As a rule, Diprivan® requires additional use of analgesic agents.
Diprivan® is combined with spinal and epidural anesthesia; with drugs commonly used for premedication; with muscle relaxants, means for inhalation anesthesia and analgesics, while there was no pharmacological incompatibility. Lower doses of Diprivan® may be required in cases where general anesthesia is used as a supplement to the methods of regional anesthesia used.
Guidance on the preparation of the introduction of Diprivan® target concentration by the infusion system that includes appropriate software "Diprifyuzor" See D. This use is limited to the induction and maintenance of general anesthesia in adults. The infusion system for the target concentration (DIC) "Diprifuge" is not recommended for sedation in patients in intensive care units, for a sedative effect with conserved consciousness, or in children.
A. ADULTS
Induction of general anesthesia
Diprivan® can be used to induce anesthesia through slow bolus injections or infusion.Regardless of whether premedication was or was not performed, the administration of Diprivan® is recommended to be titrated (bolus injections or infusion of approximately 40 mg every 10 seconds - the average adult in satisfactory condition), depending on the patient's response before the appearance of clinical signs of anesthesia. For most adult patients under 55 years of age, the average dose of Diprivan® is 1.5-2.5 mg / kg. The required total dose can be reduced using lower administration rates (20-50 mg / min). For patients older than this age, usually a lower dose is required. Patients 3 and 4 classes ASA (Classification of the patient's physical status American Society of Anesthesiology (ASA) Classification), administration should be performed at a lower rate (approximately 20 mg every 10 seconds).
Maintaining general anesthesia
Anesthesia can be maintained either by a constant infusion of the Diprivan® drug, or by repeated bolus injections necessary to maintain the required depth of anesthesia.
Continuous infusion
The required rate of administration varies considerably depending on the individual characteristics of the patients.Typically, a rate of between 4-12 mg / kg / h ensures adequate anesthesia.
Repeated bolus injections
If a technique involving repeated bolus injections is used, then the administration of increasing doses from 25 mg to 50 mg, depending on the clinical need, is used.
Sedation during intensive care
The introduction of Diprivan® with the help of the Diprifuge system for the sedation of patients during intensive care is not recommended.
When using the drug Diprivan ® for sedation of adult patients who are on ventilation and receiving intensive therapy, it is recommended to use it through continuous infusion. The rate of infusion should be adjusted to the required depth of sedation, but a rate of 0.3-4.0 mg / kg / h should ensure satisfactory sedation. The infusion rate should not exceed 4.0 mg / kg / h, unless the potential benefit to the patient outweighs the risk of side effects.
Sedation of patients who are conscious, during surgical and diagnostic procedures
The introduction of Diprivan® with the help of the Diprifusor system for sedation with preservation of consciousness is not recommended.
To ensure sedation during surgical and diagnostic procedures, the rate of administration and dosage should be selected individually depending on the clinical response of the patient.
For the majority of patients, 0.5-1.0 mg / kg is required for 1-5 minutes for the onset of sedation.
To maintain sedation, the infusion rate should be adjusted according to the required depth of sedation; for most patients, a rate of 1.5-4.5 mg / kg / h is required. If a rapid increase in the depth of sedation is required, bolus administration of 10-20 mg of Diprivan® can be used as an adjunct to the infusion. For patients 3 and 4 classes ASA it may be necessary to reduce the dose and rate of administration.
B. Older patients
Older patients require lower doses of Diprivan® for anesthesia. When reducing the dose should be guided by the physical status and age of the patient. A reduced dose should be administered at a lower rate than usual and titrated according to the patient's response. When using Diprivan ® to maintain anesthesia or sedation, the infusion rate or "target concentration" of the drug should be reduced. For patients 3 and 4 classes ASA a further reduction in dose and rate of administration may be required. To avoid oppression of the cardiovascular and respiratory systems, elderly patients are not recommended for rapid bolus administration (single or repeated).
V. CHILDREN
Children are not advised to administer Diprivan® with the help of the Diprifuge system at any indications.
Induction of general anesthesia
Diprivan® is not recommended for use in children under 1 month of age (see "Contraindications").
When using the drug Diprivan ® in order to ensure the induction of anesthesia in children, it is recommended to inject it slowly until the appearance of clinical signs of anesthesia. The dose should be adjusted according to the age and / or body weight of the child.
For most children over the age of 8, approximately 2.5 mg / kg of Diprivan® is probably needed to induce anesthesia.
