1. Name Of The Medicinal Product
Diprivan 10 mg/ml (1%) emulsion for injection or infusion
2. Qualitative And Quantitative Composition
Propofol 10 mg/ml
3. Pharmaceutical Form
Emulsion for injection or infusion.
White aqueous isotonic oil-in-water emulsion.
4. Clinical Particulars
4.1 Therapeutic Indications
Diprivan 1% is a short-acting intravenous general anaesthetic for:
• Induction and maintenance of general anaesthesia in adults and children>1 month.
• Sedation for diagnostic and surgical procedures, alone or in combination with local or regional anaesthesia in adults and children>1 month.
• Sedation of ventilated patients >16 years of agein the intensive care unit.
4.2 Posology And Method Of Administration
For specific guidance relating to the administration of Diprivan 1% with a target controlled infusion (TCI) device, which incorporates 'Diprifusor' TCI Software, see Section 4.2.5. Such use is restricted to induction and maintenance of anaesthesia in adults. The 'Diprifusor' TCI system is not recommended for use in ICU sedation or sedation for surgical and diagnostic procedures, or in children.
4.2.1 Induction of General Anaesthesia
Adults
In unpremedicated and premedicated patients, it is recommended that Diprivan 1% should be titrated (approximately 4 ml [40 mg] every 10 seconds in an average healthy adult by bolus injection or infusion) against the response of the patient until the clinical signs show the onset of anaesthesia. Most adult patients aged less than 55 years are likely to require 1.5–2.5 mg/kg of Diprivan 1%. The total dose required can be reduced by lower rates of administration (2–5 ml/min [20–50 mg/min]). Over this age, the requirement will generally be less. In patients of ASA Grades 3 and 4, lower rates of administration should be used (approximately 2 ml [20 mg] every 10 seconds).
Elderly Patients
In elderly patients the dose requirement for induction of anaesthesia with Diprivan 1% is reduced. The reduction should take into account of the physical status and age of the patient. The reduced dose should be given at a slower rate and titrated against the response.
Children
Diprivan 1% is not recommended for induction of anaesthesia in children aged less than 1 month.
For induction of anaesthesia in children over 1 month of age, Diprivan 1% should be titrated slowly until clinical signs show the onset of anaesthesia. The dose should be adjusted according to age and/or body weight. Most patients over 8 years of age require approximately 2.5 mg/kg body weight of Diprivan 1% for induction of anaesthesia. In younger children, especially between the age of 1 month and 3 years, dose requirements may be higher (2.5–4 mg/kg body weight).
For ASA 3 and 4 patients lower doses are recommended (see also Section 4.4).
Administration of Diprivan 1% by a 'Diprifusor' TCI system is not recommended for induction of general anaesthesia in children.
4.2.2 Maintenance of General Anaesthesia
Adults
Anaesthesia can be maintained by administering Diprivan 1% either by continuous infusion or by repeat bolus injections to prevent the clinical signs of light anaesthesia. Recovery from anaesthesia is typically rapid and it is therefore important to maintain Diprivan 1% administration until the end of the procedure.
Continuous Infusion
The required rate of administration varies considerably between patients, but rates in the region of 4–12 mg/kg/h usually maintain satisfactory anaesthesia.
Repeat Bolus Injections
If a technique involving repeat bolus injections is used, increments of 25 mg (2.5 ml) to 50 mg (5.0 ml) may be given according to clinical need.
Elderly Patients
When Diprivan 1% is used for maintenance of anaesthesia the rate of infusion or 'target concentration' should also be reduced. Patients of ASA grades 3 and 4 will require further reductions in dose and dose rate. Rapid bolus administration (single or repeated) should not be used in the elderly as this may lead to cardiorespiratory depression.
Children
Diprivan 1% is not recommended for maintenance of anaesthesia in children aged less than 1 month.
Anaesthesia can be maintained in children over 1 month of age by administering Diprivan 1% by infusion or repeated bolus injection to maintain the depth of anaesthesia required. The required rate of administration varies considerably between patients, but rates in the region of 9–15 mg/kg/h usually achieve satisfactory anaesthesia. In younger children, especially between the age of 1 month and 3 years, dose requirements may be higher.
For ASA 3 and 4 patients lower doses are recommended (see also Section 4.4).
Administration of Diprivan 1% by a 'Diprifusor' TCI system is not recommended for maintenance of general anaesthesia in children.
