Isoflurane Piramal

Isoflurane Piramal

isoflurane

Manufacturer:

Piramal Critical Care

Distributor:

Evercare Pharma
Full Prescribing Info
Contents
Isoflurane.
Description
lsoflurane is a colourless, nonflammable general inhalation anaesthetic which contains no additive or stabiliser. It is 1-chloro-2,2,2-trifluoroethyl difluoro-methyl ether.
Indications/Uses
General inhalation anaesthetic for use in induction and maintenance.
Dosage/Direction for Use
lsoflurane has a slight pungent ethereal odour, which may limit the rate of gas induction but, despite this, induction and particularly recovery are rapid.
The use isoflurane-specific vaporisers will facilitate accurate control of the administered concentration of anaesthetic.
The minimum alveolar concentration (MAC) the standard measure of potency for anaesthetics is 1.15% in pure oxygen decreasing to 0.5% when given with 70% nitrous oxide for middle-aged humans. There is an age-relationship, the MAC is significantly higher in children and is lower in the elderly. (See table.)

Click on icon to see table/diagram/image

Premedication: Premedication drugs should be selected according to the needs of the patient. The ventilatory depressant effect of isoflurane should be taken into account. Anticholinergic drugs (eg, atropine, glycopyrrolate USP) may be used for their effects in drying oral secretions (antisialogogue) at the discretion of the anaesthetist, but they may enhance the weak effects of isoflurane in increasing heart rate.
Induction: As isoflurane has a mild pungency, inhalation should usually be preceded by the use of a short-acting barbiturate or other IV induction agent, to prevent coughing. Salivation and coughing may be troublesome in small children induced with isoflurane. Alternatively, isoflurane with oxygen or with an oxygen/nitrous oxide mixture may be administered. It is recommended that induction with isoflurane be initiated at a concentration of 0.5%. Concentrations of 1.5-3% usually produce surgical anaesthesia in 7-10 min. Blood pressure decreases during induction but this may be compensated by surgical stimulation.
Maintenance: Adequate anaesthesia for surgery may be sustained with an inspired lsoflurane concentration of 1-2.5% in an oxygen/70% nitrous oxide mixture. Additional inspired isoflurane (0.5-1%) will be required with lower nitrous oxide levels, or when isoflurane is given with oxygen alone or with air/oxygen mixtures. Blood pressure decreases during maintenance anaesthesia in relation to the depth of anaesthesia. That is, blood pressure is inversely related to the isoflurane concentration. Provided there are no other complicating factors, this is probably due to peripheral vasodilation. Cardiac rhythm remains stable. Excessive falls in blood pressure may be due to the depth of anaesthesia and in such circumstances can be corrected by reducing the inspired isoflurane concentration.
Induced hypotension can be achieved by artificially ventilating patients with isoflurane 2.5-4%. Pretreatment with clonidine significantly decreases the isoflurane requirement for maintaining induced hypotension.
Recovery: The concentration of isoflurane can be reduced to 0.5% at the start of closing the operation wound and then to 0% at the end of surgery, provided that the anaesthetist is satisfied that the effect of any neuromuscular blocking drugs has been reversed and the patient is no longer paralysed. After discontinuation of all anaesthetics, the airways of the patient should be ventilated several times with oxygen 100% until complete recovery.
Overdosage
Overdosing with isoflurane will result in marked depression of breathing and a marked decrease in blood pressure, the latter being predominantly due to peripheral vasodilation rather than direct myocardial depression.
If it appears that an overdose has been administered, stop drug inspiration immediately, ensure a clear airway and ventilate the lungs with oxygen. Institute assisted or controlled ventilation.
Contraindications
Known sensitivity to isoflurane or to other halogenated agents. Known or suspected susceptibility to malignant hyperthermia. Patients who have developed an icterus and/or fever of unknown origin, hepatic impairment or eosinophilia after administration of isoflurane or another halogenated anaesthetic.
Special Precautions
Isoflurane is a profound respiratory depressant, this effect being accentuated by narcotic premedication or concurrent use of other respiratory depressants.
Isoflurane causes an increase in cerebral blood flow at deeper levels of anaesthesia (1.5%) and this may give rise to an increase in cerebral spinal fluid pressure. Where appropriate, this can be prevented or reversed by hyperventilating the patient before or during anaesthesia. As with other halogenated anaesthetics, isoflurane must be used with caution in patients with increased intracranial pressure. In such cases, hyperventilation may be necessary.
