Drugs In Anesthesia And Intensive Care Pdf


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By Martin Sasada and Susan Smith. New York, Oxford University Press, Pages: Many anesthesiologists choose to carry a small pocket manual of the drugs most often encountered in clinical practice. The updated version of this manual is well designed for the clinical environment: it is softbound with a splash-resistant plastic cover and easily fits into a labcoat or scrub suit pocket.

Drugs in Anesthesia and Intensive Care, 5 th edition

COVID patients in the critical care unit tend to have prolonged hospital stay requiring high doses of sedation and paralysis to treat acute respiratory distress syndrome, resulting in a shortage of these drugs. In our hospital, we have instituted strategies to rationalise drug and oxygen usage. This includes prioritising time-sensitive elective cases, reducing overall elective case load, favouring opioid-reduction strategies and usage of alternative anaesthetic agents not commonly used in ICU.

Both intensive care physicians and anaesthesiologists have to cooperate on drug conservation as similar drugs are used in elective operating lists as in the ICU. Patient safety is of utmost importance and we should keep in mind some pitfalls and ethical concerns of these alternative strategies.

These patients tend to require high doses of sedatives and paralytics. This has resulted in increasing worldwide demand for critical care drugs, including and not limited to sedatives, paralytics, opioids and vasoactive agents, especially to support ventilatory strategies for ARDS such as proning and paralysis [ 3 ].

During peace time in the pre COVID era, hospital infection control adopts a general policy of discarding any portion of unused drug rather than risk contamination.

Drug sharing across patients is prohibited. However, during a pandemic, resource conservation becomes essential. There is a scarcity of literature advocating for this and a concern as to whether this comprises patient safety and recovery profile.

The Faculty of Intensive Care Medicine and Specialist Pharmacy Service in the UK has introduced guides for ICUs on adaptations to minimise wastage for critical care medications during pandemic emergency pressures [ 4 , 5 ]. We describe our local strategies for anaesthesiologists in the operating theatre OT to rationalise drug use because the same drugs are commonly used in both ICU and OT, highlighting the pitfalls that deviating from routine practice may have on patient safety and recovery.

These strategies were not a strict enforcement, but rather a guide in addition to usual anaesthetic considerations. At hospital level, elective cases were reduced to only essential time-sensitive cases such as cancer surgery as a healthy patient may end up consuming resources which may make a difference in outcome to the next critically-ill patient.

At the departmental level, pre-emptive planning of drugs needed for the elective lists was encouraged, as entire vial of drugs such as dexmedetomidine, propofol and midazolam are often discarded after using a small portion. There is a caution for cross-contamination and microbial activity especially for propofol.

Dilution of drugs for patients transferring from OT to ICU were standardized so that re-dilution of drugs can be avoided, hence minimizing medication wastage. A guide for practical considerations was published to help standardise practice and reduce periprocedure COVID transmission risks [ 6 ].

Regional techniques can provide adequate anaesthesia in majority of limb and lower abdominal surgery, reduce sedative and opioid use and oxygen utilisation compared with general anaesthesia [ 7 ]. If general anaesthesia cannot be avoided, anaesthesiologists were encouraged to use other drugs not commonly used in ICU, e.

Oral premedications like lorazepam or gabapentin were used to reduce anaesthetic requirements. Multimodal analgesia was optimised with non-opioid adjuncts, such as intravenous IV lignocaine infusion, magnesium, dexamethasone, clonidine, ketamine and non-steroidal anti-inflammatory drugs NSAIDS. Total intravenous anaesthesia TIVA commonly requires large amounts of propofol and remifentanil infusions and was recommended to be avoided as much as possible for routine anaesthesia during COVID.

If TIVA is deemed necessary, such as spine cases requiring neuromonitoring, or neurosurgery with raised intracranial pressure, modifications to the technique to reduce propofol usage were considered. Once the need for neuromonitoring is over, maintenance of anaesthesia can be switched to volatiles rather than TIVA.

Depth of anaesthesia monitoring was encouraged to avoid excessive anaesthetic use and hypotension requiring vasopressors. Oxygen was recommended to be rationalised for patients with decent cardiorespiratory reserves. Other than during preoxygenation and extubation, minimal-to-low fresh gas flows were used.

Down-titrating volatiles or using nitrous oxide near the end of surgery can aid in faster anaesthetic washout prior to extubation without the use of excessively high flows. Postoperative oxygen supplementation was titrated if needed rather than a blanket measure. While considering the use of alternative drugs for sedation and analgesia, anaesthesiologists should be aware of the potential pitfalls in the pharmacokinetics and pharmacodynamics of alternative agents.

Use of less familiar or less titratable agents may result in delayed or less favourable emergence profiles, or unanticipated side effects. For example, thiopentone has less suppression of laryngeal reflexes than propofol and may cause increased coughing or bronchospasm on emergence, further increasing aerosolisation of respiratory particles. Etomidate has been shown to cause adrenal suppression even with just one dose [ 8 ], which may affect recovery outcomes if the patient is a presymptomatic carrier of Sars-CoV-2 [ 9 ], and turns COVID-positive later.

