Emergency drugs in ot
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Now I have comprehensive information from authoritative anesthesia textbooks. Here is a complete, organized reference on emergency drugs in the OT:
Emergency Drugs in the Operation Theatre (OT)
Every OT must have emergency drugs immediately available before inducing anesthesia. Prefilled syringes are preferred for drugs that must be ready instantly - they offer longer stability and reduce error during high-stress situations. A systematic cart-top arrangement is associated with reduced error rates in simulated emergencies.
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e (p. 3748)
1. ACLS (Advanced Cardiac Life Support) Drugs
These must always be immediately available per American Heart Association protocols:
| Drug | Indication | Dose/Route |
|---|---|---|
| Epinephrine (Adrenaline) | Cardiac arrest (PEA, VF, asystole), anaphylaxis, severe bronchospasm | 1 mg IV every 3-5 min (arrest); 0.1-0.5 mg IV/IM (anaphylaxis) |
| Atropine | Bradycardia, vagal reactions, sinus node arrest | 0.5-1 mg IV (adult); 0.02 mg/kg (pediatric) |
| Amiodarone | VF/pulseless VT, intraoperative arrhythmias | 300 mg IV bolus (arrest); 150 mg IV slow (stable VT) |
| Lidocaine | VF/VT (alternative to amiodarone), local anaesthetic toxicity | 1-1.5 mg/kg IV |
| Vasopressin | Cardiac arrest, refractory vasodilatory shock | 40 units IV (arrest) |
| Sodium Bicarbonate | Metabolic acidosis, hyperkalemia, TCA toxicity | 1 mEq/kg IV |
| Calcium Chloride | Hypocalcemia, hyperkalemia, calcium channel blocker toxicity | 10 mg/kg IV slowly |
| Adenosine | SVT (supraventricular tachycardia) | 6 mg IV rapid push, then 12 mg |
2. Drugs for Intraoperative Hypotension / Vasopressors
| Drug | Mechanism | Notes |
|---|---|---|
| Ephedrine | Mixed α + β agonist | 5-10 mg IV bolus; preferred in bradycardia-associated hypotension; historically preferred in obstetric anesthesia |
| Phenylephrine | Pure α1 agonist | 50-100 mcg IV bolus or infusion; now preferred over ephedrine in neuraxial hypotension (less fetal acidosis) |
| Norepinephrine | α1 + β1 agonist | For refractory vasodilatory shock |
| Vasopressin | V1 receptor | When hypotension is refractory to catecholamines |
Phenylephrine is preferred over ephedrine as a vasopressor during neuraxial anesthesia because it lacks beta-adrenergic activity and causes less fetal acidosis. - Miller's Anesthesia, 10e (p. 2418)
3. Malignant Hyperthermia (MH) Emergency
A dedicated MH cart must be immediately available in any OT where triggering agents (volatile anesthetics, succinylcholine) are used.