As with all halogenated anaesthetics, repeat anaesthesia within a short period of time should be approached with caution since the risk of hepatotoxicity is not fully understood. There is insufficient experience of use in repeated anaesthesia to make a definite recommendation in this regard.
Isoflurane has been reported to interact with dry carbon dioxide adsorbents during closed-circuit anaesthesia to form carbon monoxide. Inhalation of carbon monoxide may lead to formation of significant levels of carboxyhaemoglobin in exposed patients. Carboxyhaemoglobin is toxic even in low concentrations and is not easily detected by standard anaesthesia monitors eg, pulse oximeters. Direct measurement of carboxyhaemoglobin should be carried out in the event that a patient on closed-circuit anaesthesia with an implicated agent develops oxygen desaturation which does not respond to the usual therapeutic measures. All necessary precautions should be taken to ensure that carbon dioxide adsorbents are not allowed to dry out.
Caution should be exercised when administering isoflurane to patients with preexisting liver disease.
Isoflurane is a powerful systemic and coronary arterial dilator. The effect on systemic arterial pressure is easily controlled in the normal healthy patient and has been used specifically as a means of inducing hypotension. However, the phenomenon of "coronary steal" means that isoflurane should be used with caution in patients with coronary artery disease. In particular, patients with subendocardial ischaemia might be anticipated to be more susceptible.
Salivation and tracheo-bronchial secretions may be stimulated in children but pharyngeal and laryngeal reflexes are quickly diminished.
Because levels of anaesthesia can be altered easily and quickly with isoflurane, only vaporisers which produce a predictable concentration with a good degree of accuracy should be used. The degree of hypotension and ventilatory depression may provide some indication as to the level of anaesthesia. The level of anaesthesia may be changed quickly with isoflurane. Heart rhythm remains stable but spontaneous breathing should be monitored closely and supported where necessary.
It is recommended that vapour from isoflurane and other inhalational agents are efficiently extracted from the area of use.
Isoflurane should only be administered by, or in the presence of, anaesthetists with the appropriate anaesthesia and resuscitation equipment.
Use of inhaled anaesthetic agents has been associated with very rare increases in serum potassium levels that have resulted in cardiac arrhythmias and death in children during the postoperative period. The condition has been described in patients with latent as well as overt neuromuscular disease particularly Duchenne muscular dystrophy. Use of suxamethonium has been associated with most, but not all of these cases. These patients showed evidence of muscle damage with increased serum creatinine kinase concentration and myoglobinuria. These patients did not have classical signs of malignant hyperthermia eg, muscle rigidity, rapid increase in body temperature or increased oxygen uptake and carbon dioxide production. Prompt and vigorous treatment for hyperkalemia and arrhythmias is recommended. Subsequent evaluation for latent neuromuscular disease is indicated.
Effects on the Ability to Drive or Operate Machinery: As with all general inhalation anaesthetics, it is advisable to allow 24 hrs to elapse before driving or operating machinery.
Use in pregnancy & lactation: Reproduction studies have been carried out on rats and rabbits after repeated exposure to isoflurane at anaesthetic concentrations. In both species, there was no effect on fertility, pregnancy or delivery. The viability of the offspring was unaffected.
The correlation between animal study results and human reactions is not known and insufficient data are present for humans and animals to estimate the risk of teratogenicity in children of women who receive isoflurane anaesthesia during pregnancy. Isoflurane is not recommended during the 1st trimester of pregnancy.
All anaesthetics should be avoided during pregnancy if possible. Unavoidable anaesthesia with isoflurane should be undertaken using due caution. There is an increasing volume of information on the use of isoflurane in pregnancy and obstetrics anaesthesia and use in operative obstetrical interventions eg, caesarean section is established.
A suitable level of anaesthesia for caesarean section can be maintained with 0.5-0.75% isoflurane in oxygen/nitrous oxide. Increased blood loss has been observed, comparable with other volatile anaesthetics (eg, halothane), in patients undergoing uterine curettage or other gynaecological surgical procedures.
Should isoflurane be administered during lactation, lactation is to be interrupted after the anaesthesia. Lactation can be restarted after the drug has been discharged from the circulation.