Ketamine may raise BIS readings and confound the interpretation of depth of anaesthesia. In the process of modifying anaesthetic technique to conserve drugs, it is important to consider the risks of alternatives.

Inadequate regional block necessitating conversion to general anaesthesia halfway through surgery may pose more harm from manipulating airway under less-than-ideal conditions. Opioid-sparing analgesia should not result in inadequate analgesia. Some anaesthesiologists may be uncomfortable in providing what they perceive to be substandard care by using alternatives.

Hence, drug rationalisation is a more appropriate term than drug conservation, as every patient should receive tailored anaesthetic care based on their individual risk-benefit ratio. In patients with moderate to high risk, delivery of a safe anaesthetic with drugs that have favourable profiles should definitely supercede concerns of drug shortage.

To conclude, multidisciplinary coordination is needed to make a concerted effort for drug conservation during COVID pandemic and allocating them to dire areas of need. Anaesthesiologists can contribute by meticulously planning ahead and modifying usual techniques without increased risks to the patient.

This article is part of the Topical Collection on Covid Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. National Center for Biotechnology Information , U.

SN Compr Clin Med. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Accepted Jun 1. This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. Abstract COVID patients in the critical care unit tend to have prolonged hospital stay requiring high doses of sedation and paralysis to treat acute respiratory distress syndrome, resulting in a shortage of these drugs.

Prioritising Surgeries and Drug Conservation At hospital level, elective cases were reduced to only essential time-sensitive cases such as cancer surgery as a healthy patient may end up consuming resources which may make a difference in outcome to the next critically-ill patient.

Oxygen Use during Anaesthesia Oxygen was recommended to be rationalised for patients with decent cardiorespiratory reserves. Limitations and Potential Pitfalls While considering the use of alternative drugs for sedation and analgesia, anaesthesiologists should be aware of the potential pitfalls in the pharmacokinetics and pharmacodynamics of alternative agents.

Ethical Considerations In the process of modifying anaesthetic technique to conserve drugs, it is important to consider the risks of alternatives. Conclusion To conclude, multidisciplinary coordination is needed to make a concerted effort for drug conservation during COVID pandemic and allocating them to dire areas of need. Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. References 1. World Health Organization. Statement on the second meeting of the International Health Regulations.

Emergency committee regarding the outbreak of novel coronavirus nCoV. Mezher M, Taylor NP. Guidance on adaptations to standard UK critical care medication prescribing and administration practices during pandemic emergency pressures. Practical considerations for performing regional anesthesia: lessons learned from the COVID pandemic [published online ahead of print, Mar 24]. Opioid reduction strategies are important for laparotomies during the covid outbreak.

Reg Anesth Pain Med. Etomidate is associated with mortality and adrenal insufficiency in sepsis. Crit Care Med. Support Center Support Center. External link.

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Ketamine: Current applications in anesthesia, pain, and critical care

In anesthesiology, pain medicine, and critical care, practitioners at all levels need help to stay current with the continually evolving drug knowledge-base, and trainees need tools to prepare for in-training and board exams that increasingly test their knowledge of pharmacology. This practical book is aimed at both readerships. The editors and contributors are pharmacology experts representing a cross-section of clinical specialties and institutions in the United States and include pharmacologists, pharmacists, as well as physicians. Skip to main content Skip to table of contents. Advertisement Hide.

Essentials of Pharmacology for Anesthesia, Pain Medicine, and Critical Care

Experts and industry representatives were contacted, personal files were searched, and reference lists of relevant primary and review articles were reviewed. At least 2 sedative agents had to be compared and the quality of sedation, time to extubation, or length of ICU stay analyzed. Of these, 20 compared propofol with midazolam. Most trials were not double-blind and did not report or standardize important cointerventions.

Anaesthesia and Intensive Care Medicine

COVID patients in the critical care unit tend to have prolonged hospital stay requiring high doses of sedation and paralysis to treat acute respiratory distress syndrome, resulting in a shortage of these drugs. In our hospital, we have instituted strategies to rationalise drug and oxygen usage. This includes prioritising time-sensitive elective cases, reducing overall elective case load, favouring opioid-reduction strategies and usage of alternative anaesthetic agents not commonly used in ICU. Both intensive care physicians and anaesthesiologists have to cooperate on drug conservation as similar drugs are used in elective operating lists as in the ICU. Patient safety is of utmost importance and we should keep in mind some pitfalls and ethical concerns of these alternative strategies.

Deepak K. Tempe, Drugs in Anaesthesia and Intensive Care. Scarth and S. Smith editors. This pocket book was first published in and is now in its fifth edition. The book aims to provide the main pharmacodynamics and pharmacokinetics of the drugs with which a practising anaesthetist is expected to be familiar.

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Anaesthesia and Intensive Care Medicine , an invaluable source of up-to-date information, with the curriculum of both the Primary and Final FRCA examinations covered over a three-year cycle. Published monthly this ever-updating text book will be an invaluable source for both trainee and experienced anaesthetists Published monthly this ever-updating text book will be an invaluable source for both trainee and experienced anaesthetists.

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Она все еще не могла свыкнуться с мыслью о шифре, не поддающемся взлому. И взмолилась о том, чтобы они сумели вовремя найти Северную Дакоту.

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