4.2.3 Sedation During Intensive Care
Adults
For sedation during intensive care it is advised that Diprivan 1% should be administered by continuous infusion. The infusion rate should be determined by the desired depth of sedation. In most patients sufficient sedation can be obtained with a dosage of 0.3–4 mg/kg/h of Diprivan 1% (See 4.4 Special warnings and precautions for use). Diprivan 1% is not indicated for sedation in intensive care of patients of 16 years of age or younger (see 4.3 Contraindications). Administration of Diprivan 1% by Diprifusor TCI system is not advised for sedation in the intensive care unit.
Diprivan 1% may be diluted with 5% Dextrose (see "Dilution and Co-administration" table below).
It is recommended that blood lipid levels be monitored should Diprivan 1% be administered to patients thought to be at particular risk of fat overload. Administration of Diprivan 1% should be adjusted appropriately if the monitoring indicates that fat is being inadequately cleared from the body. If the patient is receiving other intravenous lipid concurrently, a reduction in quantity should be made in order to take account of the amount of lipid infused as part of the Diprivan 1% formulation; 1.0 ml of Diprivan 1% contains approximately 0.1g of fat.
If the duration of sedation is in excess of 3 days, lipids should be monitored in all patients.
Elderly Patients
When Diprivan 1% is used for sedation the rate of infusion should also be reduced. Patients of ASA grades 3 and 4 will require further reductions in dose and dose rate. Rapid bolus administration (single or repeated) should not be used in the elderly as this may lead to cardiorespiratory depression.
Children
Diprivan 1% is contraindicated for the sedation of ventilated children aged 16 years or younger receiving intensive care.
4.2.4 Sedation For Surgical And Diagnostic Procedures
Adults
To provide sedation for surgical and diagnostic procedures, rates of administration should be individualised and titrated to clinical response.
Most patients will require 0.5–1 mg/kg over 1– 5 minutes for onset of sedation.
Maintenance of sedation may be accomplished by titrating Diprivan 1% infusion to the desired level of sedation - most patients will require 1.5–4.5 mg/kg/h. In addition to the infusion, bolus administration of 10–20 mg may be used if a rapid increase in the depth of sedation is required. In patients of ASA Grades 3 and 4 the rate of administration and dosage may need to be reduced.
Administration of Diprivan 1% by a 'Diprifusor' TCI system is not recommended for sedation for surgical and diagnostic procedures.
Elderly Patients
When Diprivan 1% is used for sedation the rate of infusion or 'target concentration' should also be reduced. Patients of ASA grades 3 and 4 will require further reductions in dose and dose rate. Rapid bolus administration (single or repeated) should not be used in the elderly as this may lead to cardiorespiratory depression.
Children
Diprivan 1% is not recommended for surgical and diagnostic procedures in children aged less than 1 month.
In children over 1 month of age, doses and adminisation rates should be adjusted according to the required depth of sedation and the clinical response. Most paediatric patients require 1–2 mg/kg body weight of Diprivan 1% for onset of sedation. Maintenance of sedation may be accomplished by titrating Diprivan 1% infusion to the desired level of sedation. Most patients require 1.5–9 mg/kg/h Diprivan 1%. The infusion may be supplemented by bolus administration of up to 1 mg/kg body weight if a rapid increase of depth of sedation is required.
In ASA 3 and 4 patients lower doses may be required.
4.2.5 Administration
Diprivan 1% has no analgesic properties and therefore supplementary analgesic agents are generally required in addition to Diprivan 1%.
Diprivan 1% can be used for infusion undiluted from glass containers, plastic syringes or Diprivan 1% pre-filled syringes or diluted with 5% Dextrose (Intravenous Infusion BP) only, in PVC infusion bags or glass infusion bottles. Dilutions, which must not exceed 1 in 5 (2 mg propofol per ml) should be prepared aseptically immediately before administration and must be used within 6 hours of preparation.
It is recommended that, when using diluted Diprivan 1%, the volume of 5% Dextrose removed from the infusion bag during the dilution process is totally replaced in volume by Diprivan 1% emulsion. (see "Dilution and Co-administration" table below).
The dilution may be used with a variety of infusion control techniques, but a giving set used alone will not avoid the risk of accidental uncontrolled infusion of large volumes of diluted Diprivan 1%. A burette, drop counter or volumetric pump must be included in the infusion line. The risk of uncontrolled infusion must be taken into account when deciding the maximum amount of Diprivan 1% in the burette.
When Diprivan 1% is used undiluted to maintain anaesthesia, it is recommended that equipment such as syringe pumps or volumetric infusion pumps should always be used to control infusion rates.
