Search

Summary: Propfol‐remifentanil‐based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol‐based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α‐2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target‐control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic‐opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non‐opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose. [ABSTRACT FROM AUTHOR]

This article discusses the practice of mixing injectable medications in anesthesia, which is not covered in recent guidelines on safe administration. The authors highlight the increasing prevalence of mixing medications, such as the components of total intravenous anesthesia (TIVA), antibiotics, anti-emetics, and analgesics. While guidelines do not endorse the mixing of propofol and remifentanil, there is emerging discourse within the anesthesia community on its acceptability. The article emphasizes the need for a stronger consensus on mixing injectable medications, considering factors like chemical compatibility and pharmacokinetic properties. The authors also mention the lack of a validated pharmacokinetic model for propofol and remifentanil admixtures, leading to complexities in dosing recommendations. The article suggests that separate guidance may be needed for adult and pediatric anesthesia, and highlights the risks and responsibilities associated with using unlicensed ad-hoc admixtures. [Extracted from the article]

With different pharmacokinetics in a drug mixture, a decision must be made to guide the infusion by one of the drugs with the potential risk of over- or under-dosing the other. The Medicines and Healthcare products Regulatory Agency in the UK and the US Food and Drug Administration have not approved the use of other medications including ketamine, remifentanil and dexmedetomidine but these practices have gained popularity. In some circumstances, there may be persuasive reasons for mixing two or more parenteral drug solutions, such as difficult intravenous access or in palliative care syringe drivers, but most of these situations are not applicable to routine intra-operative drug administration. Keywords: pharmacokinetics: pharmacodynamics; pharmacology; safety EN pharmacokinetics: pharmacodynamics pharmacology safety 260 263 4 02/07/22 20220301 NES 220301 The development and refinement of anaesthetic drugs and their administration have markedly increased safety and titratability while decreasing morbidity. [Extracted from the article]

Many drugs given to children are not licensed for the particular indication, age or route of administration, because the manufacturer has not applied to the Licensing Authority for a Marketing Authorisation in paediatrics. In 2007, European law introduced a requirement for pharmaceutical companies to undertake studies in children as part of the development plan for most new medicines so, although this may change, out of necessity the use of unlicensed medication in paediatric anaesthesia is still common. [Extracted from the article]