transient bradycardia resulting from a weak peripheral muscarinic cholinergic agonist effect in small doses (less than 0.5 mg in adults), tachycardia (high doses), urinary hesitancy, retention, mydriasis, blurred vision, increased intraocular pressure, decreased sweating, excitement, agitation, drowsiness, confusion, hallucinations, dry nose and mouth, allergic reactions, constipation.

Children and elderly patients are more susceptible to these adverse effects.

Precautions and contraindications: Avoid atropine in situations in which tachycardia would be harmful (i.e., thyrotoxicosis, pheochromocytoma, coronary artery disease). Avoid in hyperpyrexial states because it inhibits sweating. It is contraindicated in acute-angle glaucoma, obstructive disease of the gastrointestinal tract, obstructive uropathy, paralytic ileus or intestinal atony, and acute hemorrhage in patients with unstable cardiovascular status. Use it with caution in patients with tachyarrhythmias, hepatic or renal disease, congestive heart failure, chronic pulmonary disease (because a reduction in bronchial secretions may lead to formation of bronchial plugs), autonomic neuropathy, hiatal hernia, gastroesophageal reflux, gastric ulcers, gastrointestinal infections, and ulcerative colitis.

Anesthetic considerations: Additive anticholinergic effects may occur when atropine is administered concomitantly with meperidine, some antihistamines, phenothiazines, tricyclic antidepressants, and antiarrhythmic drugs that possess anticholinergic activity (e.g., quinidine, disopyramide, procainamide).

Classification: Loop diuretic

Indications: Treatment of edema of cardiac, hepatic, or renal origin; hypertension, pulmonary edema; usually reserved for patients who do not respond to thiazide diuretics or in whom a rapid onset of diuresis is desired.

Dose: Initial dose: 0.5 to 1 mg intravenously over 1 to 2 minutes. If response is not adequate after the initial dose, a second or third dose may be administered at intervals of up to 2 to 3 hours, up to a maximum of 10 mg/day.

Children: intravenous, intramuscular, oral: 0.015 to 0.1 mg/kg. maximum, 2 mg/day

Onset and duration: Onset: intravenous: few minutes. Peak effect: 15 to 30 minutes. Duration: 4 hours with normal doses of 1 to 2 mg and up to 6 hours with higher doses. Elimination half-life: 1 to 1.5 hours

Adverse effects: Transient leukopenia, granulocytopenia, thrombocytopenia, hypotension, chest pain, dizziness; electrolyte abnormalities such as hyperuricemia, hypomagnesemia, hypokalemia, hypochloremia, azotemia, hyponatremia, or metabolic alkalosis; hyperglycemia; diarrhea; pancreatitis; nephrotoxicity; muscle cramps; arthritic pain; ototoxicity (less frequent than with furosemide)

Precautions and contraindications: Patients may have anuria, hypersensitivity to bumetanide, severe fluid and electrolyte imbalances, and hepatic coma if an increase in blood urea nitrogen or creatinine occurs. Patients who are allergic to sulfonamides may have hypersensitivity to bumetanide.

Anesthetic considerations: Loop diuretics may increase the neuromuscular blocking effect of nondepolarizing relaxants.

Classification: Amide-type local anesthetic

Indication: Regional anesthesia

Dose: Infiltration or peripheral nerve block: less than 150 mg (0.25%-0.5% solution). Epidural: 50 to 100 mg (0.25%-0.75% solution); children: 1.5 to 2.5 mg/kg (0.25%-0.5% solution). Caudal: 37.5 to 150 mg (15-30 mL of 0.25% or 0.5% solution); children: 0.4 to 0.7 mL/kg. Spinal bolus/infusion: 7 to 17 mg (0.75% solution); children: 0.5 mg/kg with minimum of 1 mg. Do not exceed 400 mg in 24 hours (maximum single dose, 175 mg).

Onset and duration: Onset: infiltration: 2 to 10 minutes. Epidural: 4 to 7 minutes. Spinal: less than 1 minute. Peak effect: infiltration and epidural: 30 to 45 minutes. Spinal: 15 minutes. Duration: infiltration, spinal, epidural: 200 to 400 minutes (prolonged with epinephrine).

Adverse effects: Hypotension, arrhythmias, cardiac arrest, respiratory impairment or arrest, seizures, tinnitus, blurred vision, urticaria, anaphylactoid symptoms; high spinal: urinary retention, lower extremity weakness and paralysis, loss of sphincter control, backache, palsies, slowing of labor

Precautions and contraindications: Use bupivacaine with caution in patients with hypovolemia, severe congestive heart failure, shock, and all forms of heart block. It is not recommended for obstetric paracervical block or in concentrations higher than 0.5% because of the incidence of intractable cardiac arrest. It is contraindicated in patients with hypersensitivity to amide-type local anesthetics.

Anesthetic considerations: Intravenous access is essential during major regional block. Toxic plasma levels of bupivacaine may cause cardiopulmonary collapse and seizures.

Classification: Ester-type local anesthetic

Indications: Regional anesthesia; local anesthesia, including infiltration, epidural (including caudal), peripheral nerve block, sympathetic nerve block

Dose: Infiltration and peripheral nerve block: less than 40 mL (1%-2% solution). Epidural: bolus 10 to 25 mL (2%-3% solution), approximately 1.5 to 2 mL for each segment to be anesthetized. Repeat doses at 40- to 60-minute intervals. Infusion: 30 mL/hr (0.5% solution). Caudal: 10 to 25 mL (2%-3% solution); children: 0.4 to 0.7 mL/kg (L2-T10 level of anesthesia). Repeat doses at 40- to 60-minute intervals.

Onset and duration: Rate of onset and potency of local anesthetic action may be enhanced by carbonation. Onset: infiltration or epidural: 6 to 12 minutes. Peak effect: infiltration or epidural: 10 to 20 minutes. Duration: infiltration or epidural: 30 to 60 minutes (prolonged with epinephrine).

Adverse effects: Hypotension, arrhythmias, bradycardia, respiratory depression or arrest, seizures, tinnitus, tremors, urticaria, pruritus, angioneurotic edema; high spinal: backache; loss of perianal sensation and sexual function; permanent motor, sensory, autonomic (sphincter control) deficit in lower segments; slowing of labor

Precautions and contraindications: Use with caution in patients with severe disturbances of cardiac rhythm, shock, heart block, or impaired hepatic function. Inflammation or infection may occur at the injection site. Elderly and pregnant patients are most at risk. It is contraindicated in patients with hypersensitivity to ester-type local anesthetics and to para-aminobenzoic acid or parabens. Do not use for spinal anesthesia.

Anesthetic considerations: Reduce doses in obstetric, elderly, hypovolemic, and high-risk surgical patients and in those with increased intraabdominal pressure.

Classification: Histamine (H₂) antagonist

Indications: Treatment of duodenal or gastric ulcers, gastroesophageal reflux disease; prophylaxis of aspiration pneumonitis in patients at high risk during surgery

Dose: Prophylaxis of aspiration pneumonitis: adults: 300 to 400 mg orally 1.5 to 2 hours before induction of anesthesia with or without a similar dose the preceding evening. When a more rapid onset of effect is needed, intravenous: dilute 300 to 400 mg in D₅W or normal saline to a volume of at least 20 mL and inject over a period not less than 5 minutes. A slower infusion, over 15 to 30 minutes, may be preferable owing to association of occasional severe bradycardia and hypotension with rapid infusion. Children younger than 12 years: use not indicated.

Dosage forms: tablets: 300, 400 mg; parenteral injection: 150 mg/mL

Onset and duration: Onset: 15 to 45 minutes. Peak effect: 1 to 2 hours orally. Duration: 2 to 4 hours. Elimination half-life: 2 hours. Plasma cimetidine levels that suppress gastric acid secretion by 50% were maintained 4 to 5 hours after intravenous injection.

Adverse effects: Mental status changes such as delirium, confusion, depression, primarily in elderly patients or those with hepatic or renal impairment; leukopenia, thrombocytopenia, and gynecomastia rarely (1%)

Hypotension and severe bradycardia are associated with rapid intravenous infusion. Serum creatinine and liver enzymes may rise during treatment, although hepatotoxicity and renal dysfunction are usually reversible.

Precautions and contraindications: Caution is suggested in renal or hepatic insufficiency. Microsomal metabolism of many drugs may be inhibited. It is contraindicated in patients allergic to cimetidine or other H₂ antagonists.

Anesthetic considerations: Cimetidine inhibits the hepatic mixed-function oxidase system; therefore, it may prolong the half-life of many drugs, including diazepam, midazolam, metoprolol, propranolol, theophylline, lidocaine, and other amide local anesthetics. Ranitidine may be the drug of choice in patients receiving lidocaine local or regional anesthesia.

Classification: Intravenous calcium channel blocker; antihypertensive

Indication: Antihypertensive, when oral drugs are not feasible

Dose: Clevidipine is a milky white lipid emulsion. Titrate to achieve desired blood pressure reduction. Initial dose is 1 to 2 mg/hr. Double the dose every few minutes until blood pressure goals are met. Maintenance doses usually range from 4 to 6 mg/hr. Maximum doses are usually less than 16 mg/hr.

Onset and duration: Onset: 2 to 4 minutes. Duration: 5 to 15 minutes after the infusion is stopped

Adverse effects: Hypotension, tachycardia, negative inotropic effects in heart failure patients

Precautions and contraindications: Contraindicated in patients with allergies to soybeans, soy products, eggs or egg products, defects in lipid metabolism such as pathologic hyperlipemia, lipoid nephrosis, or acute pancreatitis, and patients with severe aortic stenosis

Caution handling the lipid emulsion. Use aseptic technique and discard if not used in 12 hours. Caution in patients on beta-blocker therapy.

Anesthetic considerations: Useful for titration to control blood pressure. Insertion of an arterial line advised to closely monitor pressures. Monitor for rebound hypertension for 8 hours after the infusion is discontinued.

Classification: Central-acting α₂-adrenergic agonist; reduces sympathetic outflow by directly stimulating α₂-receptors in the medulla vasomotor center

Epidural action produces dose-dependent analgesia by preventing pain signal transmission at presynaptic and postjunctional α₂-adrenoreceptors in the spinal cord.

Indications: Hypertension; epidural and spinal anesthesia; symptomatic control of alcohol, opiate, nicotine, and benzodiazepine withdrawal; diagnosis of pheochromocytoma; growth hormone stimulation test; cancer-related pain; Tourette syndrome; attention deficit disorder; migraines.

The use of epidural clonidine in combination with epidural opiate agonists results in a decreased opiate requirement that treats neuropathic pain more effectively than visceral pain.

Dose: Maintenance: 0.2 to 0.6 mg/day orally in two divided doses. Hypertensive emergencies: 0.15 mg intravenously over 5 minutes. Transdermal patch: every 7 days (maximum dose: 0.6 mg/day). The same doses are used in renal impairment.

Epidural: must be preservative free. Postoperative pain: epidural clonidine combined with an opiate analgesic: 30 mcg/hr if added to fentanyl. Neuropathic pain: continuous epidural infusion combined with an opiate analgesic is 30 mcg/hr.

All dosages must be titrated to pain relief and the incidence of side effects.

The recommended starting dose of epidural clonidine HCl for continuous epidural infusion is 30 mcg/hr. Although dosage may be titrated up or down, depending on pain relief and occurrence of adverse events, experience with dosage rates above 40 mcg/hr is limited.

Familiarization with the continuous epidural infusion device is essential. Patients receiving epidural clonidine from a continuous infusion device should be closely monitored for the first few days to assess their response.

