haemostasis.haemorrhagic diatheses.history of gastro-
intestinal perforation.hypovolaemia.severe heart failure
lCAUTIONSAllergic disorders.cardiac impairment (NSAIDs
may impair renal function).cerebrovascular disease.
coagulation defects.connective-tissue disorders.Crohn’s
disease (may be exacerbated).heart failure.ischaemic
heart disease.peripheral arterial disease.risk factors for
cardiovascular events.ulcerative colitis (may be
exacerbated).uncontrolled hypertension
lINTERACTIONS→Appendix 1 : NSAIDs
lSIDE-EFFECTSAgranulocytosis.angioedema.anxiety.
aplastic anaemia.appetite decreased.asthenia.asthma.
azotaemia.bradycardia.burping.chest pain.
concentration impaired.confusion.constipation.Crohn’s
disease aggravated.depression.diarrhoea.dizziness.
drowsiness.dry mouth.dyspnoea.electrolyte imbalance.
embolism and thrombosis.euphoric mood.fever.flank
pain.fluid retention.flushing.gastrointestinal
discomfort.gastrointestinal disorders.haemolytic
anaemia.haemorrhage.hallucination.headache.hearing
impairment.heart failure.hepatic disorders.
hyperhidrosis.hyperkinesia.hypersensitivity.
hypertension.hypotension.infertility female.malaise.
meningitis aseptic (patients with connective-tissue
disorders such as systemic lupus erythematosus may be
especially susceptible).musculoskeletal disorder.myalgia
.myocardial infarction.nausea.nephritis
tubulointerstitial.nephropathy.neutropenia.oedema.
optic neuritis.oral disorders.pallor.palpitations.
pancreatitis.paraesthesia.perforation.photosensitivity
reaction.platelet aggregation inhibition.psychotic
disorder.pulmonary oedema.renal impairment.
respiratory disorders.seizure.severe cutaneous adverse
reactions (SCARs).skin reactions.sleep disorders.stroke.
taste altered.thinking abnormal.thirst.
thrombocytopenia.ulcer.urinary disorders.vertigo.
visual impairment.vomiting.weight increased.wound
haemorrhage
SIDE-EFFECTS, FURTHER INFORMATIONFor information
about cardiovascular and gastrointestinal side-effects, and
a possible exacerbation of symptoms in asthma, see Non-
steroidal anti-inflammatory drugs p. 650.
lALLERGY AND CROSS-SENSITIVITYContra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID.
lPREGNANCYAvoid unless the potential benefit outweighs
the risk. Avoid during the third trimester (risk of closure of
fetal ductus arteriosusin uteroand possibly persistent
pulmonary hypertension of the newborn); onset of labour
may be delayed and duration may be increased.
lBREAST FEEDINGAmount too small to be harmful.
lHEPATIC IMPAIRMENTUse with caution; there is an
increased risk of gastro-intestinal bleeding andfluid
retention. Avoid in severe liver disease.
lRENAL IMPAIRMENTAvoid if possible or use with caution.
Avoid if serum creatinine greater than 160 micromol/litre.
Dose adjustmentsThe lowest effective dose should be used
for the shortest possible duration. Max. 60 mg daily by
intramuscular injection or intravenous injection.
MonitoringIn renal impairment monitor renal function;
sodium and water retention may occur and renal function
may deteriorate, possibly leading to renal failure.
lDIRECTIONS FOR ADMINISTRATIONForintravenous
injection, give over at least 15 seconds.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Solution for injection
▶Ketorolac trometamol (Non-proprietary)
Ketorolac trometamol 30 mg per 1 mlKetorolac 30 mg/ 1 ml solution
for injection ampoules| 5 ampouleP£ 4. 00 (Hospital only)|
5 ampouleP£ 4. 00 | 6 ampouleP£ 6. 56
▶Toradol(Atnahs Pharma UK Ltd)
Ketorolac trometamol 30 mg per 1 mlToradol 30 mg/ 1 ml solution
for injection ampoules| 5 ampouleP£ 5. 36ANALGESICS›OPIOIDS
eiiiiF 273Alfentanil
lINDICATIONS AND DOSE
Assisted ventilation: analgesia and enhancement of
anaesthesia for short procedures
▶BY INTRAVENOUS INJECTION
▶Neonate:Initially 5 – 20 micrograms/kg, dose to be
administered over 30 seconds; supplemental doses up to
10 micrograms/kg.▶Child:Initially 10 – 20 micrograms/kg, dose to be
administered over 30 seconds; supplemental doses up
to 10 micrograms/kg
Assisted ventilation: analgesia and enhancement of
anaesthesia during maintenance of anaesthesia for
longer procedures
▶BY INTRAVENOUS INFUSION
▶Neonate:Initially 10 – 50 micrograms/kg, dose to be
administered over 10 minutes, followed by
30 – 60 micrograms/kg/hour.▶Child:Initially 50 – 100 micrograms/kg, dose to be
administered over 10 minutes, followed by
30 – 120 micrograms/kg/hour, usual dose with
intravenous anaesthetic, 60 micrograms/kg/hour
DOSESATEXTREMESOFBODY-WEIGHT
▶To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
PHARMACOKINETICS
▶Half-life is prolonged in neonates and accumulation is
likely with prolonged use. Clearance may be increased
in children 1 month– 12 years and higher infusion
doses might be needed.lCAUTIONS
CAUTIONS, FURTHER INFORMATION
▶Repeated intra-operative dosesRepeated intra-operative
doses of alfentanil should be given with care since the
resulting respiratory depression can persist
postoperatively and occasionally it may become apparent
for thefirst time postoperatively when monitoring of the
patient might be less intensive.
lINTERACTIONS→Appendix 1 : opioids
lSIDE-EFFECTS
▶Common or very commonApnoea.chills.fatigue.
hypertension.movement disorders.muscle rigidity
▶UncommonArrhythmia.coma.hiccups.hypercapnia.
pain.post procedural complications.respiratory disorders
.skin reactions
▶Rare or very rareAgitation.crying.epistaxis.vascular
pain
▶Frequency not knownCardiac arrest.cough.disorientation
.fever.loss of consciousness.seizure
SIDE-EFFECTS, FURTHER INFORMATIONAlfentanil can
cause muscle rigidity, particularly of the chest wall or jaw;
this can be managed by the use of neuromuscular blocking
drugs.818 Anaesthesia adjuvants BNFC 2018 – 2019
Anaesthesia15