▶Ultiva(Aspen Pharma Trading Ltd)
Remifentanil (as Remifentanyl hydrochloride) 1 mgUltiva 1 mg
powder for solution for injection vials| 5 vialP£ 25. 58 (Hospital
only)b
Remifentanil (as Remifentanyl hydrochloride) 2 mgUltiva 2 mg
powder for solution for injection vials| 5 vialP£ 51. 15 (Hospital
only)b
Remifentanil (as Remifentanyl hydrochloride) 5 mgUltiva 5 mg
powder for solution for injection vials| 5 vialP£ 127. 88 (Hospital
only)b1.4 Peri-operative sedation
Conscious sedation for clinical
procedures
Overview
Sedation of children during diagnostic and therapeutic
procedures is used to reduce fear and anxiety, to control
pain, and to minimise excessive movement. The choice of
sedative drug will depend upon the intended procedure and
whether the child is cooperative; some procedures are safer
and more successful under anaesthesia.
Midazolam p. 223 and chloral hydrate p. 294 are suitable
for sedating children for painless procedures, such as
imaging. For painful procedures, alternative choices include
nitrous oxide p. 808 , local anaesthesia, ketamine below, or
concomitant use of sedation withopioidornon-opioid
analgesia.ANAESTHETICS, GENERAL›NMDA RECEPTOR
ANTAGONISTSKetamine
lINDICATIONS AND DOSE
Induction and maintenance of anaesthesia for short
procedures
▶BY INTRAMUSCULAR INJECTION
▶Neonate: 4 mg/kg, adjusted according to response, a
dose of 4 mg/kg usually produces 15 minutes of surgical
anaesthesia.▶Child: 4 – 13 mg/kg, adjusted according to response, a
dose of 4 mg/kg sufficient for some diagnostic
procedures, a dose of 10 mg/kg usually produces
12 – 25 minutes of surgical anaesthesia
▶BY INTRAVENOUS INJECTION
▶Neonate: 1 – 2 mg/kg, adjusted according to response, to
be given over at least 60 seconds, a dose of 1 – 2 mg/kg
produces 5 – 10 minutes of surgical anaesthesia.▶Child 1 month–11 years: 1 – 2 mg/kg, adjusted according
to response, to be given over at least 60 seconds, a dose
of 1 – 2 mg/kg produces 5 – 10 minutes of surgical
anaesthesia
▶Child 12–17 years: 1 – 4. 5 mg/kg, adjusted according to
response, to be given over at least 60 seconds, a dose of
2 mg/kg usually produces 5 – 10 minutes of surgical
anaesthesia
Induction and maintenance of anaesthesia for long
procedures
▶INITIALLY BY INTRAVENOUS INJECTION
▶Neonate:Initially 0. 5 – 2 mg/kg, followed by (by
continuous intravenous infusion)
8 micrograms/kg/minute, adjusted according to
response, doses up to 30 micrograms/kg/minute may be
used to produce deep anaesthesia.▶Child:Initially 0. 5 – 2 mg/kg, followed by (by continuous
intravenous infusion) 10 – 45 micrograms/kg/minute,
adjusted according to response
Sedation prior to invasive or painful procedures
▶BY INTRAVENOUS INJECTION
▶Child: 1 – 2 mg/kg for 1 doseIMPORTANT SAFETY INFORMATION
Ketamine should only be administered by, or under the
direct supervision of, personnel experienced in its use,
with adequate training in anaesthesia and airway
management, and when resuscitation equipment is
available.lCONTRA-INDICATIONSAcute porphyrias p. 603 .eclampsia
.head trauma.hypertension.pre-eclampsia.raised
intracranial pressure.severe cardiac disease.stroke
lCAUTIONSAcute circulatory failure (shock).
cardiovascular disease.dehydration.fixed cardiac output.
hallucinations.head injury.hypertension.hypovolaemia.
increased cerebrospinalfluid pressure.intracranial mass
lesions.nightmares.predisposition to seizures.psychotic
disorders.raised intra-ocular pressure.respiratory tract
infection.thyroid dysfunction
lINTERACTIONS→Appendix 1 : ketamine
lSIDE-EFFECTS
▶Common or very commonAnxiety.behaviour abnormal.
confusion.diplopia.hallucination.muscle tone increased
.nausea.nystagmus.skin reactions.sleep disorders.
tonic clonic movements.vomiting
▶UncommonAppetite decreased.arrhythmias.hypotension
.respiratory disorders
▶Rare or very rareApnoea.cystitis.cystitis haemorrhagic.
delirium.dysphoria.flashback.hypersalivation
▶Frequency not knownDrug-induced liver injury
SIDE-EFFECTS, FURTHER INFORMATIONIncidence of
hallucinations can be reduced by premedicaton with a
benzodiazepine (such as midazolam).
lPREGNANCYMay depress neonatal respiration if used
during delivery.
lBREAST FEEDINGAvoid for at least 12 hours after last
dose.
lHEPATIC IMPAIRMENT
Dose adjustmentsConsider dose reduction.
lDIRECTIONS FOR ADMINISTRATIONForintravenous
injection, dilute 100 mg/mL strength to a concentration of
not more than 50 mg/mL with Glucose 5 %orSodium
Chloride 0. 9 %. Forcontinuous intravenous infusion, dilute
to a concentration of 1 mg/mL with Glucose 5 %orSodium
Chloride 0. 9 %; use microdrip infusion for maintenance of
anaesthesia.
lPATIENT AND CARER ADVICE
Driving and skilled tasksPatients given sedatives and
analgesics during minor outpatient procedures should be
very carefully warned about the risk of driving or
undertaking skilled tasks afterwards. For a short general
anaesthetic the risk extends toat least 24 hoursafter
administration. Responsible persons should be available to
take patients home. The dangers of takingalcoholshould
also be emphasised.
For information on 2015 legislation regarding driving
whilst taking certain controlled drugs, including ketamine,
seeDrugs and drivingunder Guidance on prescribing p. 1.820 Anaesthesia adjuvants BNFC 2018 – 2019
Anaesthesia15