The 500 mcg/mL (0.5 mg/mL) strength product must be diluted before use in 0.9% sodium chloride for injection to a final concentration of 100 mcg/mL.

Onset and duration: Onset: intravenous or oral: 30 to 60 minutes. Peak effect: 2 to 4 hours. May take too long for a true hypertensive crisis. Duration: antihypertensive: 6 to 10 hours, dose dependent.

Adverse effects: Rebound hypertension, atrioventricular block, bradycardia, congestive heart failure, orthostatic hypotension, sedation, nightmares, constipation, dry mouth, pruritus, urinary retention, contact dermatitis

The most common noncardiovascular adverse reactions to epidural clonidine include anxiety, asthenia, chest pain, confusion, diaphoresis, dizziness, drowsiness, dyspnea, fever, nausea or vomiting, and xerostomia.

Precautions and contraindications:

Anesthetic considerations:

Classification: Topical anesthetic and vasoconstrictor, ester-type local anesthetic

Indications: Topical anesthesia and vasoconstriction of mucous membranes (oral, laryngeal, and nasal)

Dose: Topical: 1.5 mg/kg (1%-4% solution). Nasal: 1 to 2 mL each nostril (1%-10% solution). Concentrations greater than 4% increase potential for systemic toxic reactions. Maximum dose: 1.5 mg/kg.

Onset and duration: Onset: less than 1 minute. Peak effect: 2 to 5 minutes. Duration: 30 to 120 minutes. It is rapidly absorbed from all areas of application.

Adverse effects: Seizures, sloughing of nasal mucosa, arrhythmias, tachycardia, hypertension

Precautions and contraindications: Cocaine is for topical use only, not for intraocular or intravenous use. It potentiates other sympathomimetics; therefore, use reduced doses (if any at all) in patients receiving pressors or ketamine. Use it with caution in patients with nasal trauma.

Anesthetic considerations: Hypertension, bradyarrhythmias, tachyarrhythmias, ventricular fibrillation, tachypnea, respiratory failure, euphoria, excitement, seizures, and sloughing of corneal epithelium may occur. Use it with caution in patients with a history of drug sensitivities or drug abuse (high addiction potential) and pregnancy. Prolonged use can cause ischemic damage to nasal mucosa. Cocaine is contraindicated for intraocular or intravenous use. It sensitizes the heart to catecholamines (epinephrine and monoamine oxidase inhibitors may increase cardiac arrhythmias, ventricular fibrillation, hypertensive episodes). It potentiates arrhythmogenic effects of sympathomimetics, and it has a high addiction potential.

Classification: Opioid agonist

Indications: Preoperative and postoperative analgesia

Dose: Oral: 15 to 60 mg every 4 hours; intramuscular or subcutaneous: 15 to 60 mg every 4 hours.

Onset and duration: Onset: oral: 30 to 60 minutes; intramuscular or subcutaneous: 20 to 60 minutes. Duration: oral: 2 to 4 hours; intramuscular or subcutaneous: 2 to 3 hours.

Adverse effects: Sedation, clouded sensorium, euphoria, dizziness, seizures with large doses, hypotension, bradycardia, nausea, vomiting, constipation, dry mouth, ileus, urinary retention, pruritus, flushing

Precautions and contraindications: Use codeine with caution in patients with head injury, owing to respiratory depression and resulting increased intracranial pressure; in hepatic or renal disease; hypothyroidism; Addison disease; acute alcoholism; seizures; severe central nervous system depression; bronchial asthma; chronic obstructive pulmonary disease; respiratory depression; and shock. Use it with caution in patients with known hypersensitivity to the drug and in elderly patients. It may produce histamine release.

Anesthetic considerations: General anesthetics, other narcotic analgesics, tranquilizers, sedatives, hypnotics, alcohol, tricyclic antidepressants, or monoamine oxidase inhibitors increase central nervous system depression.

Classification: Immunosuppressant

Indications: Prevention of rejection of organ or tissue (kidney, liver, heart) allograft in combination with steroid therapy

Dose: Initial: oral: 15 mg/kg as a single dose 4 to 24 hours before transplantation; continue for 1 to 2 weeks. Taper to maintenance dose: 5 to 10 mg/kg/day. Intravenous: 5 to 6 mg/kg/day as a single dose 4 to 12 hours before transplantation; continue until the patient is able to take oral medication.

Coadministration of a corticosteroid is recommended, as well as possibly azathioprine.

Onset and duration: Onset: 1 to 6 hours (variable). Duration: 1 to 4 days. After oral administration, onset is variable. Elimination half-life: 10 to 27 hours.

Adverse effects: Hypertension, hirsutism, tremor, acne, gum hyperplasia, headache, blurred vision, diarrhea, nausea, paresthesia, mild nephrotoxicity or hepatotoxicity

Precautions and contraindications: History of hypersensitivity to cyclosporine or polyoxyethylated castor oil. Use it with caution in patients with impaired hepatic, renal, cardiac function, or malabsorption syndrome and in those who are pregnant.

Anesthetic considerations: Altered laboratory values may occur. Cyclosporine may elevate blood urea nitrogen, serum creatinine, serum bilirubin, serum glutamic-oxaloacetic transaminase (aspartate aminotransferase), serum glutamic-pyruvic transaminase (alanine aminotransferase), and lactate dehydrogenase. It may prolong the duration of neuromuscular blockade by nondepolarizing muscle relaxants.

Classification: Skeletal muscle relaxant

Indications: Treatment of malignant hyperthermia (MHT); prophylaxis of MHT in patients with a family history; control of spasticity secondary to multiple sclerosis, spinal cord injury, cerebral palsy, or stroke

Dose: Adults: MHT: 1 mg/kg rapid intravenous bolus; repeat every 5 to 10 minutes until symptoms are controlled; the dose may be repeated to a cumulative dose of 10 mg/kg; oral doses of 4 to 8 mg/kg/day for 1 to 3 days may be administered in three or four divided doses to prevent recurrence of the manifestations. Prophylaxis of MHT: 2.5 mg/kg intravenous bolus 10 to 30 minutes preinduction; then 1.25 mg/kg intravenous bolus 6 hours later.

Dosage forms: capsules: 25, 50, 100 mg; parenteral injection: 20 mg. Administration: reconstitute by adding 60 mL of preservative-free sterile water for injection to each 20-mg vial and shake the vial until clear. Avoid diluent that contains a bacteriostatic agent. Protect from light and use within 6 hours. For direct intravenous injection. Avoid extravasation.

Onset and duration: Effective blood concentrations: 100 to 600 ng/mL. Intravenous blood concentrations of the drug remain at approximately steady-state levels for 3 or more hours after infusion is completed. Mean half-life: 5 to 9 hours. Onset: oral: 1 to 2 hours; intravenous: less than 5 minutes. Duration: 8 to 12 hours.

Adverse effects: Hepatotoxicity (hepatitis): 0.5%, with mortality reported as high as 10%; muscle weakness, tachycardia, erratic blood pressure, fatigue, central nervous system (CNS) depression, visual and auditory hallucinations, bowel obstruction, hematuria, crystalluria, urinary frequency, phlebitis, pericarditis, pleural effusion, postpartum uterine atony, myalgias

Precautions and contraindications: Monitor liver function at the beginning of dantrolene therapy. Observe for hepatotoxicity, hepatitis. Owing to the increased risk of hepatotoxicity, use it with caution in patients with severely impaired cardiac or pulmonary function and in women or patients older than 35 years. It is contraindicated in active hepatic disease such as hepatitis or cirrhosis, when spasticity is used to maintain motor function, and in lactation.

Anesthetic considerations: Enhanced CNS and respiratory depression occurs with other CNS depressants. Avoid the concomitant use of calcium channel blockers, which can precipitate hyperkalemia and cardiovascular collapse.

Classification: Inhalation anesthetic

Indication: General anesthesia

Dose: Titrate to effect for induction or maintenance of anesthesia. Minimum alveolar concentration: 6%.

Dosage forms: volatile liquid

Onset and duration: Onset: loss of eyelid reflex: 1 to 2 minutes. Duration: emergence time: 8 to 9 minutes.

Adverse effects: Hypotension, arrhythmia, respiratory depression, apnea, dizziness, euphoria, increased cerebral blood flow and intracranial pressure, nausea, vomiting, ileus, hepatic dysfunction, MHT

Precautions and contraindications: Desflurane is contraindicated in patients with known or suspected genetic susceptibility to MHT. Changes in mental function may persist beyond the period of anesthetic administration and the immediate postoperative period.

Anesthetic considerations: Abrupt onset of MHT may be triggered by desflurane; early signs include muscle rigidity, especially in the jaw muscles, and tachycardia and tachypnea unresponsive to increased depth of anesthesia. It crosses the placental barrier.

Classification: Synthetic vasopressin analog

Indications: Treatment of neurogenic diabetes insipidus; nocturnal enuresis; and, in hemophilia A or von Willebrand disease, to increase factor VIII activity; reduction of perioperative blood loss after cardiac surgery

Dose: Preoperative: 30 minutes before the procedure. Diabetes insipidus: 2 to 4 mcg intravenously or subcutaneously daily in two divided doses; intranasal: 10 to 40 mcg (0.1-0.4 mL) in one to three doses.

Pediatrics: 3 months to 12 years: hemophilia A or von Willebrand disease: 0.3 mcg/kg intravenously, diluted in saline and infused over 15 to 30 minutes. In children who weigh more than 10 kg, use 50 mL of diluent, and in children who weigh less than 10 kg, use 10 mL of diluent. Repeated doses in less than 48 hours may increase the possibility of tachyphylaxis.

Intranasal: 0.05 to 0.3 mL daily in single or divided doses. Doses should start at 0.05 mL or less and be individualized because an extreme decrease in plasma osmolarity in very young patients may produce convulsions.

Dosage forms: injection: 4 mcg/mL; desmopressin acetate for injection should be stored at 4° C; nasal: 10 to 40 mcg; may be divided into three doses; supplied as 10 mcg/0.1 mL or 100 mcg/mL

Onset and duration: Onset: intranasal: 1 hour; intravenous: 30 minutes. Duration: 8 to 20 hours. Elimination half-life: 3.6 hours.

Adverse effects: Hypotension, hypertension, transient headache (with higher doses), psychosis, seizures, water retention, hyponatremia, abdominal cramps, nasal congestion, rhinitis, facial flushing, hypersensitivity reactions

Precautions and contraindications: This agent is contraindicated in hypersensitivity to desmopressin acetate and in children younger than 3 months. Patients with type IIB von Willebrand disease should not receive desmopressin because platelet aggregation may be reduced. Owing to an increased risk of thrombosis, use it with caution in patients with coronary artery disease. Fluid intake should be decreased in those who do not need the antidiuretic effects of desmopressin. Seizure activity may be related to rapid decreases in serum sodium concentrations secondary to desmopressin. Avoid overhydration; postoperative abdominal cramping may occur.

Anesthetic considerations: None

Classification: Long-acting corticosteroid

Indications: Croup, septic shock, cerebral edema, respiratory distress syndrome including status asthmaticus, acute exacerbations of chronic allergic disorders, corticosteroid-responsive bronchospastic states, allergic or inflammatory nasal conditions, and nasal polyps

Dose: Initial: 0.5 to 9 mg, intramuscularly or intravenously daily, depending on the disease being treated. In less severe diseases, doses lower than 0.5 mg intramuscularly or intravenously may suffice, but in others, doses higher than 9 mg may be required.

Cerebral edema: 10 mg intravenously initially followed by 4 mg intramuscularly every 6 hours. Reduce dose after 2 to 4 days, then taper over 5 to 7 days.

Corticosteroid-responsive bronchospastic states: Respihaler: three inhalations three to four times daily (maximum dose: 12 inhalations/day).

