Formulary Chapter 15: Anaesthesia - Full Chapter
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15.01 |
General anaesthesia |
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15.01 |
Anaesthesia, sedation and resuscitation in dental practice |
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15.01 |
Gas cylinders |
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15.01.01 |
Intravenous anaesthetics |
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15.01.01 |
Barbiturates |
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15.01.01 |
Other intravenous anaesthetics |
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Propofol
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First Choice
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- 1% (10mg/ml) injections (Propofol Lipuro®) available as 200mg in 20ml ampoules.
- 500mg in 50ml and 1g in 100ml bottles.
- 1% (10mg/ml) 50ml (500mg) prefilled syringes for use in Diprifusor pumps (Diprivan®).
- 2% (20mg/ml) injection - 1g in 50ml bottles for ITU use only.
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Ketamine (Palliative Care)
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Formulary
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North of Tyne, Gateshead and North Cumbria - Ketamine in Palliative Care Pain (2020)
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Etomidate 20mg/10ml injection
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Alternatives
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Ketamine
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Alternatives
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- 200mg in 20ml (10mg/ml), 500mg in 10ml (50mg/ml) & 1g in 10ml (100mg/ml) injections
- 50mg in 5ml oral solution unlicensed
- Often used as an analgesic in the management of neuropathic pain by specialist pain teams
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Thiopental Sodium 500mg/20ml injection (Thiopentone)
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Alternatives
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15.01.02 |
Inhalational anaesthetics |
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Isoflurane
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First Choice
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Heliox21®
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Formulary
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Nitric Oxide
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Formulary
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Oxygen
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Formulary
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Methoxyflurane (Penthrox®)
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Alternatives
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- 99.9% inhalation vapour
- Approved for use in trauma related pain in Emergency Departments, in adults only
- Approved for procedural analgesia in procedures such as VAC dressing change/stent change/brachytherapy rod change, in adults only
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Sevoflurane
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Alternatives
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15.01.02 |
Volatile liquid anaesthetics |
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15.01.02 |
Nitrous oxide |
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Entonox®
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Alternatives
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50% nitrous oxide and 50% oxygen mixture used for analgesia
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Nitrous oxide
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Alternatives
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MHRA Drug Safety Update (Dec 2008): Nitrous oxide: neurological and haematological side-effects
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15.01.03 |
Antimuscarinic drugs |
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Atropine 600microgram injection
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Formulary
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Atropine pre-filled syringes (minijet®)
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Formulary
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- 1mg in 5ml and 3mg in 30ml injections in prefilled syringes used in cardiac resuscitation.
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Glycopyrronium injection (200mcg)
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Formulary
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Hyoscine Hydrobromide 400microgram injection
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Formulary
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15.01.04 |
Sedative and analgesic peri-operative drugs |
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15.01.04.01 |
Benzodiazepines |
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Diazepam
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Formulary
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- 2mg, 5mg tablets – 10mg tablets should no longer be used.
- 2mg in 5ml oral solution.
- 10mg in 2ml injection (plain & emulsion) .
- For use in epilepsy see section 4.8.2 and use in anxiety see
section 4.1.2.
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Lorazepam
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Formulary
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Midazolam
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Formulary
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- 5mg in 5ml, 10mg in 2ml injections
- 50mg in 50ml prefilled syringes - ITU use only
- Intranasal midazolam 40mg/ml + lidocaine 20mg/ml
- approved for use prior to cannulation for adult patients with
special needs receiving dental treatment under IV sedation.
- Miprosed® 5mg in 1ml (7.5ml) oral solution is approved for use as a sedative and pre-medication in children
Palliative care
- 10mg/2ml injection
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Temazepam
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Formulary
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Alimemazine (Trimeprazine)
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Formulary
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- 30mg/5ml syrup.
- see section 03.04.01 for other formulations.
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15.01.04.01 |
Benzodiazepines |
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15.01.04.02 |
Non-opioid analgesics |
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Diclofenac 75mg/1ml injection
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Formulary
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- Mainly for use in post-operative analgesia - see section 10.01.01 for other formulations
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MHRA Drug Safety Update (June 2013): Diclofenac: new contraindications and warnings
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Parecoxib 40mg injection (Dynastat®)
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Formulary
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- For peri-operative use only.