For children aged 1 month to 8 years, the required dose may be higher. A lower dose is recommended for children of grades 3 and 4 ASA.
Maintaining general anesthesia
Diprivan® is not recommended for use in children under 1 month of age.
Maintenance of anesthesia is achieved by the administration of Diprivan® through continuous infusion or by repeated bolus injections,Required to maintain the required depth of anesthesia. The required rate of administration differs significantly in different patients; satisfactory anesthesia is usually provided at infusion rate of 9-15 mg / kg / h.
Sedation of patients who are conscious, during surgical and diagnostic procedures
Diprivan® is not recommended for use in children under 1 month of age.
To ensure short-term sedation during surgical and diagnostic procedures, the rate of administration and dose should be selected individually depending on the clinical response of the patient.
In most cases, the onset of sedation is achieved with the administration of the drug at a dose of 1-2 mg / kg for at least 1 minute. To maintain sedation, the infusion rate should be adjusted in accordance with the required depth of sedation; for most patients, a rate of 1.5-9 mg / kg / h is required. If a rapid increase in the depth of sedation is required, bolus injection of Diprivan® in a dose of up to 1 mg / kg may be used as an adjunct to the infusion.
For patients in grade 3 and 4, ASA may require a reduction in dose and rate of administration.
Sedation during intensive care
Diprivan® is not recommended for sedation in children, since its safety and efficacy in this application have not yet been confirmed. With unlicensed use, serious adverse events (including deaths) were noted, although there was no causal relationship with Diprivan®. These adverse events were most often observed in children with respiratory tract infections that received doses exceeding the recommended doses for adults.
D. INTRODUCTION
Diprivan® can be administered undiluted using plastic syringes or glass vials for infusion or filled with Diprivan® glass syringes. In cases where Diprivan® is used in undiluted form to maintain general anesthesia, it is recommended to always use perfusors or infusomats in order to control the rate of administration.
Diprivan® can also be used diluted with only 5% dextrose solution for intravenous administration, in PVC bags or in glass bottles.The solution, the dilution of which should not exceed a ratio of 1: 5 (2 mg / ml propofol), should be prepared in accordance with the rules of aseptic immediately before use. The mixture remains stable for 6 hours.
A diluted solution of Diprivan® can be administered using a variety of adjustable infusion systems, however, the use of only such devices does not completely avoid the risk of accidental, uncontrolled administration of large volumes of diluted Diprivan®. Burettes, drip counters or dosing pumps should always be part of the infusion line. When choosing the maximum volume of diluted Diprivan® in a burette, one should keep in mind the risk of uncontrolled administration.
Diprivan® can be administered via a tee with a valve close to the injection site, concomitantly with the administration of a 5% dextrose solution for intravenous administration, 0.9% sodium chloride solution for intravenous administration or 4% dextrose solution with 0.18% sodium chloride solution for intravenous administration .
A ready-to-use glass syringe has less piston resistance than a plastic disposable syringe and is easier to drive.When Diprivan® is administered manually with a ready-to-use glass syringe, the infusion system between the syringe and the patient should not be left open if there is no observation from the medical staff.
Appropriate compatibility should be ensured if a ready-to-use glass syringe is used in a syringe pump. In particular, the design of the pump must prevent siphoning and should provide an alarm for clogging at a pressure of not more than 1000 mm Hg. If a programmable or equivalent pump is used, suggesting the possibility of using different syringes, then in the case of using a ready-to-use glass syringe, only the "B-D"50/60 ml Plastipak. Diprivan® can be pre-mixed with alfentanil for injection containing 500 μg / ml of alfentanil, in a volume ratio of 20: 1 to 50: 1. Mixtures should be prepared using sterile equipment, and applied within 6 hours after preparation.
To reduce pain at the start of the injection, the induction dose of Diprivan® immediately before administrationcan be mixed with lidocaine for injection in a plastic syringe in the following proportion: 20 parts Diprivan® and up to one part either 0.5% or 1% lidocaine solution for injection.