Nasal conditions: Turbinaire: two sprays each nostril two to three times daily (maximum dose: 12 sprays/day)

Children: intramuscular or by intravenous push: 6 to 40 mcg/kg or 0.235 to 1.25 mg/m² administered one or two times daily. Must be administered slowly over 3 to 5 minutes by intravenous push.

Dosage forms: Respihaler inhalation: 0.1 mg/spray dexamethasone phosphate; Turbinaire intranasal: 0.1 mg/spray; solution for injection: 4, 10, 24 mg/mL; tablets: 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6 mg

Onset and duration: Onset: intravenous or intramuscular: within 10 to 30 minutes; inhalation: within 20 minutes. Elimination half-life: 200 minutes; however, metabolic effects at the tissue level persist for up to 72 hours.

Adverse effects: Cushing syndrome, adrenal suppression, hyperglycemia, hyperthyroidism, hypercalcemia, peptic ulcer, gastrointestinal hemorrhage, increased intraocular pressure, glaucoma, irritability, psychosis, osteoporosis

Precautions and contraindications: Dexamethasone is contraindicated in patients with peptic ulcer, osteoporosis, psychosis or psychoneurosis, acute bacterial infections, herpes zoster, herpes simplex ulceration of the eye, and other viral infections. Use it with caution in patients with diabetes mellitus, chronic renal failure, or infectious disease and in elderly patients. Corticosteroids may increase the risk of developing tuberculosis in patients with a positive purified protein derivative test. They may increase the risk of development of serious or fatal infection in persons exposed to viral illnesses such as chickenpox.

Anesthetic considerations: Short-term administration of intravenous or inhalation steroids may be helpful in shock and asthma. Dexamethasone may have some benefit in anaphylaxis. Toxicity after acute dosing is minimal.

Classification: Adrenergic agonist; sedative hypnotic

Indications: A selective α₂-receptor agonist with sedative properties for short-term sedation in critical care settings. Patients are commonly intubated and mechanically ventilated. Administered by continuous infusion not exceeding 24 hours. Off-label use as an anesthesia adjunct.

Dose: Dexmedetomidine HCl should be administered using a controlled infusion device.

Dexmedetomidine HCl dosing should be individualized and titrated to the desired clinical effect. For adult patients, dexmedetomidine HCl is generally initiated with a loading infusion of 1 mcg/kg over 10 minutes followed by a maintenance infusion of 0.2 to 0.7 mcg/kg/hr. The rate of the maintenance infusion should be adjusted to achieve the desired level of sedation. Dexmedetomidine is not indicated for infusions lasting longer than 24 hours.

Dexmedetomidine HCl has been continuously infused in mechanically ventilated patients before extubation, during extubation, and after extubation. It is not necessary to discontinue dexmedetomidine HCl before extubation provided the infusion does not exceed 24 hours.

Onset and duration: Onset: 10 to 30 minutes, depending on the dose. Duration: 15 minutes to 4 hours, depending on the dose and duration of infusion

Adverse effects: Hypotension, bradycardia, hypertension, nausea, vomiting, and fever are most frequently reported.

Precautions and contraindications: Because of the known pharmacologic effects of dexmedetomidine, patients should be continuously monitored while receiving dexmedetomidine. Clinically significant episodes of bradycardia and sinus arrest have been associated with dexmedetomidine administration in young, healthy volunteers with high vagal tone or with different routes of administration, including rapid intravenous or bolus administration.

Anesthetic considerations: Adjunct to general and regional anesthesia, bridge to intensive care unit sedation and analgesia, supplement to regional block when avoiding respiratory depression is desirable, awake craniotomy

Classification: Central nervous system agent; benzodiazepine; anticonvulsant and anxiolytic

Indications: Anxiety, alcohol withdrawal, status epilepticus, preoperative sedation, sedation for cardioversion; used adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff man syndrome, tetanus

Dose: Status epilepticus: adults: intramuscular or intravenous: 5 to 10 mg; repeat if needed at 10- to 15-minute intervals up to 30 mg; repeat if needed in 2 to 4 hours. Children: intramuscular or intravenous: younger than 5 years: 0.2 to 0.5 mg slowly 2 to 5 minutes, up to 5 mg total dose. Children older than 5 years: 1 mg slowly 2 to 5 minutes up to 10 mg; repeat if needed in 2 to 4 hours.

Anxiety, muscle spasm, convulsions, alcohol withdrawal. Adults: oral: 2 to 10 mg two to four times daily; intramuscular or intravenous: 2 to 10 mg; repeat if needed in 3 to 4 hours. Children: oral: older than 6 months: 1 to 2.5 mg two to three times daily.

Dosage forms: tablets: 2, 5, 10 mg; capsules (sustained release): 15 mg; oral solution: 5 mg/5 mL and 5 mg/mL; injection: 5 mg/mL

Onset and duration: Onset: oral: 30 to 60 minutes; intramuscular: 15 to 30 minutes; intravenous: 1 to 5 minutes. Peak effect: 1 to 2 hours orally. Duration: intravenous: 15 minutes to 1 hour; oral: up to 3 hours. Elimination half-life: 20 to 50 hours; excreted primarily in urine. It is metabolized in liver to active metabolites.

Adverse effects: Drowsiness, fatigue, ataxia, confusion, paradoxical dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor, muscle weakness, electroencephalogram changes, tardive dyskinesia, hypotension, tachycardia, edema, cardiovascular collapse, blurred vision, diplopia, nystagmus, xerostomia, nausea, constipation, incontinence, urinary retention, changes in libido

Precautions and contraindications: Diazepam is contraindicated in acute narrow-angle glaucoma, untreated open-angle glaucoma, and during or within 14 days of monoamine oxidase inhibitor therapy. Safe use during pregnancy (category D) and lactation has not been established.

Anesthetic considerations: Diazepam reduces requirements for volatile anesthetics. A potential for thrombophlebitis exists with intravenous administration. Elderly patients have decreased clearance and dosage requirements. Its effects are antagonized by flumazenil. It may cause neonatal hypothermia.

Classification: Inotropic agent

Indications: Treatment of supraventricular arrhythmias, heart failure, atrial fibrillation, flutter

Dose: Adults: loading: intravenous or oral: 0.5 to 1 mg in divided doses (administer 50% of loading dose as first dose; then 25% fractions at 4- to 8-hour intervals until adequate therapeutic response is noted, toxic effects occur, or the total digitalizing dose has been administered). Monitor clinical response before each additional dose. Maintenance: intravenous or oral: 0.0625 to 0.25 mg; dosages should be individualized. Elderly patients (older than 65 years): oral: 0.125 mg or less daily as maintenance dose. Small patients may require less.

Children older than 2 years: loading: oral: 0.02 to 0.06 mg/kg divided every 8 hours for 24 hours; intravenous: 0.015 to 0.035 mg/kg divided every 8 hours for 24 hours; maintenance: oral: 25% to 35% of digitalizing dose daily, divided into two doses

Children 1 month to 2 years: loading: oral: 0.035 to 0.060 mg/kg in three divided doses over 24 hours; intravenous: 0.02 to 0.05 mg/kg; maintenance: oral: 25% to 35% of digitalizing dose daily divided every 12 hours

Neonates younger than 1 month: loading: oral: 0.025 to 0.035 mg/kg divided every 8 hours over 24 hours; intravenous: 0.015 to 0.025 mg/kg; maintenance: oral: 25% to 35% of digitalizing dose daily divided every 12 hours

Premature infants: loading: intravenous: 0.015 to 0.025 mg/kg in three divided doses over 24 hours. Maintenance: intravenous: 0.01 mg/kg daily divided every 12 hours.

Dosage forms: tablets: 0.125, 0.25, 0.5 mg; capsules (Lanoxicaps): 0.05, 0.1, 0.2 mg; oral solution: 0.05 mg/mL; injection: 0.1 mg/mL, 1-mL ampule (100 mcg); 0.25 mg/mL, 2-mL ampule (500 mcg)

Onset and duration: Onset: intravenous: 5 to 30 minutes; oral: 30 minutes to 2 hours. Duration: intravenous or oral: 3 to 4 days.

Adverse effects: Enhanced toxicity in hypokalemia, hypomagnesemia, hypercalcemia; wide range of arrhythmias, atrioventricular block, headache, psychosis, confusion, nausea, vomiting, ocular changes, diarrhea, gynecomastia

Overdosage may cause complete heart block, atrioventricular dissociation, tachycardia, and fibrillation.

Precautions and contraindications: Digoxin is contraindicated in ventricular fibrillation.

Anesthetic considerations: Decrease the dosage in patients with impaired renal function and in elderly patients. Monitor serum potassium, calcium, and digoxin levels. The use of synchronized cardioversion in patients with digitalis toxicity should be avoided because it may initiate ventricular fibrillation.

Digoxin interacts with numerous drugs. Increased serum levels are seen with calcium channel blockers (e.g., verapamil, diltiazem, nifedipine), esmolol, flecainide, captopril, quinidine, amiodarone, benzodiazepines, anticholinergics, oral aminoglycosides, and erythromycin. Succinylcholine may cause arrhythmias in digitalized patients. Additive bradycardia may occur with cardiac depressant anesthetics.

Classification: Calcium channel blocker

Indications: Angina pectoris; supraventricular tachycardia

Dose: Bolus intravenous: 0.25 mg/kg over 2 minutes. If needed, follow after 15 minutes with 0.35 mg/kg over 2 minutes. Maintenance infusion: 5 to 15 mg/hr. Adults: oral: 30 mg three or four times daily before meals and at bedtime. Dosage may be gradually increased to a maximum of 360 mg/day in divided doses. Sustained-release capsules: 90 mg; oral: twice daily, titrate dosage to effect (maximum dose: 360 mg/day).

Dosage forms: oral: 30, 60, 90, 120 mg; sustained release: 60, 90, 120, 180, 240, 300 mg; intravenous: 5 mg/mL, 5- and 10-mL vials

Onset and duration: Onset: oral: 30 minutes; intravenous: 1 to 3 minutes. Elimination half-life: 3 to 5 hours. Duration: 4 to 6 hours.

Adverse effects: Hypotension, flushing, atrioventricular block, constipation, pruritus, bradycardia, edema, nausea, vomiting, diarrhea, depression, headache, fatigue, dizziness

Precautions and contraindications: Hypotension occurs with coadministration with digoxin, β-blockers, and cimetidine. Diltiazem potentiates the cardiovascular depressant effects of volatile, injectable anesthetic agents.

Anesthetic considerations: Intravenous infusions of diltiazem are useful for intraoperative treatment of atrial tachyarrhythmias.

Classification: Histamine (H₁) antagonist, ethanolamine class

Indications: Adjuvant with epinephrine in the treatment of anaphylactic shock and severe allergic reactions; treatment of drug-induced extrapyramidal effects, motion sickness; antiemetic

Dose: Antihistamine or antiemetic: 10 to 50 mg intramuscularly or intravenously every 2 to 3 hours (maximum dose: 400 mg/day).

Recommend increasing the dosing interval to every 6 to 12 hours in patients with moderate renal failure (glomerular filtration rate, 10-50 mL/min).

Children: 1 to 2 mg/kg up to 150 mg/m²/day in up to four divided doses by slow intravenous push (3 to 5 minutes)

Dosage forms: injection: 10 mg/mL, 50 mg/1 mL Steri-dose syringe or ampule; capsules: 25, 50 mg; elixir and syrup: 12.5 mg/15 mL

Onset and duration: Onset: oral: 1 hour. Duration: 4 to 6 hours. Elimination half-life: 4 to 8 hours

Adverse effects: Sedation (most frequent); dizziness, tinnitus, tremors, euphoria, blurred vision, nervousness, palpitations, hypotension, psychotic reactions, hypersensitivity

Other side effects are probably related to the antimuscarinic actions of diphenhydramine and include dry mouth, cough, and urinary retention.

