| Formulary Chapter 15: Anaesthesia - Full Chapter
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| 15.01 |
General anaesthesia |
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| 15.01 |
Anaesthesia, sedation and resuscitation in dental practice |
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| 15.01.01 |
Intravenous anaesthetics |
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| 15.01.01 |
Barbiturates |
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Thiopental
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 Restricted
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- Thiopental should only be used when the patient is under the supervision of an Anaesthetist.
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| 15.01.01 |
Other intravenous anaesthetics |
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Etomidate (Etomidate-Lipuro®)
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Formulary
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Provider notes
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Etomidate (Hypnomidate®)
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Formulary
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Provider notes
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Ketamine injection
(Anaesthetic)
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Formulary
 
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Lidocaine injection
(Anaesthesia)
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Restricted
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications.
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- The use of lidocaine (lignocaine) 2% cartridge, bupivacaine 0.0625% infusion andropivacaine is restricted to theatres only.
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Propofol
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Formulary
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Provider notes
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| 15.01.02 |
Inhalational anaesthetics |
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| 15.01.02 |
Volatile liquid anaesthetics |
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Desflurane
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Formulary
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Provider notes
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Isoflurane
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Formulary
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Provider notes
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Sevoflurane
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Formulary
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Provider notes
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Nitrous oxide
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Restricted
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Provider notes - NMUH:
- RFL:
- Procedure for the Administration of Entonox for Pain Relief
- RNOH:
- UCLH:
- WH:
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| 15.01.03 |
Antimuscarinic drugs |
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Atropine injection
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Formulary
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Provider notes
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Atropine Minijet® injection
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Formulary
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Provider notes
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Glycopyrronium injection
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Formulary
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Provider notes
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Hyoscine Hydrobromide
(injection)
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Formulary
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Provider notes
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| 15.01.04 |
Sedative and analgesic peri-operative drugs |
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| 15.01.04.01 |
Benzodiazepines |
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Diazepam
(Pre-medication)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications. Provider notes
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Lorazepam
(Pre-medication)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications. Provider notes
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Midazolam
(Pre-medication)
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Formulary
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NOTE: There is more than one monograph for Midazolam, click here to search for formulary status and its use for other indications. Provider notes - NMUH:
- RFL:
- RNOH:
- For paediatric sedation before procedures (including but not limited to MRI and pre-operatively).
 Unlicensed - Midazolam 2.5 mg/mL oral solution is an unlicensed product
- UCLH:
- WH:
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Temazepam
(Pre-medication)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications. Provider notes
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| 15.01.04.01 |
Benzodiazepines |
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| 15.01.04.02 |
Non-opioid analgesics |
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Ketorolac
(Post-operative pain)
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Restricted
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Provider notes
- NMUH:
- RFL:
- Restricted to anaesthetics
- RNOH:
- UCLH:
- WH:
- Ketorolac tablets are not available
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Parecoxib
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Formulary
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Provider notes
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| 15.01.04.03 |
Opioid analgesics |
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Alfentanil
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Formulary
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Fentanyl
(Injection)
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Formulary
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Provider notes
- NMUH:
- RFL:
- RNOH:
- Restricted Only on the recommendation of the Pain Team for patients intolerant to or with contraindications to morphine and oxycodone
- UCLH:
- WH:
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Remifentanil
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Restricted
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Provider notes - NMUH:
- For use in ICU (Intensive Care Unit) ONLY
- RFL:
- RNOH:
- UCLH:
- WH:
- CD = Controlled drug. The Misuse of Drug Regulations apply. For further details see. Prescribing Guidelines. Ideally, remifentanil should be administered as an infusion, either with a standard syringe driver or as a Target Controlled Infusion using the Minto pharmacokinetic model (with the Alaris PK pump). Remifentanil should be diluted before administration, typically to a concentration of 20 to 40 mcg/ml, though higher concentrations can be used. A recommended induction infusion rate is 0.5 mcg/kg/min or8 ng/ml target for a ventilated patient and the rate halved for maintenance and titrated to clinical need (considerably higher or lower rates may be required). Beware the elderly or those with significant comorbidity when initial rates should be reduced. A dedicated cannula or antireflux valve should be used if an IV cannula is shared with fluids or other drugs. The cannula and giving set should be flushed at the end of use to avoid boluses of remifentanil accidentally being administered postop. Boluses of remifentanil should be administered carefully, by slow injection over a period of 30 to 60seconds.
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| 15.01.04.04 |
Other drugs for sedation |
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Dexmedetomidine injection
(Sedation in ITU)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications.
Approved for light sedation (RASS 0 to -3) in mechanically ventilated adult patients with CAM ICU positive agitated delirium where agitation precludes weaning and extubation only after standard sedative agents (including propofol, clonidine or a benzodiazepine) had been trialled for 48 hours. (JFC January 2019).
