UNCONVENTIONAL MODES OF UNCONVENTIONAL MODES OF ANAESTHETIC DRUG ANAESTHETIC DRUG

ADMINISTRATIONADMINISTRATION

Dr.R.Selvakumar.,MD.,DA.,DNB.,Dr.R.Selvakumar.,MD.,DA.,DNB.,

Professor of AnaesthesiologyProfessor of Anaesthesiology

K.A.P.Viswanatham Govt Medical College ,K.A.P.Viswanatham Govt Medical College ,

Trichirapalli-IndiaTrichirapalli-India

Why Anaesthesia Has to be ThroughInhalational route?

Volatile Chemicals Volatile Chemicals possessing anaesthetic possessing anaesthetic propertyproperty No Complex Apparatus No Complex Apparatus neededneeded Late Development of Late Development of Parentral drugs.Parentral drugs.

REASONS MAY BE..REASONS MAY BE..

IT BECAME CONVENTIONAL ………BECAUSEIT BECAME CONVENTIONAL ………BECAUSE

Ease of Ease of AdministrationAdministration Simple Simple Anesthetic Anesthetic ApparatusApparatus Better and Better and quick Reversibilityquick Reversibility

Why to go for Why to go for Unconventional Unconventional Methods…..?Methods…..?

Unconventional Methods May……Unconventional Methods May……

Improve Patient Improve Patient ComplianceCompliance ConvenienceConvenience Increased Bio- Increased Bio- AvailabilityAvailability Improved Improved Analgesic EfficacyAnalgesic Efficacy

Trans dermal Drug Trans dermal Drug deliverydelivery Trans mucosal /OralTrans mucosal /Oral Intra Nasal Intra Nasal RectalRectal Intra ArticularIntra Articular Inter PleuralInter Pleural Peri neural OpioidsPeri neural Opioids Intra trachealIntra tracheal

What What AreAre They………..? They………..?

Skin as a barrierSkin as a barrier Drug absorption depends Drug absorption depends

onon Drug concentration in the Drug concentration in the vehiclevehicle-Aqueous solubility-Aqueous solubility-Oil-Water partition co--Oil-Water partition co-efficientefficient-Lipid solubility-Lipid solubility-Low molecular weight-Low molecular weight-High potency-High potency

Trans dermal Drug DeliveryTrans dermal Drug Delivery

Trans Dermal Drug DeliveryTrans Dermal Drug Delivery

TDFCTDFC NTG Skin patch.NTG Skin patch. EMLA creamEMLA cream

TDFCTDFCTransdermal fentanyl citrateTransdermal fentanyl citrate

Skin patch has four layers :Skin patch has four layers :

a)a) Backing LayerBacking Layer

b)b) Drug reservoir Drug reservoir

c)c) Rate controlling membraneRate controlling membrane

d)d) Adhesive Adhesive

TDFC-STRUCTURETDFC-STRUCTURE

25, 50,75& 10025, 50,75& 100μgμg/ hour patches/ hour patches

Elimination half-life 17 Elimination half-life 17 ±± 2.3 hours 2.3 hours

Plasma level decrease slowly even after removal Plasma level decrease slowly even after removal

Onset slowOnset slow

Variable relationship between dose & plasma levelVariable relationship between dose & plasma level

TDFC- contd…TDFC- contd…

2.5% Lignocaine +2.5 prilocaine2.5% Lignocaine +2.5 prilocaine Eutectic mixtureEutectic mixture Skin harvesting for SSGSkin harvesting for SSG Neonatal circumcisionNeonatal circumcision Canular insertionCanular insertion

EMLA CREAM

Can EMLA cream be used for Ear boring?Can EMLA cream be used for Ear boring?

It has to be applied as an adhesive dressing 2 hours priorto the ear boring…

NTG PATCH

Easy way of administering Nitroglycerine

Variable rate of absorption

Transmucosal Drug DeliveryTransmucosal Drug Delivery

ORALORAL

TRANS NASALTRANS NASAL

SUBLINGUALSUBLINGUAL

TRANSMUCOSAL - ORALTRANSMUCOSAL - ORAL

ORAL NARCOTICSORAL NARCOTICS

VARIABLE BIO-AVAILABILITYVARIABLE BIO-AVAILABILITY

SUBLINGUAL BUPRENORPHINESUBLINGUAL BUPRENORPHINE

PREMED,POSTOP & CANCER PAINPREMED,POSTOP & CANCER PAIN

BIO AVAILABILITY OF ORAL OPIOIDSBIO AVAILABILITY OF ORAL OPIOIDS

ORAL -MSTORAL -MST

- - Low Bio AvailabilityLow Bio Availability

- Delayed onset timeDelayed onset time

- 30-200mg per day30-200mg per day

- Constipation & ToleranceConstipation & Tolerance

ORAL – OTFCORAL – OTFCOral Transmucosal Fentanyl citrateOral Transmucosal Fentanyl citrate