Precautions and contraindications: Diphenhydramine is contraindicated in patients with a hypersensitivity to it and other antihistamines of a similar chemical structure. Antihistamines are contraindicated in patients taking monoamine oxidase inhibitor therapy. Avoid in patients with narrow-angle glaucoma.

Anesthetic considerations: Concurrent central nervous system depressants may produce an additive effect with diphenhydramine.

Classification: β₁-Adrenergic agonist

Indications: Vasopressor; positive inotrope

Dose: Infusion: 0.5 to 30 mcg/kg/min. Note: Must be diluted, and an intravenous pump (syringe pump in pediatric patients) must be used.

Onset and duration: Onset: 1 to 2 minutes. Duration: less than 10 minutes

Adverse effects: Hypertension, tachycardia, arrhythmias, angina, shortness of breath, headache, phlebitis at injection site

Precautions and contraindications: Arrhythmias and hypertension occur at high dobutamine doses. Use it with caution in patients with idiopathic hypertrophic subaortic stenosis. Do not mix dobutamine with sodium bicarbonate, furosemide, or other alkaline solutions; correct hypovolemia before or during treatment.

Anesthetic considerations: Dobutamine is useful for short-term intraoperative therapy for shock and congestive heart failure. Arterial line monitoring is highly recommended.

Classification: Antiemetic; select serotonin antagonist

Indications: Postoperative nausea and vomiting

Dose: 12.5 mg (intravenous) 15 minutes before the cessation of anesthesia or 100 mg (oral) within 2 hours before surgery

Onset and duration: Onset: 20 to 60 minutes. Duration: 4 to 9 hours

Adverse effects: Headache, asthenia, somnolence, diarrhea, and constipation

Dolasetron can cause ECT interval changes (PR, QTc, JT prolongation, and QRS widening). These changes are related in magnitude and frequency to blood levels of the active metabolite. These changes are self-limiting with declining blood levels. Some patients have interval prolongations for 24 hours or longer. Interval prolongation could lead to cardiovascular consequences, including heart block or cardiac arrhythmias.

Precautions and contraindications: Caution when using in patients with ischemic heart disease or arrhythmias.

Anesthetic considerations: Monitor cardiovascular status, especially in patients with a history of coronary artery disease.

Classification: Naturally occurring catecholamine

Indications: Vasopressor; positive inotrope

Dose: Infusion: 1 to 5 mcg/kg low dose; pressor dose range: 5 to 20 mcg/kg, greater than 20 mcg/kg for extreme cases. Note: Must be diluted, and an intravenous pump must be used.

Onset and duration: Onset: 2 to 4 minutes. Duration: less than 10 minutes after termination of infusion

Adverse effects: Nausea, vomiting, tachycardia, angina, arrhythmias, dyspnea, headache, anxiety

Precautions and contraindications: Caution administering through a peripheral line; may see excessive tachycardia at higher doses.

Anesthetic considerations: Avoid dopamine or use it at greatly reduced dose if the patient has received a monamine oxidase inhibitor. Infuse it into a large vein; extravasation may cause sloughing. Treat extravasation by local infiltration of phentolamine (≈1 mg in 10 mL normal saline). Correct hypovolemia as quickly as possible before or during dopamine treatment.

Classification: Anticholinesterase agent

Indications: Reversal of neuromuscular blockade; diagnostic assessment of myasthenia gravis, and supraventricular tachycardia

Dose: Reversal: slow intravenous: 0.5 to 1 mg/kg (maximum dose: 40 mg), with atropine (0.007-0.015 mg/kg), administered before the edrophonium

Assessment of myasthenia or cholinergic crisis: slow intravenous: 1 mg every 1 to 2 minutes until change in symptoms (maximum dose: 10 mg); intramuscular: 10 mg.

Onset and duration: Onset: intravenous: 30 to 60 seconds; intramuscular: 2 to 10 minutes. Duration: intravenous: 20 to 40 minutes; intramuscular: 20 to 60 minutes.

Adverse effects: Bradycardia, tachycardia, atrioventricular block, nodal rhythm, hypotension; increased oral, pharyngeal, bronchial secretions; bronchospasm; respiratory depression; seizures; dysarthria; headaches; lacrimation; miosis; visual changes; nausea; emesis; flatulence; increased peristalsis; rash; urticaria; allergic reactions; anaphylaxis

Precautions and contraindications: Use edrophonium with caution in patients with bradycardia, bronchial asthma, cardiac arrhythmias, peptic ulcer, peritonitis, or mechanical obstruction of the intestines or urinary tract.

Overdosage may induce a cholinergic crisis characterized by nausea, vomiting, bradycardia or tachycardia, excessive salivation and sweating, bronchospasm, weakness, and paralysis. Treatment involves discontinuation of edrophonium and administration of atropine, 10 mcg/kg intravenously every 10 minutes until muscarinic symptoms disappear.

Owing to the brief duration of action of edrophonium, neostigmine or pyridostigmine is generally preferred for reversal of the effects of nondepolarizing muscle relaxants.

Anesthetic considerations: Administer with an anticholinergic to avoid cholinergic side effects (e.g., bronchoconstriction, bradycardia). Edrophonium is not recommended when deep block is present.

Classification: Local anesthetic

Indication: Topical local anesthesia

Dose: Adults: A thick layer of lidocaine–prilocaine cream is applied to intact skin and covered with an occlusive dressing, or alternatively, a lidocaine–prilocaine anesthetic disc is applied to intact skin:

Pediatrics: age up to 3 months or weighing less than 5 kg: 1 g over 10 cm² of skin for up to 1 hour maximum; age 3 months up to 12 months and weighing more than 5 kg: 2 g over 20 cm² of skin for up to 4 hours maximum; age 1 to 6 years and weighing more than 10 kg: 10 g over 100 cm² of skin for up to 4 hours maximum; age 7 to 12 years and weighing more than 20 kg: 20 g over 200 cm² of skin for up to 4 hours maximum

Onset and duration: The onset, depth, and duration of dermal analgesia on intact skin provided by EMLA depend primarily on the duration of application. To provide sufficient analgesia for clinical procedures such as venipuncture, EMLA should be applied under an occlusive dressing for at least 1 hour. To provide dermal analgesia for clinical procedures such as split-thickness skin graft harvesting, EMLA should be applied under occlusive dressing for at least 2 hours. Satisfactory dermal analgesia is achieved 1 hour after application, peaks at 2 to 3 hours, and persists for 1 to 2 hours after removal. Absorption from the genital mucosa is more rapid and onset time is shorter (5-10 minutes) than after application to intact skin. After a 5- to 10-minute application of EMLA to female genital mucosa, the average duration of effective analgesia to an argon laser stimulus (which produces a sharp, pricking pain) is 15 to 20 minutes (with individual variations in the range of 5-45 minutes).

Adverse effects: During or immediately after treatment with lidocaine or prilocaine on intact skin, possible erythema, edema, or abnormal sensation of skin at treatment site

Systemic adverse reactions after appropriate use of EMLA are unlikely because of the small dose absorbed.

Precautions and contraindications: Application of EMLA to larger areas or for longer times than those recommended could result in sufficient absorption of lidocaine and prilocaine to result in serious adverse effects. EMLA is contraindicated in patients who exhibit allergies to amide local anesthetics. EMLA should be used with care in patients with conditions or therapy associated with methemoglobinemia.

Anesthetic considerations: EMLA is generally safe. When EMLA is used, the patient should be aware that the production of dermal analgesia may be accompanied by the block of all sensations in the treated skin. For this reason, the patient should avoid inadvertent trauma to the treated area caused by scratching, rubbing, or exposure to extreme hot or cold temperatures until complete sensation has returned.

Classification: Angiotensin-converting enzyme (ACE) inhibitor

Indication: Hypertension

Dose: Intravenous: 0.625 to 1.25 mg over 5 minutes every 6 hours.

Dosage forms: 1.25 mg/mL, 1- and 2-mL vials

Onset and duration: Onset: 10 to 15 minutes. Duration: approximately 6 hours

Adverse effects: Cough, hypotension, renal impairment, angioedema

Precautions and contraindications: Patients taking diuretics may have to adjust the dose while they are receiving ACE inhibitors. Enalaprilat is contraindicated during pregnancy.

Anesthetic considerations: This is a useful addition to antihypertensive drug choices for perioperative use.

Classification: Anticoagulant (antithrombotic), inhibiting factors Xa and IIa and only slightly affecting clotting times

Indications: Prevention of postoperative pulmonary embolism (PE) or deep venous thrombosis (DVT); reduction of ischemic complications in patients with cardiovascular disease who have unstable angina and non–Q-wave myocardial infarctions

Dose: Immediately after surgery: 30 mg or 40 mg subcutaneously every 12 hours to prevent DVT or PE; 1 mg/kg subcutaneously every 12 hours with 100 to 325 mg oral aspirin daily to treat patients with unstable angina or non–Q-wave myocardial infarction.

Onset and duration: Onset: subcutaneous: 20 to 60 minutes. Peak effect: 3 to 5 hours. Duration: 12 hours. Elimination half-life: 3 to 4.5 hours.

Adverse effects: Hemorrhage; epidural or subarachnoid or injection site hematomas; thrombocytopenia; increased aspartate aminotransferase; alanine aminotransferase; liver enzymes; chills, fever, urticaria

Precautions and contraindications: Avoid intramuscular injections of enoxaparin. Use it with caution in pregnant patients and those with a history of coagulopathies or gastrointestinal bleeding. Enoxaparin is absolutely contraindicated in patients with active bleeding, thrombocytopenia, a history of heparin-induced thrombocytopenia, and pork or heparin sensitivities.

Anesthetic considerations: Central axis blocks or removal of indwelling catheters should not occur at least 12 hours before or after the last administration of enoxaparin or, conservatively, not within the previous 24 hours. Coagulation tests do not need to be routinely ordered while the patient is taking enoxaparin. However, if coagulation test results are abnormal or bleeding occurs, anti–factor Xa is the most sensitive test to indicate therapeutic anticoagulation levels. Treat an overdose with protamine sulfate. Each milligram of protamine will neutralize 1 mg of enoxaparin.

Classification: Noncatecholamine sympathomimetic with mixed direct and indirect actions as well as central nervous system effects

Indications: Hypotension, bradycardia

Dose: Intravenous: 5 to 25 mg (or 100-300 mcg/kg); intramuscular: 25 to 50 mg; oral: 25 to 50 mg every 3 hours

Onset and duration: Onset: intravenous: almost immediate; intramuscular: a few minutes. Duration: intravenous: 10 to 60 minutes.

Adverse effects: Hypertension, tachycardia, arrhythmias, pulmonary edema, anxiety, tremors, hyperglycemia, transient hyperkalemia and then hypokalemia, necrosis at the site of injection, possible tolerance

Precautions and contraindications: Use ephedrine cautiously in patients with hypertension and ischemic heart disease. It has an unpredictable effect in patients in whom endogenous catecholamines are depleted; it may produce central nervous system stimulation.

Anesthetic considerations: Ephedrine is associated with an increased risk of arrhythmias. It is potentiated by tricyclic antidepressants and monoamine oxidase inhibitors.