Diprivan 1% may be administered via a Y-piece close to the injection site into infusions of the following:
• Dextrose 5% Intravenous Infusion B.P.
• Sodium Chloride 0.9% Intravenous Infusion B.P.
• Dextrose 4% with Sodium Chloride 0.18% Intravenous Infusion B.P.
The glass pre-filled syringe (PFS) has a lower frictional resistance than plastic disposable syringes and operates more easily. Therefore, if Diprivan 1% is administered using a hand held pre-filled syringe, the line between the syringe and the patient must not be left open if unattended.
When the pre-filled syringe presentation is used in a syringe pump appropriate compatibility should be ensured. In particular, the pump should be designed to prevent syphoning and should have an occlusion alarm set no greater than 1000 mm Hg. If using a programmable or equivalent pump that offers options for use of different syringes then choose only the 'B-D' 50/60 ml 'PLASTIPAK' setting when using the Diprivan 1% pre-filled syringe.
Diprivan 1% may be premixed with alfentanil injection containing 500 micrograms/ml alfentanil in the ratio of 20:1 to 50:1 v/v. Mixtures should be prepared using sterile technique and used within 6 hours of preparation.
In order to reduce pain on initial injection, Diprivan 1% may be mixed with preservative-free Lidocaine Injection 0.5% or 1%; (see "Dilution and Co-administration" table below).
Target Controlled Infusion - Administration of Diprivan 1% by a 'Diprifusor' TCI System in Adults
Administration of Diprivan 1% by a 'Diprifusor' TCI system is restricted to induction and maintenance of general anaesthesia in adults. It is not recommended for use in ICU sedation or sedation for surgical and diagnostic procedures, or in children.
Diprivan 1% may be administered by TCI only with a 'Diprifusor' TCI system incorporating 'Diprifusor' TCI software. Such systems will operate only on recognition of electronically tagged pre-filled syringes containing Diprivan 1% or 2% Injection. The 'Diprifusor' TCI system will automatically adjust the infusion rate for the concentration of Diprivan recognised. Users must be familiar with the infusion pump users' manual, and with the administration of Diprivan 1% by TCI and with the correct use of the syringe identification system.
The system allows the anaesthetist or intensivist to achieve and control a desired speed of induction and depth of anaesthesia by setting and adjusting target (predicted) blood concentrations of propofol.
The 'Diprifusor' TCI system assumes that the initial blood propofol concentration in the patient is zero. Therefore, in patients who have received prior propofol, there may be a need to select a lower initial target concentration when commencing 'Diprifusor' TCI. Similarly, the immediate recommencement of 'Diprifusor' TCI is not recommended if the pump has been switched off.
Guidance on propofol target concentrations is given below. In view of interpatient variability in propofol pharmacokinetics and pharmacodynamics, in both premedicated and unpremedicated patients the target propofol concentration should be titrated against the response of the patient in order to achieve the depth of anaesthesia required.
Induction and Maintenance of General Anaesthesia
In adult patients under 55 years of age anaesthesia can usually be induced with target propofol concentrations in the region of 4–8 microgram/ml. An initial target of 4 microgram/ml is recommended in premedicated patients and in unpremedicated patients an initial target of 6 microgram/ml is advised. Induction time with these targets is generally within the range of 60–120 seconds. Higher targets will allow more rapid induction of anaesthesia but may be associated with more pronounced haemodynamic and respiratory depression.
A lower initial target concentration should be used in patients over the age of about 55 years and in patients of ASA grades 3 and 4. The target concentration can then be increased in steps of 0.5–1.0 microgram/ml at intervals of 1 minute to achieve a gradual induction of anaesthesia.
Supplementary analgesia will generally be required and the extent to which target concentrations for maintenance of anaesthesia can be reduced will be influenced by the amount of concomitant analgesia administered. Target propofol concentrations in the region of 3–6 microgram/ml usually maintain satisfactory anaesthesia.
The predicted propofol concentration on waking is generally in the region of 1.0–2.0 microgram/ml and will be influenced by the amount of analgesia given during maintenance.
Sedation during intensive care
Target blood propofol concentration settings in the range of 0.2–2.0 microgram/ml will generally be required. Administration should begin at low target setting which should be titrated against the response of the patient to achieve the depth of sedation desired.