Trigger agents to stop immediately: Volatile anesthetics (halothane, sevoflurane, desflurane, isoflurane), Succinylcholine
Clinical features: Muscle rigidity, rising EtCO2, tachycardia, hyperthermia, hyperkalemia, metabolic acidosis
| Drug | Dose | Mechanism |
|---|---|---|
| Dantrolene sodium | 2.5 mg/kg IV rapidly, repeat every 5 min as needed (max 10 mg/kg) | Reduces Ca²⁺ release from sarcoplasmic reticulum (RyR1 blocker) |
| Dantrolene nanosuspension (Ryanodex) | 2.5 mg/kg IV | Faster reconstitution, improved solubility |
At least 12 vials of dantrolene must be stocked (per MHAUS guidelines). Supportive treatment: active cooling, sodium bicarbonate, insulin + dextrose (hyperkalemia), furosemide (myoglobinuria). - Katzung's Basic and Clinical Pharmacology, 16e (p. 2209)
4. Airway Emergency Drugs
| Drug | Indication | Dose |
|---|---|---|
| Succinylcholine | Laryngospasm (refractory), RSI | 1-2 mg/kg IV; 4 mg/kg IM if no IV access |
| Propofol | Laryngospasm (first-line deepening), bronchospasm, emergence delirium | 1-2 mg/kg IV |
| Rocuronium | RSI (non-depolarizing alternative) | 1.2 mg/kg IV |
| Sugammadex | Reversal of rocuronium/vecuronium | 16 mg/kg (immediate reversal); 4 mg/kg (post-TOF) |
| Neostigmine + Glycopyrrolate | Reversal of non-depolarizing NMBs | 50 mcg/kg + 10 mcg/kg IV |
Laryngospasm protocol: 100% O2 + CPAP (15-20 cmH2O) → jaw thrust + deepen with propofol → if persistent: succinylcholine 1-2 mg/kg IV (or 4-5 mg/kg IM if no IV). - Barash, 9e (p. 3757)
5. Anaphylaxis in OT
| Step | Drug | Dose |
|---|---|---|
| 1st line | Epinephrine | 0.1-1 mg IV (titrated); 0.3-0.5 mg IM if no IV |
| Fluids | Crystalloid (NS/RL) | 500-2000 mL rapid IV |
| 2nd line | Hydrocortisone | 100-200 mg IV |
| 2nd line | Chlorpheniramine (H1 blocker) | 10-20 mg IV slow |
| Bronchospasm | Salbutamol nebulization | 2.5-5 mg via nebulizer |
Common triggers in OT: neuromuscular blocking agents (most common), latex, antibiotics, chlorhexidine, colloids.
6. Local Anaesthetic Systemic Toxicity (LAST)
Available whenever nerve blocks are being performed:
| Drug | Dose |
|---|---|
| 20% Lipid Emulsion (Intralipid) | 1.5 mL/kg IV bolus → 0.25 mL/kg/min infusion |
| Epinephrine (low dose) | Avoid high doses (impairs lipid rescue) |
The OT emergency equipment list should include 20% lipid emulsion + syringes of phenylephrine and ephedrine whenever regional blocks are performed. - Barash, 9e (p. 2810)
7. Quick-Reference Summary Table
| Emergency | First Drug | Backup/Support |
|---|---|---|
| Cardiac arrest | Epinephrine 1 mg IV | Amiodarone, Atropine (bradycardia) |
| Anaphylaxis | Epinephrine 0.1-1 mg IV | Hydrocortisone, Antihistamine |
| Malignant hyperthermia | Dantrolene 2.5 mg/kg IV | Cooling, NaHCO3, Insulin/Dextrose |
| Laryngospasm | Propofol 1 mg/kg IV + CPAP | Succinylcholine 1-2 mg/kg IV |
| Bronchospasm | Propofol IV + Salbutamol | Epinephrine, Hydrocortisone |
| Intraoperative hypotension | Ephedrine 5-10 mg IV | Phenylephrine, Noradrenaline |
| Bradycardia | Atropine 0.5-1 mg IV | Epinephrine, Isoproterenol |
| SVT | Adenosine 6 mg IV rapid | Amiodarone |
| LAST | 20% Lipid emulsion 1.5 mL/kg | Benzodiazepines (seizures) |
| Bronchospasm (inhalation trigger) | Sevoflurane depth increase | Salbutamol, Epinephrine |
| Opioid overdose/apnea | Naloxone 0.4 mg IV | Repeat q2-3 min PRN |
Key Points from Textbooks
- Always have ACLS drugs available before inducing anesthesia - epinephrine, atropine, and succinylcholine are the minimum. - Barash, 9e
- Use code sheets with prepopulated weight-based doses (especially in pediatrics) to reduce cognitive load during emergencies. - Barash, 9e (p. 3748)
- Check expiry dates regularly and replace outdated drugs.
- Use a systematic cart-top arrangement - associated with reduced medication errors in simulated emergencies.
- The Society for Pediatric Anesthesia critical events cards / smartphone app serve as excellent cognitive aids.
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