Sweetened lozenge on a stickSweetened lozenge on a stick

Onset of action –5-10minOnset of action –5-10min

200, 300,400200, 300,400μgμg units units

5-155-15μg per kgμg per kg

50% Bio -Availability50% Bio -Availability

ORAL KETAMINE PREMEDICATIONORAL KETAMINE PREMEDICATION

Ketamine mixed in sweetened drinksIn a dose of 0.5-4 mg /kg

Large Surface areaLarge Surface area

Good VascularityGood Vascularity

Butorphanol –Metered dose pump sprayButorphanol –Metered dose pump spray

Midazolam 0.1-02mg/kgMidazolam 0.1-02mg/kg

INTRANASAL ROUTEINTRANASAL ROUTE

INTRANASAL APPLICATIONSINTRANASAL APPLICATIONS

Intranasal nifedipine can be tried instead of Sublingual application

NebulizationNebulization

• Upper Airway Nebulization with 4% lignocaineUpper Airway Nebulization with 4% lignocaine

• Fentanyl –Liposome Encapsulated formFentanyl –Liposome Encapsulated form

• Morphine in aqueous solution.Morphine in aqueous solution.

NebulizationNebulization

Rectal MedicationsRectal Medications Position Decides Bio-AvailabilityPosition Decides Bio-Availability

Induction of anaesthesiaInduction of anaesthesia

Post op painPost op pain

Ketamine, Midazolam, DiazepamKetamine, Midazolam, Diazepam

Morphine Hydrogel suppositoriesMorphine Hydrogel suppositories

100mg & 12.5mg100mg & 12.5mg Postoperative pain reliefPostoperative pain relief Bottom surgeriesBottom surgeries Vaginal hysterectomyVaginal hysterectomy Circumcision, hydrocoeleCircumcision, hydrocoele

Rectal DiclofenacRectal Diclofenac

Following ArthroscopyFollowing Arthroscopy

Local AnestheticsLocal Anesthetics

Opioids-Morphine (1-5mg)Opioids-Morphine (1-5mg)

Ketoralac ,FentanylKetoralac ,Fentanyl

Sufentanyl, NeostigmineSufentanyl, Neostigmine..

Intra Articular ApplicationIntra Articular Application

Demonstration of Peripheral Opioid SystemDemonstration of Peripheral Opioid System

Controversial Prolongation of LA Blocks by Opioids.Controversial Prolongation of LA Blocks by Opioids.

Perineural Application Of OpioidsPerineural Application Of Opioids

Local Anesthetic solution in pleural cavityLocal Anesthetic solution in pleural cavity

Tuohy needle –Epidural catheterTuohy needle –Epidural catheter

LA diffusing through posterior pleural membraneLA diffusing through posterior pleural membrane

Dose 0.4-0.5ml/Kg (20-25ml)Dose 0.4-0.5ml/Kg (20-25ml)

Post-thoracotomy pain reliefPost-thoracotomy pain relief

Post cholecystectomy, Post herpetic pain.Post cholecystectomy, Post herpetic pain.

Multiple rib fracture.Multiple rib fracture.

InterpleuralInterpleural Analgesia Analgesia

Technique of Interpleural AnalgesiaTechnique of Interpleural Analgesia

Tumuscent AnesthesiaTumuscent Anesthesia

An easy way of releasing the scar….An easy way of releasing the scar….

Tumuscent AnesthesiaTumuscent Anesthesia

Subcutaneous injection of large volume of LASubcutaneous injection of large volume of LA

35-55mg/kg Lignocaine35-55mg/kg Lignocaine

LiposuctionLiposuction

Scar excisionScar excision

Intra tracheal AdministrationIntra tracheal Administration

Adrenaline ,Atropine ,LignocaineAdrenaline ,Atropine ,Lignocaine

2.5 times the normal dose2.5 times the normal dose

During C P RDuring C P R

INTRA OSSEOUS ADMINISTRATIONINTRA OSSEOUS ADMINISTRATION

For resuscitation in infants & children.For resuscitation in infants & children.

Below the tubercle of tibia.Below the tubercle of tibia.

18G spinal needle.18G spinal needle.

In to the marrow cavityIn to the marrow cavity

Conclusion Conclusion

Have we left out any routes in the body?Have we left out any routes in the body?

Are they really helpful?Are they really helpful?

CONCLUSION-CONCLUSION-Contd…Contd…

Unconventional methods definitely increase Unconventional methods definitely increase the versatility of the Anesthesiologistthe versatility of the Anesthesiologist..

WHO KNOWS…

they may turn out to be conventional one day….!

THANK YOUThank You