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ISA KAN can dextometomidine be used as premedication in im route ? what dose ? can we use propofol in infants? thanks
Dr.Palanivel Rajan


ISA KAN additives to sab bupivacaine -adrenaline and magnesium how and in what doses are they used. someanesthetis flush syringe with adrenaline then load bupivacaine anesthesia lasts for 6hrs without any complications.are these drugs approved to be used it


ISA KAN sir is spinal anaesthesia contraindicated in patients with multiple sclerosis?
sai suraj
Multiple sclerosis is a degenerative disease of the CNS, characterised by multiple sites of demyelination in the brain and spinal cord. The course of the disease consists of exacerbations and remissions of symptoms. Stress, surgery and fatigue have been implicated in the exacerbation of multiple sclerosis. Spinal anaesthesia which results in high concentration on L.A. in the spinal white matter may produce relapse of the demyelination. Even though direct correlation between local anaesthetics and white mater toxicity is lacking, it is better to avoid spinal anaesthesia in multiple sclerosis. If regional anaesthesia is compulsory because of coexisting illnesses (pulmonary or difficult airway) epidural is better compared to spinal. Because of the fact that the local anaesthetic concentration inside the spinal cord is lower with epidural technique than with subarachnoid block. And another strong reason to avoid neuraxial block in Multiple sclerosis is medico legal. In a progressive neurological illness like Multiple sclerosis, which may coincidentally worsen in the post- operativeperiod and the anaesthetic technique will be blamed. If at all regional anaesthesia has to be contemplated, peripheral nerve block has to be considered as the peripheral nerves are not involved in M.S.

Ref: Regional anaesthesia in the patient with pre-existing neurologic dysfunction.-Terese .T.Horlocker , Mayo clinic, Minnesota.
Prof. Dr.R.Selvakumar



ISA KAN Why is there no preservative in Bupivicaine Heavy while it is there in Bupivicaine Plain?
ISA KAN The preservative, Methyl Paraben is added to the multi dose bupivacaine vial as an anti-microbial agent. It doesnot prevent the drug being degraded on prolonged storage or stored in unfavourable climatic conditions. Anti-microbial agent is needed only for multi-dose vials, not for single dose spinal ampoules. That is why bupivacaine heavy is marketed without preservative.

Some additional facts about parabens:

Metabolism of parabens results in the formation of PABA derivatives which are potentially allergic products. Often the allergic incidences following amide local anaesthetics are blamed due to its preservatives (parabens) and may be true also. But animal studies and human volunteer studies show that parabens( methyl,ethyl,butyl and propyl) are relatively safe additives. They have been approved by the FDA as standard preservative agents as an anti-microbial agent in many foodstuffs, cosmetics and dermatological preparations (with a safe limit of less than 0.1%). They have not demonstrated any untoward reactions with parabens except some contact dermatitis.

If accidental injection of multi dose local anaesthetic agent with paraben in to the thecal sac occurs after an attempted epidural (Total Spinal), the nervous tissue is exposed to the parabens. Even though there is a theoretical possibility of neurotoxicity is there, there is no direct conclusive evidence for the same. It is proved that Rabbit vagus nerve incubation with 0.1% methyl paraben suppresses nerve excitability in a dose dependant manner but does not destroy nervous tissue. Even then FDA did not approve preservative containing local anaesthetic being used in epidural and caudal anaesthesia.




ISA KAN How do you use sugamadex?
julia oliveira

Sugammadex is not available in the drug market because it is not approved by FDA. Here are few interesting facts about Sugammadex.

Sugammadex Is Unique:

  • First product that can reverse a profound` neuromuscular block
  • Can provide immediate reversal when required
  • Avoids the need to use acetylcholinesterase inhibitors (AChEIs) and muscarinic antagonists Proposed Indication

Sugammadex is indicated in adults for:

  • Routine reversal of shallow and profound neuromuscular blockade induced by rocuronium or vecuronium
  • Immediate reversal of neuromuscular blockade at 3 minutes after administration of rocuronium.

Dosing Recommendations
The recommended dose of sugammadex depends on the level of neuromuscular blockade to be reversed

    Routine Reversal
  • A dose of 2.0 mg/kg is only recommended if spontaneous recovery has occurred up to the reappearance of T2 (shallow blockade) following rocuronium or vecuronium induced blockade.
  • A dose of 4.0 mg/kg is recommended if recovery has reached 1-2 post-tetanic counts (PTC) (profound blockade) following rocuronium or vecuronium induced blockade.
    Immediate Reversal
  • A dose of 16.0 mg/kg is recommended 3 minutes following the administration of rocuronium
    (There are no data to support the use of sugammadex for immediate reversal following vecuronium induced blockade)

Mechanism of Action
Sugammadex rapidly encapsulates rocuronium and vecuronium .
Sugammadex is inactive against non-steroidal neuromuscular blocking agents, like succinylcholine and Cisatracurium.


  • Sugammadex has been shown to be safe and efficacious in more than 2000 administrations in patients and volunteers
  • Its properties are expected to lead to safety benefits for patients
  • Sugammadex will become a valuable new drug in the management of neuromuscular blockade specifically and general anesthesia, overall.

FDA Approval Status
Monday, September 23, 2013

On September 23, Merck Inc. announced it had received a Complete Response Letter from the U.S. Food and Drug Administration (FDA) informing the company that its resubmitted New Drug Application for sugammadex had been rejected. According to Merck, the FDA raised issues with \\\"operational aspects of a hypersensitivity study\\\" that the FDA had requested in 2008.

ASA had previously expressed strong support for the approval of sugammadex in a formal comment letter to the FDA's Anesthetic and Analgesic Drug Products Advisory Committee.



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