Use In Pregnancy & Lactation
Reproduction studies have been carried out on rats and rabbits after repeated exposure to isoflurane at anaesthetic concentrations. In both species, there was no effect on fertility, pregnancy or delivery. The viability of the offspring was unaffected.
The correlation between animal study results and human reactions is not known and insufficient data are present for humans and animals to estimate the risk of teratogenicity in children of women who receive isoflurane anaesthesia during pregnancy. Isoflurane is not recommended during the 1st trimester of pregnancy.
All anaesthetics should be avoided during pregnancy if possible. Unavoidable anaesthesia with isoflurane should be undertaken using due caution. There is an increasing volume of information on the use of isoflurane in pregnancy and obstetrics anaesthesia and use in operative obstetrical interventions eg, caesarean section is established.
A suitable level of anaesthesia for caesarean section can be maintained with 0.5-0.75% isoflurane in oxygen/nitrous oxide. Increased blood loss has been observed, comparable with other volatile anaesthetics (eg, halothane), in patients undergoing uterine curettage or other gynaecological surgical procedures.
Should isoflurane be administered during lactation, lactation is to be interrupted after the anaesthesia. Lactation can be restarted after the drug has been discharged from the circulation.
Adverse Reactions
Adverse reactions encountered with isoflurane are similar to those observed with other halogenated anaesthetics that includes hypotension, respiratory depression and arrhythmias.
Other minor side effects encountered while using isoflurane are increase in the white blood cell count (even in the absence of surgical stress) and also shivering, nausea and vomiting during the postoperative period. These side effects are only observed in a similar number of patients to other anaesthetics.
Increase in heart rate has been reported. Rare cases of bronchospasm have also been reported.
During marketing, there have been rare reports of mild, moderate and severe (some fatal) postoperative hepatic dysfunction. The causal relationship is unknown.
Drug Interactions
Muscle Relaxants: Isoflurane produces sufficient muscle relaxation for some intra-abdominal operations. It is compatible with all commonly used muscle relaxants, the effects of which may be markedly potentiated by isoflurane. The effect is most notable in nondepolarising agents, thus lower doses should be used in the presence of isoflurane. The effect of nondepolarising muscle relaxants can be counteracted by administering neostigmine as this has no effect on the relaxant properties of isoflurane.
Adrenaline: Administration of adrenaline (epinephrine) by any route during isoflurane anaesthesia may cause supraventricular or ventricular arrhythmias. Where adrenaline is used, the amount used should be limited to a maximum of 3 mg/kg of body weight in patients with normal hearts and less in those with rhythm disturbances.
Concurrent use of other β-sympathomimetic drugs eg, amphetamines may predispose to arrhythmias. If possible, interrupt treatment a few days before surgery.
Calcium Antagonists (and Other Vasodilators): Isoflurane can cause marked hypotension in patients receiving concomitant therapy with calcium antagonists, especially those of the dihydropyridine class. Patients receiving chronic therapy with other vasodilators eg, ACE inhibitors (eg, captopril, enalapril, lisinopril) or α1-adrenoceptor antagonists (eg, prazosin), may show unpredictable hypotension with any type of anaesthesia.
Monoamine Oxidase Inhibitors (MAOI):
Monoamine oxidase inhibitors have been shown to enhance the effects of general anaesthetics. If possible, patients should stop taking the MAOI drug at least 14 days before anticipated surgery.
Beta-Blockers:
Beta-blockers used in the peri-operative period will prevent or reduce any tendency for isoflurane to increase the heart rate. Thus, β-blockade will normally tend to be cardioprotective. Should an increase in heart rate or vasoconstriction be required, appropriate sympathomimetics should be given by the anaesthetist. A full drug history should always be taken by the anaesthetist.
Isoniazid: Isoniazid induces enzymes. Patients receiving isoniazid may be more susceptible to hepatotoxicity from volatile anaesthetics. If possible, cease isoniazid treatment 1 week before surgery.
Opioid Analgesics:
Opioid analgesics potentiate the respiratory depressant effect of isoflurane.
Storage
Store at controlled temperature (15-30°C) with cap tightly closed.
Shelf-Life: 5 years.
ATC Classification
N01AB06 - isoflurane ; Belongs to the class of halogenated hydrocarbons. Used as general anesthetics.
Presentation/Packing
Inhalation liqd 100% x 100 mL, 250 mL.
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