Provider notes
- NMUH:
- RFL:
- see above indication
- Refer to local protocol for use
- RNOH:
- UCLH:
- WH:
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| 15.01.05 |
Neuromuscular blocking drugs |
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| 15.01.05 |
Non-depolarising muscle relaxants |
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Atracurium besilate
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Formulary
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Provider notes
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Cisatracurium
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Restricted
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- The use of cisatracurium is restricted to theatres only.
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Mivacurium
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Restricted
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- The use of mivacurium is restricted to theatres only
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Pancuronium
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Formulary
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Provider notes
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Rocuronium bromide
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Restricted
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- The use of rocuronium is restricted to theatres only
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Vecuronium Bromide
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Formulary
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Provider notes
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| 15.01.05 |
Depolarising muscle relaxants |
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Suxamethonium chloride
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Formulary
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Provider notes
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| 15.01.06 |
Drugs for reversal of neuromuscular blockade |
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| 15.01.06 |
Anticholinesterases |
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Neostigmine metilsulfate + Glycopyrronium bromide
(Reversal of neuromuscular blockade)
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Formulary
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Provider notes
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Neostigmine metisulfate
(Reversal of neuromuscular blockade)
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Formulary
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Provider notes
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| 15.01.06 |
Other drugs for reversal of neuromuscular blockade |
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Sugammadex
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Restricted
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Provider notes
- NMUH:
- Restricted to consultant anaesthetists only.
- RFL:
- For reversal of rocuronium or vecuronium induced neuromuscular blockade when:
- Neostmigmine / glycopyrrolate is unsuitable due to the patient’s clinical condition (e.g. history of ischaemic heart disease with proven rate-related myocardial ischaemia, atrial fibrillation/tachydysrhythmias, a-v conduction defects, brittle asthma)
- There is residual blockade despite standard doses of neostigmine / glycopyrrolate
- The patient is morbidly obese and there is concern of prolonged residual neuromuscular blockade
- Immediate reversal is required in an emergency situation (e.g. when the patient cannot be ventilated).
- RNOH:
- Restricted for the emergency reversal of rocuronium
- UCLH:
- WH:
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| 15.01.07 |
Antagonists for central and respiratory depression |
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Doxapram
(Anaesthesia)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications.
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Flumazenil
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Formulary
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- Flumazenil is used to reverse the sedative effects of benzodiazepines in anaesthetic, intensive care and diagnostic procedures. It should not be used for routine benzodiazepine reversal. It has a shorter half-life than diazepam and midazolam and care is required to avoid the risk of resedation.
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Naloxone
(Central and respiratory depression)
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Formulary
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Provider notes - NMUH:
- RFL:
- RNOH:
- Use in accordance with the RNOH guidelines, see link below
- UCLH:
- WH:
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 RNOH: Naloxone Use and Administration in Opioid Toxicity
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| 15.01.08 |
Drugs for malignant hyperthermia |
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Dantrolene sodium injection
(Malignant hyperthermia)
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Formulary
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Provider notes - NMUH:
- Check MHRA Drug Safety Update
- RFL:
- Stock kept in theatres on Malignant Hyperthermia trolley
- RNOH:
- UCLH:
- WH:
- Dantrolene Injection is kept in the following locations: Main Theatres, Obstetrics Theatre
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| 15.02 |
Local anaesthesia |
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Bupivacaine
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Formulary
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Approved for post-operative pain management following limb amputation for peripheral arterial disease to reduce post-operative opioid requirement (0.125% infusion via perineural stump catheter) (JFC September 2019).
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- Inj 0.25% (25mg/10mL); 0.5% (50mg/10mL) only
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Bupivacaine + Adrenaline
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Formulary
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Provider notes
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Bupivacaine + Fentanyl
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Formulary
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Provider notes
- NMUH:
- A ready-mixed bag of Fentanyl + Bupivicaine is available from Pharmacy
- RFL:
- Theatres: Bupivacaine 0.125% + Fentanyl 4micrograms/mL in NaCl 0.9% 480mL epidural bag
- Labour: Bupivacaine 0.1% + Fentanyl 2micrograms/mL in NaCl 0.9% 15mL epidural syringe
- RNOH:
- UCLH:
- WH:
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Bupivacaine + Glucose (Marcain Heavy®)
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Formulary
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Provider notes
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Levobupivacaine
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Formulary
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Provider notes
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Levobupivacaine + Fentanyl
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Formulary
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Provider notes
- NMUH:
- RFL:
- BCF: Levobupivacaine 0.125% + Fentanyl 4mcg/ml in 500ml
- RFH: Levobupivacaine 0.1% + Fentanyl 0.0002% in 100ml
- RNOH:
- UCLH:
- WH:
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Lidocaine + Adrenaline injection (Xylocaine®)
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Formulary
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- For emergency caesarean section
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Lidocaine 10% spray (Xylocaine®)
(Surface anaesthesia)
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Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications. Provider notes
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Lidocaine 2% + Chlorhexidine 0.25% gel (Instillagel®)
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Formulary
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Provider notes
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Lidocaine 2.5% + Prilocaine 2.5% cream (EMLA®)
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Formulary
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Provider notes
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Lidocaine 4% cream (LMX4®)
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Restricted
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Approved for topical anaesthetic of first-choice prior to venous cannulation or venepuncture for paediatrics (JFC July 2013)
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Lidocaine 4% solution (Laryngojet®)
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Formulary
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Provider notes
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Lidocaine 5% + Phenylephrine 0.5% topical solution
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Restricted
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Provider notes - NMUH:
- Formulary for ENT use only
- RFL:
- RNOH:
- UCLH:
- WH:
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Lidocaine 5% ointment
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Formulary
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Provider notes
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LAT gel (Lidocaine 4% + Adrenaline 0.1% + Tetracaine 0.5%)
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Unlicensed
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Approved for second-line management of pain in children requiring sutures/debridement (JFC February 2018)
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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| 15.02 |
Mepivacaine |
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Prilocaine 1% injection (Citanest®)
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Formulary
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Provider notes
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Prilocaine 3% + Felypressin injection (Citanest with Octapressin®)
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Formulary
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Prilocaine hydrochloride 2% hyperbaric solution (Prilotekal®)
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Restricted
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Approved for short duration spinal anaesthesia restricted to use in day surgery setting only (JFC February 2018).
Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Chloroprocaine
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Formulary
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Procaine hydrochloride
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Formulary
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Provider notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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Ropivacaine
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Restricted
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Approved for:
- Infiltration anaesthesia; restricted to RFH for knee surgery only (JFC January 2013)
- Single dose in an off-label manner as a local infiltration during total hip replacement (THR) and total knee replacement (TKR) (JFC January 2017)
- Surgical wound infiltration via Painbuster; for post-operative management of patients undergoing live-donor nephrectomy and patients undergoing Deep Inferior Epigastric Perforators (DIEP) flap breast reconstruction (JFC July 2015)
- Ropivacaine continuous surgical wound infiltration via Painbuster; for colorectal surgery and incisional hernia (JFC May 2016)
Provider notes
- NMUH:
- RFL:
- Local infiltration during total hip replacement (THR) and total knee replacement (TKR).
- RNOH:
- UCLH:
- WH:
- The use of Lidocaine (lignocaine) 2% cartridge, bupivacaine 0.0625% infusion and ropivacaine is restricted to theatres only.
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Tetracaine 4% gel (Ametop®)
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Restricted
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Provider notes - NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
- The use of tetracaine (Ametop) gel is restricted to Paediatrics DSU and A&E only.
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| 15.02 |
Other local anaesthetics |
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Articaine hydrochloride + Adrenaline injection
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Formulary
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Provider notes
- NMUH:
- RFL:
- For dental use at BCF only
- RNOH:
- UCLH:
- WH:
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Cocaine oromucosal solution
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Restricted
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Provider notes
- NMUH:
- RFL:
- 5% and 10% mouthwash available
- RNOH:
- Restricted - 10% available
- UCLH:
- WH:
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Ethyl Chloride (Cryogesic® Spray)
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Formulary
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econdary care notes
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Mepivacaine injection (Scandonest Plain®)
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Formulary
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econdary care notes
- NMUH:
- RFL:
- RNOH:
- UCLH:
- WH:
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| .... |
| Non Formulary Items |
Benzocaine 3% cream
(Local anaesthesia)
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Non Formulary
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Cocaine + Adrenaline
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Non Formulary
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Dermogesic spray
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Non Formulary
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Dexmedetomidine injection
(Opthalmic surgery)
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Non Formulary
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NOTE: There is more than one monograph for this medicine, click here to search for formulary status and its use for other indications.
Not approved for conscious sedation in Opthalmic surgery (May 2014) |
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Lidocaine + Tetracaine cream (Pliaglis®)
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Non Formulary
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Lidocaine 5% patch
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Non Formulary
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Not approved for neuropathic pain (November 2012) |
 NCL JFC: Position Statement - Lidocaine patch
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Mepivacaine + Adrenaline injection (Scandonest 2% Special®)
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Non Formulary
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Naloxone pre-filled syringes (Prenoxad®)
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Non Formulary
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Key |
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
| Status |
Description |
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Medicines suitable for first-line use within primary care.
Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing. |
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Medicines suitable for second-line use within primary care.
Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing. |
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Medicines that should be initiated by a specialist. Prescribing can be transferred to primary care once the patient has been stabilised.
Shared care: For drugs with regular, ongoing need for monitoring and/or assessment of efficacy or toxicity. Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the North Central London JFC.
Fact sheet: For drugs with some concerns surrounding safety or efficacy but do not require regular monitoring and/or monitoring of effectiveness/toxicity. |
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Medicines which should normally be prescribed by specialists only (hospital only).
For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care. |
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Medicines on hospital formularies which have not been reviewed for suitability in primary care. |
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Medicines not recommended for routine use in primary or secondary care.
Medicines, which the North Central London JFC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data. |
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