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Ketorolac injection
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Alternatives
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- 10mg/1ml & 30mg/1ml injection
- the use of this is no longer recommended, other parenteral analgesics are now preferred
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15.01.04.03 |
Opioid analgesics |
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Alfentanil
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Formulary
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- All non-palliative care indications
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Alfentanil (Palliative Care)
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Formulary
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- 500micrograms in 1ml [ST&S], 1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampouless - approved for initiation by specialists in palliative care
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Fentanyl
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Formulary
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- 100 microgram in 2ml & 500 microgram in 10ml injections
- 2.5mg in 50ml (50 micrograms/ml) syringe unlicensed
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Levobupivacaine with Fentanyl
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Formulary
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- 2 micrograms/ml with levobupivacaine 0.1% in sodium chloride 0.9% infusion, 100ml, 250ml & 500ml unlicensed
- 4 micrograms/ml with levobupivacaine 0.125% in sodium chloride 0.9% infusion, 500ml (RVI) unlicensed
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Remifentanil
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Formulary
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- 1mg, 2mg & 5mg injections.
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15.01.04.04 |
Other drugs for sedation |
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Dexmedetomidine (Dexdor®)
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Formulary
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- 100 micrograms in 1ml injection approved for use in patients:
- with traumatic brain injury, have no respiratory problems but require prolonged ventilatory support due to severe agitation, confusion and requirement for propofol/midazolam; and
- who are difficult to sedate e.g. with overdose of MDMA/PMA/”legal highs” or who have pre-existing drug or alcohol dependence or who have failed conventional methods of treatment.
- Paediatric patients undergoing cardiac surgery with a high risk of post-operative Junctional Ectopic Tachyarrhythmia (JET) or those suitable for fast-track surgery.
- 100 micgrograms in 1ml injection (intranasal) unlicensed route
- approved for pre-operative sedation in anxious children at risk of respiratory depression in whom midazolam is contraindicated or those who have failed pre-operative sedation with other agents.
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15.01.05 |
Neuromuscular blocking drugs |
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Suxamethonium Chloride
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Formulary
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15.01.05 |
Non-depolarising muscle relaxants |
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Atracurium
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Formulary
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- 25mg in 2.5ml
- 50mg in 5ml
- 250mg in 25ml injection
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Cisatracurium (Nimbex®)
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Formulary
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- 20mg in 10ml (2mg/ml) injection
- 150mg in 30ml (5mg/ml) injection
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Mivacurium (Mivacron®)
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Formulary
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- 10mg in 5ml injection
- 20mg in 10ml injection
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Pancuronium
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Formulary
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Papaverine
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Formulary
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- 30mg/2ml injection unlicensed
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Rocuronium (Esmeron®)
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Formulary
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Vecuronium (Norcuron®)
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Formulary
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15.01.05 |
Depolarising muscle relaxants |
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15.01.06 |
Drugs for reversal of neuromuscular blockade |
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15.01.06 |
Anticholinesterases |
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Edrophonium
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Formulary
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Neostigmine
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Formulary
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Neostigmine with Glycopyrronium
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Formulary
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- Glycopyrronium 500 microgram & neostigmine 2.5mg in 1ml injection (Robinul – neostigmine)
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Physostigmine
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Formulary
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- 1mg in 1ml injection unlicensed
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15.01.06 |
Other drugs for reversal of neuromuscular blockade |
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Sugammadex (Bridion®)
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Formulary
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- 200mg in 2ml & 500mg in 5ml injections
- Approved for the emergency reversal of blockade in cases of failed intubation in patients who are undergoing rapid sequence induction anaesthesia with rocuronium because of contra-indications to suxamethonium.
- Approved for the reversal of rocuronium blockade in obstetric general anaesthesia for caesarean sections.
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15.01.07 |
Antagonists for central and respiratory depression |
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Doxapram
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Formulary
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- 100mg in 5ml injection
- 2mg/ml 500ml intravenous infusion in glucose 5%
see section 03.05.01
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Flumazenil
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Formulary
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- 500 microgram in 5ml injection
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Naloxone
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Formulary
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- 400 microgram in 1ml injection (ampoules).
- 2mg/2ml pre-filled syringes (as per ACMD guidance).
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15.01.08 |
Drugs for malignant hyperthermia |
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Dantrolene Sodium (Dantrium Intravenous®)
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Formulary
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MHRA Drug Safety Update (July 2014): Intravenous dantrolene: risk of undissolved crystals
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15.01.09 |
Prophylaxis of acid aspiration |
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Sodium citrate (50ml packs)
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Formulary
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- 0.3 molar peppermint falvoured solution.