Classification: Endogenous catecholamine

Indications: Inotropic support; treatment of anaphylaxis; to increase duration of action of local anesthetic; hemostasis; cardiac arrest; bronchodilation

Dose: Cardiac arrest: 0.5 to 1 mg intravenous bolus every 5 minutes as necessary. Inotropic support: 2 to 20 mcg/min (0.1-1 mcg/kg/min). Anaphylaxis: 100 to 300 mcg intravenous push, depending on severity.

Onset and duration: Onset: intravenous: immediate. Duration: intravenous: 5 to 10 minutes

Adverse effects: Restlessness, fear, throbbing headache, tachycardia, tachydysrhythmias, premature ventricular contractions, ventricular tachycardia, ventricular fibrillation, severe hypertension, angina, extension of myocardial infarction, pulmonary edema

Precautions and contraindications: Use epinephrine with caution in patients with coronary artery disease, hypertension, diabetes mellitus, or hyperthyroidism and in patients taking monoamine oxidase inhibitors.

Anesthetic considerations: Epinephrine may be administered through the endotracheal tube.

Classification: Cardioselective β-blocker

Indications: Supraventricular tachycardia (SVT); perioperative hypertension

Dose: SVT: loading: 50 to 200 mcg/kg/min for 1 minute; follow by infusion of 50 mcg/kg/min for 4 minutes. If the desired effect is not achieved, repeat loading dose and increase infusion to 100 mcg/kg/min. May repeat the process up to a maximum of 300 mcg/kg/min.

Dosage forms: 10 mg/mL in 10-mL vial for direct intravenous injection; 250 mg/mL in 10-mL ampule for intravenous infusion

Onset and duration: Onset: 1 to 2 minutes. Duration: 10 to 20 minutes. Peak effect: 5 to 6 minutes. Do not infuse for more than 48 hours.

Adverse effects: Hypotension, bradycardia, congestive heart failure, bronchospasm, confusion, depression, urinary retention, nausea and vomiting, rash

Precautions and contraindications: Use esmolol with caution in patients with asthma; chronic obstructive pulmonary disease; atrioventricular heart block, or cardiac failure not caused by tachycardia; and diabetes.

Anesthetic considerations: Esmolol may have additive cardiovascular depressant effects when it is coupled with volatile or intravenous anesthetic agents. Use it with caution in bronchospastic patients, owing to minimal cardioselectivity.

Classification: Loop diuretic

Indications: Edema of cardiac, hepatic, or renal origin; hypertension, pulmonary edema; usually reserved for patients who do not respond to thiazide diuretics or in whom a rapid onset of diuresis is desired

Dose: 0.5 to 1 mg/kg slowly over several minutes up to a maximum of 100 mg in a single dose. The usual average dose is 50 mg. Children: 1 mg/kg over 20 to 30 minutes.

Dosage forms: 50-mg vial, powder for injection; reconstitute by adding 50 mL D₅W or normal saline; tablets: 25, 50 mg

Onset and duration: Onset: intravenous: 5 to 15 minutes. Duration: intravenous: 2 hours but may last 6 to 7 hours. Elimination half-life: 1 to 4 hours.

Adverse effects: Fluid and electrolyte imbalance, including hypomagnesemia, hypocalcemia, hypokalemia, hypochloremia, metabolic alkalosis, hyperuricemia; hypoglycemia and hyperglycemia; thrombocytopenia; agranulocytopenia; vertigo; ototoxicity (associated with rapid intravenous injection); pancreatitis; gastrointestinal hemorrhage; hepatotoxicity; hypotension; diarrhea

Precautions and contraindications: Avoid rapid intravenous injection of ethacrynic acid. Use it with extreme caution in patients with impaired renal or hepatic function. It is contraindicated for use in patients after anuric renal failure is established, as well as in patients with hypotension; dehydration with low serum sodium or metabolic alkalosis with hypokalemia; nursing mothers; infants; and patients with severe watery diarrhea.

Anesthetic considerations: Loop diuretics have been reported to increase the neuromuscular blocking effect of nondepolarizing relaxants, possibly because of their potassium-depleting effects.

Classification: Central nervous system agent; nonbarbiturate hypnotic without analgesic activity

Indication: Induction of general anesthesia

Dose: Adult: intravenous: 0.2 to 0.3 mg/kg over 30 to 60 seconds.

Dosage forms: injection: 2 mg/mL, ampules and prefilled syringe.

Onset and duration: Onset: 1 minute. Duration: 3 to 10 minutes. Metabolized in the liver. Half-life: 75 minutes; excreted primarily in the urine.

Adverse effects: Myoclonus, tonic movements, eye movements, hypertension, hypotension, tachycardia, bradycardia, other arrhythmias, postoperative nausea and vomiting, hypoventilation, hyperventilation, transient apnea, laryngospasm, hiccups, snoring, adrenocortical suppression

Precautions and contraindications: Use etomidate cautiously in immunosuppressed patients. Its safety during pregnancy, in nursing women, and in children younger than 4 years has not been established.

Anesthetic considerations: Use etomidate with caution in patients with steroid deficiency. Use the large veins. Myoclonus is reduced by premedication with a benzodiazepine or an opioid.

Classification: Histamine (H₂) antagonist

Indications: Treatment of duodenal or gastric ulcers and gastroesophageal reflux; prophylaxis of aspiration pneumonitis in patients at high risk during surgery

Dose: Prophylaxis of aspiration pneumonitis: adults: 20 to 40 mg orally the evening before surgery or the morning of surgery before induction of anesthesia (or both the evening before and the morning of surgery). If a more rapid onset is desired, 2 mL of intravenous famotidine (10 mg/mL) may be diluted to a concentration of 5 to 10 mL with D₅W, normal saline, or lactated Ringer’s solution and administered over at least 2 minutes before induction.

Dosage forms: tablets: 20, 40 mg; parenteral injection: 10 mg/mL in 2- or 4-mL vials

Onset and duration: Onset: 20 to 45 minutes. Peak effect: 1 to 3 hours orally. Duration: Plasma famotidine concentrations that suppress gastric acid secretion by 50% are maintained for 12 hours after an oral dose of 40 mg and 7 to 9 hours after a 20-mg dose.

Adverse effects: Headache (2%-4.5%), constipation (1.4%), and drowsiness (most frequently reported); mental confusion in elderly patients (occasionally)

Potential bradydysrhythmias and hypotension may be associated with rapid infusion.

Precautions and contraindications: Caution suggested in patients with hepatic or renal dysfunction (possible dose reductions required). This drug is contraindicated in patients with known hypersensitivity to famotidine or other H₂ antagonists.

Anesthetic considerations: Famotidine is a safe alternative to gastric prophylaxis preoperatively.

Classification: Antihypertensive (dopamine DA-1-receptor agonist)

Indications: A potent vasodilator that stimulates the postsynaptic dopamine DA receptors, thereby lowering blood pressure, peripheral vascular resistance, and renal vascular resistance and increasing cardiac hemodynamics; short-term use (up to 48 hours) for patients with severe hypertension or malignant hypertension

Dose: Administer fenoldopam as a continuous infusion; no loading dose is needed. The infusion range is 0.04 to 0.8 mcg/kg/min; titrate slowly for blood pressure reduction. Initial doses less than 0.1 mcg/kg/min are marginally antihypertensive but have less reflex tachycardia. Initial doses higher than 0.3 mcg/kg/min have been associated with reflex tachycardia.

Onset and duration: Onset: 5 minutes. Peak effect: 15 minutes. Rapidly metabolized. Half-life: 5 minutes.

Adverse effects: Reflex tachycardia with a higher initial dosing regimen possibly causing increased intraocular pressure, hypotension, hypokalemia (infusion time greater than 6 hours can cause potassium to fall to less than 3 mEq), headache, flushing, nausea

Precautions and contraindications: Fenoldopam has no absolute contraindications. Use it with caution in patients with severe hepatic disease. It contains a metabisulfite compound, so do not use this drug in patients sensitive to sulfites (especially patients with asthma) because allergic reaction may result. The concomitant use of other antihypertensive agents (calcium channel blockers, nitrates, β₁-blockers, and α₂-blockers) may result in unexpected hypotension.

Anesthetic considerations: Titrate the drug slowly to prevent reflex tachycardia. Check the patient’s potassium level if titrating a long-term infusion (greater than 6 hours). Review for sulfite allergies, especially in patients with asthma. Use with caution in patients with open globe injuries or glaucoma because fenoldopam may increase intraocular pressure. It is generally used as an alternative to nitroprusside.

Classification: Opioid agonist

Indications: Analgesia and anesthesia

Dose: Analgesia: intravenous: 1 to 2 mcg/kg

Induction: 30 mcg/kg; infusion: 0.2 mcg/kg/min. Epidural bolus: 1 to 2 mcg/kg; infusion: 2 to 60 mcg/hr. Spinal bolus: 0.1 to 0.4 mcg/kg. Dosage forms: injection: 0.05 mg/mL; transdermal patch: 100 mcg/hr. In conjunction with epidural administration: 1 to 2 mcg/kg. For infusion with epidural: 2 to 60 mcg/hr. In conjunction with spinal anesthesia: bolus dose of 0.1 to 0.4 mcg/kg.

Onset and duration: Onset: intravenous: within 30 seconds; intramuscular: less than 8 minutes; epidural or spinal: 4 to 10 minutes. Duration: intravenous: 30 to 60 minutes; intramuscular: 1 to 2 hours; epidural or spinal; 4 to 8 hours.

Adverse effects: Hypotension, bradycardia, respiratory depression, apnea, dizziness, blurred vision, seizures, nausea, emesis, delayed gastric emptying, biliary tract spasm, muscle rigidity

Precautions and contraindications: Reduce fentanyl doses in elderly, hypovolemic, or high-risk surgical patients and with concomitant use of sedatives and other narcotics. It crosses the placental barrier and may produce depression of respiration in neonates. Prolonged depression may occur after cessation of transdermal patch use.

Anesthetic considerations: Narcotic effects reversed by naloxone (0.2-0.4 mg intravenously). Circulatory and ventilatory depressant effects are potentiated by narcotics, sedatives, volatile anesthetics, nitrous oxide, and possibly monoamine oxidase inhibitors, phenothiazines, and tricyclic antidepressants; analgesia is enhanced by α₂-agonists. Muscle rigidity in higher dose range sufficient to interfere with ventilation.

Classification: Benzodiazepine-receptor antagonist

Indication: Reversal of benzodiazepine-receptor agonist

Dose: Intravenous: 0.2 to 1 mg (4-20 mcg/kg); titrate to patient response; may repeat at 20-minute intervals (maximum single dose: 1 mg; maximum total dose: 3 mg in any 1 hour)

Dosage forms: injection: 0.1 mg/mL

Onset and duration: Onset: 1 to 2 minutes. Duration: 30 to 90 minutes, depending on the dose of flumazenil and plasma concentration of benzodiazepine to be reversed.

Adverse effects: Arrhythmia, tachycardia, bradycardia, hypertension, angina, flushing, reversal of sedation, seizures, agitation, emotional lability, nausea and vomiting, pain at injection site, thrombophlebitis

Precautions and contraindications: Institute measures to secure airway, ventilation, and intravenous access before administering flumazenil. Resedation may occur and is more common with large doses of long-acting benzodiazepines.

Anesthetic considerations: Do not use flumazenil until the effects of neuromuscular blockade have been fully reversed. Administer it in a large vein to minimize pain at the injection site. Monitor the patient for resedation.

Classification: Hypnotic sedative

Indications: Intravenous sedation

Dose: Loading dose: 6.5 mg/kg; initial dose not to exceed 16.5 mL

Maintenance dose: 1.6 mg/kg not to exceed 4 mL

Dosage forms: 35 mg/mL; 30 mL vial

Onset and duration: Onset: 4 to 12 minutes. Duration: 21 to 45 minutes

Adverse effects: Perineal paresthesias, pruritus, hypotension, apnea

Precautions and contraindications: Dose should be reduced in patients older than 65 years of age and those with significant systemic disease. Continuous monitoring by qualified providers is mandatory.