DIPRIVAN® DECOMPOSITION AND JOINT INTRODUCTION IN CONJUNCTION WITH OTHER MEDICINES OR INFUSION SOLUTIONS
| Method simultaneous applications | Drug or infusion solution | Preparation | Caveats |
| Preliminary mixing | 5% dextrose solution for intravenous administration | Mix 1 part of the Diprivan® preparation and up to 4 parts of a 5% dextrose solution for intravenous administration or in bags of PVC (PVC) or in glass bottles. When diluted in PVC bags it is recommended that the bag be full, the solution is prepared by removing a portion of the volume of the dextrose solution, replacing it with an equivalent volume of the Diprivan® preparation | Cooking vaseptic conditions, directly before use. The mixture remains stable for 6 hours |
| Lidocaine for injection (0.5% or 1% without preservatives) | Mix 20 parts of Diprivan® and up to 1 part of 0.5% or 1% solution of lidocaine for injection | Cooking, observing the conditions of asepsis, immediately before application. To be used only for the induction of anesthesia |
| Alfentanil for injection (500 μg / ml) | Mix Diprivan® with alfentanil for injection in a volume ratio of 20: 1 to 50: 1 | Cook, observing the conditions of aseptic, immediately before use. Apply within 6 hours after cooking |
| Simultaneous introduction of a tee with a valve | 5% dextrose solution for intravenous administration | Simultaneous administration using a tee with a valve | Tee with valve close to injection site |
| 0.9% solution of sodium chloride for intravenous administration | See above | See above |
| 4% dextrose solution with 0.18% sodium chloride solution for iv administration | See above | See above |
E. INFUSION ON TARGET CONCENTRATION - INTRODUCTION OF DIPRIVAN® DRUG WITH THE SYSTEM FOR AND THE DIPRIFYUSOR CENTER FOR ADULTS
The introduction of Diprivan® with the help of the Diprifuge system is limited to periods of induction and maintenance of general anesthesia in adults. It is not recommended to use sedation in intensive care, to provide a sedative effect with the preservation of consciousness or in children.
Diprivan® can be introduced by the ICC method only with the help of the Diprifusor ICP system, which includes the Diprifuser software. These systems will function only after recognizing the electronic label on a ready-to-use glass syringe filled with Diprivan®.
The Diprifuge system will automatically adjust the rate of administration of the Diprivan® preparation to that concentration that was recognized by the system. Users should be familiarized with the manual for working with the infusion pump, with the introduction of Diprivan® by the ICC method, with the correct use of the syringe recognition system, as described in the training manual provided by AstraZeneca.
This system enables the anesthesiologist to achieve and control the induction rate and depth of anesthesia by setting and adjusting the target (predicted) concentration of propofol in the patient's blood.
The Diprifyuzor system assumes that the initial concentration of propofol in the patient's blood is 0. Therefore, for patients receiving propofol earlier, probably, it is necessary to choose lower initial target concentration at the beginning of introduction of preparation Diprivan® with the help of ICP "Diprifyuzor". Also, it is not recommended to resume the work of the Diprifusor IC in the previous mode after it was shut down.
Guidance on the selection of target concentrations of propofol is attached below. Due to the individual differences in the pharmacokinetics and pharmacodynamics of propofol in patients who received premedication and who did not receive it, the target concentration of propofol should be titrated depending on the patient's clinical response in order to achieve the required depth of anesthesia.
In adult patients under 55 years of age, anesthesia can usually be induced by targeted concentrations of propofol from 4 to 8 μg / ml. The initial target concentration of propofol 4 μg / ml is recommended for patients who have been premedicated, a concentration of 6 μg / ml is recommended for patients without premedication. The time of induction of anesthesia at these target concentrations is, as a rule, 60-120 seconds. Higher values will lead to faster induction of anesthesia, but may be associated with more severe hemodynamic depression and respiratory function.
Smaller initial target concentrations should be used in patients older than 55 years and in patients 3 and 4 classes ASA. The target concentrations can then be gradually increased by a value from 0.5 to 1.0 μg / ml at intervals of 1 minute to achieve a gradual induction of anesthesia.
As a rule, additional analgesia is required, and the amount of reduction in target concentrations to maintain anesthesia will depend on the amount of additional analgesics administered. Target concentrations of propofol in the range of 3 to 6 μg / ml usually maintain a sufficient level of general anesthesia.
The predicted concentration of propofol upon awakening is generally within 1.0-2.0 μg / ml and will depend on the level of analgesia during the period of anesthesia maintenance.
Sedation during intensive care
Typically, a target concentration of propofol in the blood in the range of 0.2-2.0 μg / ml is required. The administration of Diprivan® should be started at a low target concentration and titrated with dose depending on the patient's reaction for achieving the desired sedation depth.