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15.02 |
Local anaesthesia |
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15.02 |
Articaine |
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15.02 |
Bupivacaine |
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Bupivacaine Hydrochloride
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Formulary
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- 0.25% & 0.5% injection 10ml
- 0.25% & 0.5% + adrenaline 1 in 200,000 inj. 10ml
- 0.5% in glucose 8% injection (Marcain Heavy)
- 0.1% & 0.125% unlicensed in sodium chloride 0.9% infusions
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Liposomal Bupivacaine (Exparel® )
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Formulary
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- 133mg/10ml & 266mg/20ml prolonged-release dispersion for injection.
- Alternative to local anaesthetic infusion via an indwelling brachial plexus nerve catheter for major shoulder/upper limb surgery.
- Audit of outcomes to be presented to trust Drug and therapeutic Committee's and Formulary Working Group within 12 months (from April 2024).
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15.02 |
Levobupivacaine |
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Levobupivacaine (Chirocaine®)
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Formulary
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- 0.25%, 25mg in 10ml & 0.5%, 50mg in 10ml & 0.75%, 75mg in 10ml injections
- 0.625mg/ml & 1.25mg/ml infusion bags
- for local infiltration in hip and knee replacement surgery.
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15.02 |
Lidocaine |
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Lidocaine
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Formulary
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- Injections (plain)
- 0.5% 10ml
- 1% 2ml, 5ml, & 10ml (10mg/ml)
- approved for use in post-operative pain management subject to local protocols with a review of adverse events to be submitted by October 2018
- 2% 2ml, 5ml & 20ml injection (20mg/ml)
- 5% 2ml Heavy injection (50mg/ml)
- 5% 10ml injection (50mg/ml) unlicensed
- Topical preparations
- 1% & 2% gel with chlorhexidine 0.25%
- 4% topical solution (some packs unlicensed)
- 5% ointment
- 2% spray unlicensed
- 100mg lollipops unlicensed
- Lidocaine 4%, adrenaline 0.1% & tetracaine 0.5% (LAT gel®) unlicensed
- approved for use in anaesthetising lacerations particularly in the paediatric population – not to be used in children weighing under 15kg.
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Lidocaine 2.5% with Prilocaine 2.5% (EMLA®)
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Formulary
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Lidocaine 4% cream (LMX4®)
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Formulary
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Lidocaine 5% and Phenylephrine 0.5%
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Formulary
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- 5% lidocaine & 0.5% phenylephrine solution with
applicator
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Lidocaine Spray
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Formulary
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- Metered dose spray (10mg/spray)
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Lidocaine with Adrenaline Injections
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Formulary
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15.02 |
Mepivacaine |
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15.02 |
Prilocaine |
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Prilocaine Hydrochloride
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Formulary
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- 0.5% 10ml injection unlicensed, 1% 20ml injection.
- 4% 2ml injection (cartridges).
- 2% 5ml injection (cartridges)
- Only to be used in patients undergoing spinal anaesthesia for day surgery where the procedure is anticipated to last less than 90 minutes.
- 3% & felypressin injection (cartridges).
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15.02 |
Chloroprocaine |
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Chloroprocaine hydrochloride (Ampres®)
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Formulary
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- 50mg/5ml ampoules & 400mg/20ml vials.
- Approved for spinal nerve and peripheral blocks. To be reviewed in April 2022.
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15.02 |
Ropivacaine |
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Ropivacaine Hydrochloride
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Formulary
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- 0.2% (200mL) infusion
- approved for peripheral nerve block infusions for post-operative pain
- 0.75% (10mL)
- approved for use in setting of conversion from labour epidural analgesia to surgical analgesia for emergency caesarean section
- 0.2% (10mL) solution for injection
- approved as an option for ambulatory day case hand surgery
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15.02 |
Tetracaine |
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Tetracaine (Amethocaine) (Ametop®)
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Formulary
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15.02 |
Other local anaesthetics |
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Articaine Hydrochloride with Adrenaline
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Formulary
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- Articaine 4% & adrenaline 1 in 100,000 injection
- approved for mandibular procedures in patients in whom nerve blocks are contraindicated.
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Cocaine
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Formulary
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- 4% nasal solution (drops) unlicensed
25% paste (1g syringe pack) unlicensed
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Cocaine with Adrenaline
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Formulary
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- 4% solution with adrenaline unlicensed
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Ethyl Chloride Spray
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Formulary
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Mepivacaine
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Formulary
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Mepivacaine IV
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Formulary
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PR Freeze Spray
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Formulary
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.... |
Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
Status |
Description |
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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment.
In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances.
For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement.
The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber.
If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care. |
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Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs. |
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Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care. |
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NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria. |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status. |
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