Anesthetic considerations: Fospropofol is a water-soluble prodrug of propofol. Upon administration, liver metabolism releases the active propofol. Proper airway equipment must be immediately available. Useful for sedation during nonoperating room procedures.

Classification: Loop diuretic

Indications: Edema of cardiac, hepatic, or renal origin; hypertension; pulmonary and cerebral edema; usually reserved for patients who do not respond to thiazide diuretics or in whom a rapid onset of diuresis is desired

Dose: Diuresis: adult: 20 to 40 mg intramuscularly or intravenously as a single dose. Intravenous doses should be injected slowly over 1 to 2 minutes. Additional doses of 20 mg greater than the previous dose may be administered every 2 hours until desired response is obtained. For intravenous bolus injections, do not exceed 1 g/day administered over 30 minutes. Acute pulmonary edema: 40 mg intravenously initially; may repeat in 1 hour with 80 mg if necessary. Children: intramuscular or intravenous: 1 mg/kg single dose initially, increasing by 1 mg/kg every 2 hours or more until desired response is obtained or to a maximum of 6 mg/kg/day.

Dosage forms: tablets: 20, 40, 80 mg; injection: 10 mg/mL; oral solutions: 10 mg/mL and 40 mg/5 mL.

Onset and duration: Onset: intravenous: onset of diuresis usually occurs in 5 minutes. Duration: 2 hours. Elimination half-life: widely variable; normal is 0.5 to 1 hour, but a period of 11 to 20 hours has been reported in patients with hepatic or renal insufficiency.

Adverse effects: Dehydration, hypotension, hypochloremic alkalosis, hypokalemia, hypomagnesemia, hyperglycemia, hyperuricemia

Ototoxicity has been reported with too rapid intravenous injection of large doses. Rarely reported are thrombocytopenia, neutropenia, jaundice, pancreatitis, and a variety of skin reactions.

Precautions and contraindications: Furosemide is contraindicated in anuria (except for a single dose in acute anuria) and pregnancy. Use it with caution in patients with severe or progressive renal disease and hepatic disease. Discontinue it if renal function worsens. Use caution in patients who are allergic to sulfonamides and patients with severe electrolyte imbalance.

Anesthetic considerations: Monitor electrolytes and fluid balance. Administer furosemide carefully in patients taking digitalis. It may be associated with enhancement of nondepolarizing neuromuscular blocking drugs.

Classification: Hormone; antidiabetic agent (antihypoglycemic); diagnostic agent

Indications: Treatment of hypoglycemia or β-blocker overdose; inotropic agent used to relax smooth muscle of gastrointestinal tract for radiologic studies; anaphylaxis resistant to epinephrine

Dose: Diagnostic aid for radiologic examination: intravenous or intramuscular: 0.25 to 2 mg before initiation of radiologic procedure. Hypoglycemia: intravenous, intramuscular, or subcutaneous: 0.5 to 1 mg.

Onset and duration: Onset: less than 5 minutes. Peak effect: 5 to 20 minutes. Duration: 10 to 30 minutes

Adverse effects: Hypertension, hypotension, respiratory distress, dizziness, lightheadedness, nausea and vomiting, urticaria, hypoglycemia, hyperglycemia

Precautions and contraindications: Glucagon is contraindicated in patients with a hypersensitivity to the drug (owing to its protein nature). Use it cautiously in patients with history of insulinoma or pheochromocytoma. Safe use during pregnancy and in nursing women has not been established.

Anesthetic considerations: Rapid intravenous administration may cause a decrease in blood pressure. It potentiates the hypoprothrombinemic effects of anticoagulants. Parenteral glucose must be administered because release of insulin may subsequently cause hypoglycemia.

Classification: Competitive acetylcholine antagonist at muscarinic receptor

Indications: Vagolytic premedication to block bradycardia from stimulation of the carotid sinus or traction on abdominal viscera or extraocular muscles during surgery; blockade of muscarinic effects of anticholinesterases; adjunctive therapy in the treatment of bronchospasm and peptic ulcer disease

Compared with atropine, glycopyrrolate has twice the potent antisialagogue activity, less tachycardia, and no clinically significant increases in intraocular pressure at doses used preoperatively. It has no sedative effects.

Dose: Adults: Premedication or vagolysis: intravenous, intramuscular, subcutaneous: 0.1 to 2 mg (4-6 mcg/kg) administered 30 to 60 minutes preinduction; may repeat in 2- to 3-minute intervals for vagolysis up to 1 mg total. Blockade of muscarinic effects of anticholinesterase: 0.2 mg for each 1 mg of neostigmine or 5 mg of pyridostigmine. Bronchospasm: inhalation 0.4 to 0.8 mg every 8 hours; dilute injectate solution in 2 to 3 mL normal saline and deliver by compressed air nebulizer.

Children: preoperative 2 years or older: 4 mcg/kg. For oral administration, use injectable solution and dilute in 3 to 5 mL juice or carbonated cola beverage. Oral absorption is erratic. Intraoperative vagolysis: 0.01 mg/kg intravenously not to exceed 0.1 mg; may repeat in 2 to 3 minutes.

Dosage forms: injection: 0.2 mg/mL; tablets: 1, 2 mg

Onset and duration: Onset: oral: 1 hour; intramuscular or subcutaneous: 15 to 30 minutes; inhalation: 3 to 5 minutes; intravenous administration: less than 1 minute. Duration: antisialagogue effect: 7 to 12 hours, depending on the route of administration and dose; vagal blockade: 2 to 3 hours intravenously, 8 to 12 hours orally.

Adverse effects: Tachycardia (high doses), headache, urinary hesitancy, retention, decreased sweating, dry nose and mouth, constipation

Precautions and contraindications: Avoid glycopyrrolate when tachycardia would be harmful (i.e., thyrotoxicosis, pheochromocytoma, coronary artery disease). Avoid it in hyperpyrexial states because it inhibits sweating. Use it with caution in patients with hepatic or renal disease, congestive heart failure, chronic pulmonary disease (because a reduction in bronchial secretions may lead to formation of bronchial plugs), hiatal hernia, gastroesophageal reflux, gastrointestinal infections, and ulcerative colitis. It is contraindicated in acute-angle glaucoma, obstructive disease of the gastrointestinal tract, obstructive uropathy, paralytic ileus, intestinal atony, and acute hemorrhage in patients whose cardiovascular status is unstable.

Anesthetic considerations: Additive anticholinergic effects may occur with meperidine, some antihistamines, phenothiazines, tricyclic antidepressants, and antiarrhythmic drugs that possess anticholinergic activity (e.g., quinidine, disopyramide, procainamide). It is the preferred agent in pregnant patients over atropine and scopolamine because it does not cross the placental barrier.

Classification: Selective serotonin receptor antagonist

Indications: Effective single agent used to control nausea and vomiting induced by cisplatin and other cytotoxic agents and for postoperative nausea and vomiting

Dose: The recommended dosage for prevention of postoperative nausea and vomiting is 1 mg.

Onset and duration: Onset: peak plasma concentrations demonstrate wide interindividual variation. After a 40-mcg/kg dose, nausea and vomiting subside within several minutes. Duration: serum levels decline to less than 10 ng/mL at 24 hours after a single 40-mcg/kg infusion. Antiemetic effects last up to 24 hours after intravenous infusion of 40 mcg/kg.

Adverse effects: Headache and constipation (most common); also somnolence, dizziness, diarrhea, flushing, transient elevation of liver enzymes

Precautions and contraindications: Previous hypersensitivity to granisetron or ondansetron, liver disease (owing to the noted elevation of liver enzymes after repeat administration of granisetron), pregnancy, and breastfeeding are contraindications.

Anesthetic considerations: The injection should not be mixed in solution with other drugs. No specific antidote for overdose exists; give symptomatic treatment. Inducers or inhibitors of cytochrome P450 drug-metabolizing enzymes may change the clearance and duration of granisetron.

Classification: Anticoagulant; accelerates the rate at which antithrombin III neutralizes thrombin and factors VII, IX, X, and XI

Indications: Prophylaxis and treatment of deep venous thrombosis (DVT) and pulmonary thromboembolism (PE); acute arterial occlusion, intracardiac mural thrombosis, after myocardial infarction after intravenous thrombolytic treatment, disseminated intravascular coagulation with gross thrombosis, anticoagulation during cardiopulmonary bypass (CPB), prophylaxis of thromboembolism in patients with mitral valve disease or atrial fibrillation; maintenance of patency of indwelling venipuncture devices (lock flush)

The value of this drug in transient ischemic attacks secondary to cerebral embolism has not been established.

Dose: Dosage is highly individualized and based on daily activated partial thromboplastin time (aPTT) compared with aPTT 6 hours after each dosage change. Obtain baseline aPTT and adjust the dose according to clinical state. For prophylaxis (i.e., hip surgery, atrial fibrillation, valve disease): the ratio of aPTT to baseline aPTT should be 1.2 to 1.5; for prosthetic heart valves, DVT, PE, recurrent embolism: 1.5 to 2. For CPB, monitor the activated clotting time (ACT) and maintain an ACT of 400 to 480 seconds. Baseline ACT values are 80 to 150 seconds. ACT should be determined 5 minutes after heparin administration. Adequate heparinization must be ensured before initiation of CPB.

CPB: before induction of anesthesia, 300 units/kg should be prepared in case emergency initiation of CPB is necessary. Intravenous bolus: 350 to 400 units/kg. Up to 500 units/kg may be required to maintain ACT greater than 400 seconds in heparin-resistant patients. Additional heparin is needed for prolonged CPB. A 100 unit/kg hourly reinforcement dose is administered starting 2 hours after the initial dose.

Prophylactic or low-dose subcutaneous therapy: 5000 units subcutaneously every 8 to 12 hours. Baseline aPTT is obtained because bleeding complications are occasionally discovered, but routine aPTT monitoring is not necessary. For surgical prophylaxis, ideally started 2 hours preoperatively.

Full-dose continuous intravenous infusion for treatment of DVT or PE is based on ideal body weight: intravenous bolus loading dose: 70 units/kg (3000-10,000 units); intravenous maintenance dose: continuous infusion 13 to 16 units/kg/hr (750-1300 units/hr). For continuous intravenous infusion, 25,000 units heparin may be mixed in 500 mL D₅W or normal saline. The resulting solution is 50 units/mL.

Dosage forms: injection: 1000, 2500, 5000, 7500, 10,000, 20,000, and 40,000 units/mL; lock flush solution: 10 units, 100 units/mL; premixed infusion in dextrose: 50 units/mL; premixed infusion in normal saline: 50 units, 100 units/mL

Onset and duration: Onset: intravenous: immediate; subcutaneous: 20 to 30 minutes. Elimination half-life: 1 to 2 hours in healthy adults. Duration: half-life and duration increase with increasing doses; prolonged in liver and renal disease.

Adverse effects: Hemorrhage, thrombocytopenia, white-clot syndrome (rare paradoxical thrombosis), necrotizing skin lesions, elevated liver enzymes, osteoporosis, priapism, hypersensitivity

Precautions and contraindications: Avoid intramuscular injections of heparin. It is contraindicated in patients with hemophilia; thrombocytopenia; acute bleeding; peptic ulcer; esophagitis; diverticulitis; esophageal varices; arterial aneurysm; gastrointestinal or urinary tract malignancy; vascular retinopathy; recent liver or renal biopsy; acute pericarditis; threatened abortion; infective endocarditis; recent regional anesthesia; severe hypertension; recent cerebrovascular accident; recent surgery; or trauma to the brain, eye, or spinal cord.

Platelet counts, hematocrit, and occult blood in stool and urine should be monitored during the entire course of therapy. An increased risk of bleeding exists with the concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, dipyridamole, thrombolytic agents, dextran, dihydroergotamine, and warfarin. Intravenous nitroglycerin may antagonize the effects of heparin and should be administered via a separate line if possible. Digoxin, nicotine, propranolol, antihistamines, and tetracycline may reduce heparin’s effects.

Bleeding and heparin overdosage may be treated with protamine sulfate; 1 mg protamine neutralizes 100 units heparin.

Anesthetic considerations: Regional anesthesia is contraindicated. A heparin continuous intravenous infusion should be discontinued 4 to 6 hours preoperatively, and the aPTT should be checked to ensure return to baseline.

Classification: Plasma expander, anticoagulant

Indications: Adjunct for plasma volume expansion in shock resulting from hemorrhage, burns, sepsis, surgery, or other trauma; mild anticoagulant effects after vascular procedures

Dose: Plasma volume expansion from 500 to 1000 mL. Total dosage does not usually exceed 1500 mL/day (20 mL/kg/day). In acute hemorrhagic shock, rates approaching 20 mL/kg/hr have been used.

Dosage forms: 6% solution in 0.9% sodium chloride, 500-mL intravenous infusion bottle

Onset and duration: Onset: 15 to 30 minutes. Duration: 24 to 48 hours. Average half-life: 17 days

Adverse effects: Anaphylactic reactions (periorbital edema, urticaria, wheezing); peripheral edema of the lower extremities; chills; mild temperature elevation; muscle pain

Large volumes may alter coagulation times and may result in transient prolongation of prothrombin time, partial thromboplastin time, and bleeding; decreased hematocrit; and excessive dilution of plasma proteins.

Precautions and contraindications: Hetastarch is contraindicated in patients with severe bleeding disorders, severe cardiac failure, and renal failure with oliguria or anuria. Hetastarch does not have oxygen-carrying capacity, nor does it contain plasma proteins such as coagulation factors. Therefore, it is not a substitute for blood or plasma.

Anesthetic considerations: Infuse it slowly to avoid volume overload. Check the patient’s coagulation profile.

Classification: Enzyme

Indications: Adjunct to increase absorption and dispersion of other injected drugs such as local anesthetics; hypodermoclysis; subcutaneous urography

Dose: Adjunct: 150 units to injection medium containing other medication. Hypodermoclysis (adults and children older than 3 years): 150 units injected subcutaneously before clysis or injected into clysis tubing near needle for each 1000-mL clysis solution. Subcutaneous urography (patient prone): 75 units subcutaneously over each scapula followed by injection of contrast medium at the same sites.

Onset and duration: Onset: immediate. Duration: 30 to 60 minutes

Adverse effects: Rash, urticaria, local irritation

Precautions and contraindications: Use hyaluronidase with caution in patients with blood-clotting abnormalities or severe hepatic or renal disease. Avoid injecting it into diseased areas to prevent spread of infection.

Anesthetic considerations: It is useful to prevent thrombus formation during vascular procedures as well as for volume expansion. It is also a useful addition for promoting the spread of local anesthetics.

Classification: Direct-acting arterial vasodilator

Indications: Antihypertensive; vasodilator

Dose: Intravenous and intramuscular: 2.5 to 40 mg (0.1-0.2 mg/kg); oral: 10 to 100 mg four times daily

Dosage forms: injection: 20 mg/mL; tablets: 10, 25, 50, and 100 mg

Onset and duration: Onset: intravenous: 5 to 20 minutes; intramuscular: 10 to 30 minutes; oral: 30 to 120 minutes. Duration: intravenous: 2 to 4 hours; intramuscular or oral: 2 to 8 hours.

Adverse effects: Hypotension, paradoxical pressor response, tachycardia, palpitations, angina, dyspnea, nasal congestion, peripheral neuritis, depression, anxiety, headache, dizziness, nausea and vomiting, diarrhea, lupuslike syndrome, rash, urticaria, eosinophilia, hypersensitivity, leukopenia, splenomegaly, agranulocytosis

Precautions and contraindications: Use hydralazine cautiously in patients with coronary artery disease and mitral valvular rheumatic heart disease, as well as in patients receiving monoamine oxidase inhibitors.

Anesthetic considerations: One may see a reduced response to epinephrine. Enhanced hypotensive effects occur in patients receiving diuretics, monoamine oxidase inhibitors, diazoxide, and other antihypertensives. It primarily dilates the arterial vasculature.

Classification: Corticosteroid (glucocorticoid and mineralocorticoid properties)

Indications: Treatment of choice for steroid-replacement therapy; also anti-inflammatory and immunosuppressive agent, although glucocorticoids (prednisone) are preferred for this use; adjunctive therapy in anaphylaxis to prevent prolonged antigen-antibody reactions; adjunctive treatment of ulcerative colitis (enema)

Dose: Adults: shock: 500 mg to 2 g (succinate) intravenously every 2 to 6 hours until the condition is stabilized. Not recommended beyond 48 to 72 hours. Adjunctive therapy in anaphylaxis: hydrocortisone phosphate or succinate intravenously 5 mg/kg initially; then 2.5 mg/kg every 6 hours. Adrenal insufficiency: acute, precipitated by trauma or surgical stress: If adrenocorticotropic hormone testing is not being performed, 200 to 300 mg intravenous hydrocortisone succinate over several minutes; then 100 mg intravenously every 6 hours for 24 hours. If the patient is stable, dosage tapering may begin on the second day. Consider steroid replacement in any patient who has received corticosteroid therapy for at least 1 month in the past 6 to 12 months, with 50 to 100 mg intravenously (succinate) before, during, and after surgery. For intraarticular, soft tissue, and intrasynovial injections, use acetate only (acetate is not for intravenous use): 10 to 50 mg combined with local anesthetic such as procaine. Injections may be repeated every 3 to 5 days (for bursae) to once every 1 to 4 weeks (for joints).

Children: 0.16 to 1 mg/kg or 6 to 30 mg/m² (phosphate or succinate) intramuscularly or intravenously one or two times daily. The dose depends on the disease being treated.

Onset and duration: Onset: intravenous or intramuscular: 5 minutes. Duration: approximates the duration of hypothalamus-pituitary-adrenal axis suppression (i.e., 30-36 hours); after a single oral dose of hydrocortisone, this is 1.25 to 1.5 days.

Adverse effects: Glaucoma and cataracts (long-term therapy); muscle weakness, sodium retention, edema, hypokalemic alkalosis, hyperglycemia, Cushing syndrome, peptic ulcer, increased appetite, delayed wound healing, psychotic behavior, congestive heart failure, hypertension, growth suppression, pancreatitis

Acute adrenal insufficiency may occur with abrupt withdrawal after long-term therapy. Withdrawal symptoms include rebound inflammation, fatigue, weakness, arthralgia, fever, dizziness, lethargy, depression, orthostatic hypotension, dyspnea, anorexia, and hypoglycemia.

Precautions and contraindications: Hydrocortisone is contraindicated in patients with systemic fungal infections. It may mask or exacerbate infections. Use it with caution in patients with ocular herpes simplex or a history of peptic ulcer disease. In patients with myasthenia gravis, hydrocortisone interacts with anticholinesterase agents to produce severe weakness.

Anesthetic considerations: Hypotension from the stress of anesthesia and surgery may occur if regular doses of steroids were taken within 2 months preceding surgery. Supplemental steroids are indicated commencing with preoperative dose and continuing for 3 days for major surgery, for 24 hours for minor surgery, and one dose for a very brief procedure and then tapered to normal therapy.

Because of adrenal suppression, etomidate should be avoided in patients with adrenal insufficiency.

Classification: Non-narcotic analgesic, antipyretic, nonsteroidal anti-inflammatory drug (NSAID)

Indications: Non-narcotic analgesic for treatment of mild to moderate pain

Dose: 400 to 800 mg intravenous every 6 hours; 3200 mg maximum per day

Infuse over 30 minutes. Dilute the 400-mg vial in 100 mL; Dilute the 800-mg vial in 200 mL.

Onset and duration: Onset: 5 to 15 minutes; duration 4 to 6 hours

Adverse effects: Dizziness with higher doses. Ibuprofen inhibits platelet function and increases bleeding time, but no increase in bleeding was reported in clinical trials. NSAIDs are contraindicated in patients undergoing coronary artery bypass surgery. Extended use may produce gastrointestinal and renal toxicity. Some orthopedic surgeons have been reluctant to use ibuprofen postoperatively because of reports that it may interfere with bone healing.

Precautions and contraindications: Contraindicated in aspirin-allergic patients with asthma

Anesthetic considerations: Ibuprofen decreases pain and reduces fever in adults. It has an opioid-sparing effect. It is effective for mild to moderate pain.

Classification: Class III antiarrhythmic; cardiac action potential prolongation

Indications: Rapid conversion of atrial fibrillation or flutter of acute onset (less than 90 days) to sinus rhythm

Dose: Adults weighing more than 60 kg: 1 vial (1 mg) infused over 10 minutes (may be repeated once in 10 minutes after completion of first dose). Adults weighing less than 60 kg: 0.01 mL/kg infused over 10 minutes (may be repeated once in 10 minutes after completion of first dose). Not recommended for pediatric patients.

Onset and duration: Onset: intravenous: immediate for antiarrhythmic properties. Peak effect: 10 minutes. Half-life: 6 hours. Atrial arrhythmias usually convert within 30 minutes after ibutilide therapy begins. Duration: 10 to 30 minutes.

Adverse effects: Ventricular arrhythmias (often sustained torsades de pointes), heart block, congestive heart failure, bradycardia, tachycardia, hypotension, nausea, headache

Precautions and contraindications: The drug is contraindicated in patients sensitive to ibutilide, those with second- or third-degree atrioventricular heart blocks or prolonged Q-T interval, and during pregnancy.

Anesthetic considerations: The risk of proarrhythmias or polymorphic ventricular tachycardia is increased when ibutilide is used with other drugs that prolong the Q-T interval (phenothiazines, procainamide, quinidine, antihistamines). Electrocardiographic monitoring for 4 hours after drug therapy is mandatory because arrhythmias (premature ventricular contractions, ventricular tachycardia, tachycardia, bradycardia, varying degrees of heart blocks) can take place. Have emergency equipment available to perform overdrive pacing, defibrillate, or cardiovert the patient. Monitor serum potassium and magnesium because deficiencies in these electrolytes can precipitate polymorphic ventricular tachycardia.

Classification: Antidiabetic agent

Indications: Diabetic ketoacidosis, treatment of diabetes mellitus, hyperkalemia

Dose: Diabetes mellitus: in general, therapy is initiated with regular insulin, subcutaneously 5 to 10 units in adults and 2 to 4 units in children 15 to 30 minutes before meals and at bedtime. The dose and frequency are carefully individualized based on blood glucose monitoring every 4 to 6 hours. After satisfactory control is achieved, an intermediate form of insulin may be substituted; this is administered before breakfast in a dose approximately two-thirds to three-fourths that of the previous total daily dose established for regular insulin. Treatment plans are highly variable and patient dependent.

Perioperative management of patients with insulin-dependent diabetes: half the usual NPH-isophane insulin dose the morning of the day of surgery. It is critical for patients who are receiving nothing orally and receiving insulin also to receive an intravenous infusion of dextrose 5 to 10 g/hr (equal to 100-200 mL of a D₅W solution) to prevent hypoglycemia.

Postoperative: sliding scale every 4 to 6 hours. Individualize to the patient.

If blood glucose is greater than 350 mg/dL, administer insulin regular, 15 units subcutaneously plus intravenously 1 to 2 units/hr. Monitor blood glucose hourly. Correct electrolyte imbalances (hypokalemia, hypophosphatemia) and acidosis.

Diabetic ketoacidosis: requires insulin by continuous infusion; hourly blood glucose determination; and correction of acidosis, dehydration, and electrolyte imbalances. After renal function is established, potassium replacement therapy may be needed.

Dosage forms: injection: 100 units/mL. U500 Insulin (500 units/mL) is available but should be used only to fill implanted insulin pumps. It should never be stocked outside the pharmacy.

Onset and duration:

Adverse effects: Dose-related hypoglycemia; local allergic reactions, lipoatrophy, and resistance (overcome by switching to more highly purified sources); anaphylaxis

In general, human insulin is least antigenic, and pork is less antigenic than beef and pork or pure beef insulin.

Precautions and contraindications:

Anesthetic considerations: Blood glucose levels of 120 to 180 mg/dL should be sought, and blood glucose should be monitored frequently intraoperatively. If it is necessary to administer insulin intraoperatively, continuous intravenous infusion may be the best method. If it is administered subcutaneously, variability of skin blood flow during anesthesia may cause unpredictable results.

Large intravenous boluses of insulin can put the patient at risk for dysrhythmias caused by intracellular shifts of potassium, phosphorus, and magnesium.

Classification: Anticholinergic, bronchodilator (parasympatholytic)

Indications: Treatment and prevention of bronchospasm resulting from chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis

Dose: Metered-dose inhaler in adults: two to four sprays (initially, 18 mcg/spray); then two sprays every 4 hours (maximum dose: 216 mcg or 12 sprays/day).

Oral nebulizer in adults: 500 mcg with 2.5 mL of normal saline mixed via oral nebulization every 6 to 8 hours; may mix with albuterol in nebulizer if used within 1 hour of mixing.

Onset and duration: Onset: within 15 to 30 minutes. Peak effect: 1 to 2 hours. Duration: 4 to 5 hours

Adverse effects: Local or systemic anticholinergic effects, angina, blurred vision, headache, dizziness

Precautions and contraindications: Use ipratropium cautiously for patients with narrow-angle glaucoma, bladder obstruction, and benign prostatic hypertrophy. It is contraindicated in patients hypersensitive to soya lecithin or related food products such as soybean and peanut, as well as in patients hypersensitive to ipratropium bromide, atropine, and its derivatives.

Anesthetic considerations: Do not use it for relief of bronchospasm in acute chronic obstructive pulmonary disease exacerbation as a first-line drug. Use drugs with a faster onset.

Classification: Inhalation anesthetic

Indication: General anesthesia

Dose: Titrate to effect for induction or maintenance of anesthesia. Minimum alveolar concentration: 1.14%.

Dosage forms: volatile liquid: 100 mL

Onset and duration: Onset: a few minutes, dose dependent. Duration: emergence time: 15 to 20 minutes.

Adverse effects: Hypotension, tachycardia, arrhythmia, respiratory depression, respiratory irritation, apnea, dizziness, euphoria, increased cerebral blood flow and intracranial pressure, nausea and vomiting, malignant hyperthermia, glucose elevation

Precautions and contraindications: Isoflurane is contraindicated in patients with known or suspected genetic susceptibility to malignant hyperthermia. Changes in mental function may persist beyond the period of anesthetic administration and the immediate postoperative period.

Anesthetic considerations: Anesthetic requirements decrease with age. It crosses the placental barrier. Abrupt onset of malignant hyperthermia may be triggered by isoflurane; early signs include muscle rigidity, especially of the jaw muscles, tachycardia, and tachypnea unresponsive to increased depth of anesthesia.

Classification: Synthetic sympathomimetic, nonspecific β-agonist

Indications:

Dose: Intramuscular or subcutaneous: 0.2 mg; intravenous: 0.02 to 0.06 mg; infusion: 2 to 20 mcg/min.

Onset and duration: Onset: intravenous: immediately. Duration: intravenous: 1 to 5 minutes.

Adverse effects: Tachyarrhythmias, hypertension, angina, paradoxical precipitation of Adams-Stokes attacks, pulmonary edema, headache, dizziness, tremors, nausea and vomiting, anorexia; possible exacerbation of ischemia or hypertension (when used for chronotropic support)

Precautions and contraindications: Isoproterenol is contraindicated in patients with tachyarrhythmias, tachycardia, or hypertension.

Anesthetic considerations: It is useful as an intravenous infusion for the treatment of refractory bradycardic states. The bronchodilating effect is better achieved with more specific β₂-agonists.

Classification: Intravenous general anesthetic

Indications: Sole anesthetic agent for diagnostic and surgical procedures of short duration; induction of anesthesia in critically ill patients; small doses for outpatient analgesia

Dose: Induction: adult: intravenous: 1 to 4.5 mg/kg slowly over 60 seconds; intramuscular: 4 to 6 mg/kg; oral: 6 to 8 mg/kg. Half of the initial dose may be repeated as needed.

Dosage forms: injection: 10, 50, 100 mg/mL

Onset and duration: Onset: intravenous: 2 to 5 minutes; intramuscular: 3 to 8 minutes; oral: 15 to 20 minutes. Duration: intravenous: 5 to 10 minutes; intramuscular: 12 to 25 minutes; oral: 30 to 60 minutes.

Adverse effects: Hypertension, tachycardia, arrhythmias, apnea with rapid administration, laryngospasm, tonic or clonic movements, emergence delirium, hypersalivation, nausea and vomiting, diplopia, nystagmus, slight elevation in intraocular tension, serious emergence reactions

Precautions and contraindications: Ketamine is contraindicated in hypertension, coronary heart disease or increased intracranial pressure, history of cerebrovascular accident, increased intraocular pressure, and psychiatric disorders. It is contraindicated for surgery or diagnostic procedures of the pharynx, larynx, and bronchial tree. Use it cautiously in patients with convulsive disorders.

Anesthetic considerations: Do not mix ketamine with barbiturates in the same syringe. Emergence reactions are common in adults with high doses and are reduced by medication with a benzodiazepine. Catecholamine-depleted patients may respond to ketamine with unexpected reductions in blood pressure and cardiac output.

Classification: Nonsteroidal anti-inflammatory agent

Indications: Short-term (less than 5 days) management of moderately severe, acute pain that requires analgesia; generally used in a postoperative setting

Patients should be switched to alternative analgesics as soon as possible. Ketorolac therapy is not to exceed 5 days because of the potential for increased frequency and severity of adverse reactions. The combined duration of use of ketorolac intravenously or intramuscularly and orally should not exceed 5 days. Oral ketorolac is indicated only for continuation therapy after intravenous or intramuscular ketorolac.

Dose: Intramuscular (administer slowly and deeply into the muscle): patients younger than 65 years: one dose of 60 mg; patients older than 65 years, renally impaired, or weighing less than 50 kg: one dose of 30 mg

Intravenous (intravenous bolus over no less than 15 seconds): patients younger than 65 years: one dose of 30 mg; patients older than 65 years, renally impaired, or weighing less than 50 kg: one dose of 15 mg

Multiple-dose treatment (intravenous or subcutaneous): patients younger than 65 years: 30 mg every 6 hours, not to exceed 120 mg/day

Patients older than 65 years, renally impaired, or weighing less than 50 kg: 15 mg every 6 hours, not to exceed 60 mg/day

Onset and duration: Onset: intravenous or intramuscular: 15 to 30 minutes. Peak effect: 1 to 2 hours. Duration: 4 to 6 hours.

Adverse effects: Gastrointestinal: peptic ulcers, gastrointestinal bleeding, or perforation; renal toxicity; risk of bleeding: inhibition of platelet function; hypersensitivity

Because ketorolac and its metabolites are eliminated primarily by the kidneys, clearance of the drug is diminished in patients with reduced creatinine clearance. Renal toxicity with ketorolac has been seen in patients with conditions leading to a reduction in blood volume or renal blood flow, in which renal prostaglandins have a supportive role in the maintenance of renal perfusion. In these patients, administration of ketorolac may cause a dose-dependent reduction in renal prostaglandin formation and may precipitate acute renal failure.

Hypersensitivity reactions ranging from bronchospasm to anaphylactic shock have occurred, and appropriate counteractive measures must be available when administering the first dose.

Precautions and contraindications: Fluid retention, edema, retention of sodium, oliguria, and elevations of serum urea nitrogen and creatinine have been reported. Therefore, ketorolac should be used only with caution in patients with cardiac decompensation, hypertension, or similar conditions. Ketorolac is contraindicated in patients with active peptic ulcer disease or recent gastrointestinal bleeding or perforation and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. Ketorolac is also contraindicated in patients with advanced renal impairment and in patients at risk for renal failure owing to volume depletion. It is contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, and incomplete hemostasis and those with a high risk of bleeding. It is contraindicated as a prophylactic analgesic before any major surgery and is contraindicated intraoperatively when hemostasis is critical. Ketorolac is also contraindicated in patients with previously demonstrated hypersensitivity to ketorolac tromethamine or allergic manifestations to aspirin (ASA) or other nonsteroidal anti-inflammatory drugs (NSAIDs). It is contraindicated for patients currently receiving ASA or NSAIDs because of the cumulative risk of inducing serious NSAID-related side effects. Ketorolac is contraindicated for intrathecal or epidural administration owing to its alcohol content. It is contraindicated in labor and delivery because it may adversely affect fetal circulation and inhibit uterine contractions. Because of the potential adverse effects of prostaglandin-inhibiting drugs on neonates, ketorolac is contraindicated in nursing mothers.

Anesthetic considerations: Do not use ketorolac as prophylactic analgesia before any major surgery or intraoperatively when hemostasis is critical; in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and at high risk of bleeding; in patients currently receiving ASA or NSAIDs; for epidural or intrathecal administration; or concomitantly with probenecid.

The use of ketorolac is not recommended in children.

Ketorolac reduced the diuretic response to furosemide in normovolemic healthy subjects by approximately 20%. Hypovolemia should be corrected before treatment with ketorolac is initiated. Ketorolac possesses no sedative or anxiolytic properties. The concomitant use with opiate-agonist analgesics can result in reduced opiate analgesic requirements. Ketorolac is highly bound to human plasma protein (99.2%).

Classification: β- and α-adrenergic antagonist

Indication: Hypertension

Dose: Intravenous bolus: 0.15 to 0.25 mg/kg administered over 2 minutes; may repeat every 5 minutes up to 300 mg. Continuous infusion: 2 mg/min; titrate to effect. Oral: 100 mg twice daily alone or with diuretic; may increase to 200 mg twice daily after 2 days; further dose increase may be made every 1 to 3 days to maximal response. Maintenance dose: 200 to 400 mg twice daily.

Onset and duration: Onset: intravenous: 1 to 3 minutes; oral: 20 to 40 minutes. Duration: intravenous: 0.25 to 2 hours; oral: 4 to 12 hours.

Adverse effects: Hypotension, bradycardia, ventricular arrhythmias, congestive heart failure, chest pain, bronchospasm, headache, diarrhea

Precautions and contraindications: Use labetalol cautiously in patients with chronic bronchitis, emphysema, preexisting peripheral vascular disease, pheochromocytoma, and diabetes. It is contraindicated in bronchial asthma, overt heart failure, greater than first-degree heart block, and hepatic failure.

Anesthetic considerations: Inhalation anesthetics may enhance the drug’s hypotensive effects.