Dilution and Co-Administration of Diprivan 1% with Other Drugs or Infusion Fluids (see also 'Additional Precautions' Section)
Co-administration Technique
|
Additive or Diluent
|
Preparation
|
Precautions
|
Pre-mixing.
|
Dextrose 5% Intravenous Infusion
|
Mix 1 part of Diprivan 1% with up to 4 parts of Dextrose 5% Intravenous Infusion B.P in either PVC infusion bags or glass infusion bottles. When diluted in PVC bags it is recommended that the bag should be full and that the dilution be prepared by withdrawing a volume of infusion fluid and replacing it with an equal volume of Diprivan 1%.
|
Prepare aseptically immediately before administration. The mixture is stable for up to 6 hours.
|
|
Lidocaine hydrochloride injection (0.5% or 1% without preservatives).
|
Mix 20 parts of Diprivan 1% with up to 1 part of either 0.5% or 1% lidocaine hydrochloride injection.
|
Prepare mixture aseptically immediately prior to administration. Use for Induction only.
|
|
Alfentanil injection (500 microgram/ml).
|
Mix Diprivan 1% with alfentanil injection in a ratio of 20:1 to 50:1 v/v.
|
Prepare mixture aseptically; use within 6 hours of preparation.
|
Co-administration via a Y-piece connector.
|
Dextrose 5% intravenous infusion
|
Co-administer via a Y-piece connector.
|
Place the Y-piece connector close to the injection site.
|
|
Sodium chloride 0.9% intravenous infusion
|
As above
|
As above
|
|
Dextrose 4% with sodium chloride 0.18% intravenous infusion
|
As above
|
As above
|
4.3 Contraindications
Diprivan is contraindicated in patients with a known hypersensitivity to propofol or any of the excipients.
Diprivan 1% must not be used in patients of 16 years of age or younger for sedation in intensive care (See 4.4 Special warnings and precautions for use).
Diprivan 1% contains soya oil and should not be used in patients who are hypersensitive to peanut or soya.
4.4 Special Warnings And Precautions For Use
Diprivan 1% should be given by those trained in anaesthesia or, where appropriate, doctors trained in the care of patients in Intensive Care. Patients should be constantly monitored and facilities for maintenance of a patient airway, artificial ventilation, oxygen enrichment and other resuscitative facilities should be readily available at all times. Diprivan 1% should not be administered by the person conducting the diagnostic or surgical procedure.
When Diprivan 1% is administered for sedation for surgical and diagnostic procedures patients should be continually monitored for early signs of hypotension, airway obstruction and oxygen desaturation.
As with other sedative agents, when Diprivan is used for sedation during operative procedures, involuntary patient movements may occur. During procedures requiring immobility these movements may be hazardous to the operative site.
As with other intravenous anaesthetic and sedative agents, patients should be instructed to avoid alcohol before and for at least 8 hours after administration of Diprivan 1%.
Diprivan 1% should be used with caution when used to sedate patients undergoing some procedures where spontaneous movements are particularly undesirable, such as ophthalmic surgery.
As with other intravenous sedative agents, when Diprivan 1% is given along with central nervous system depressants, such as potent analgesics, the sedative effect may be intensified and the possibility of severe respiratory or cardiovascular depression should be considered.
During bolus administration for operative procedures, extreme caution should be exercised in patients with acute pulmonary insufficiency or respiratory depression.
Concomitant use of central nervous system depressants e.g., alcohol, general anaesthetics, narcotic analgesics will result in accentuation of their sedative effects. When Diprivan 1% is combined with centrally depressant drugs administered parenterally, severe respiratory and cardiovascular depression may occur. It is recommended that Diprivan 1% is administered following the analgesic and the dose should be carefully titrated to the patient's response (see Section 4.5).
During induction of anaesthesia, hypotension and transient apnoea may occur depending on the dose and use of premedicants and other agents. Occasionally, hypotension may require use of intravenous fluids and reduction of the rate of administration of Diprivan 1% during the period of anaesthetic maintenance.
An adequate period is needed prior to discharge of the patient to ensure full recovery after general anaesthesia. Very rarely the use of Diprivan may be associated with the development of a period of post-operative unconsciousness, which may be accompanied by an increase in muscle tone. This may or may not be preceded by a period of wakefulness. Although recovery is spontaneous, appropriate care of an unconscious patient should be administered.
When Diprivan 1% is administered to an epileptic patient, there may be a risk of convulsion.
As with other intravenous anaesthetic agents, caution should be applied in patients with cardiac, respiratory, renal or hepatic impairment or in hypovolaemic, elderly or debilitated patients. Propofol clearance is blood flow dependent, therefore, concomitant medication that reduces cardiac output will also reduce propofol clearance.
The risk of relative vagal overactivity may be increased because Diprivan 1% lacks vagolytic activity; it has been associated with reports of bradycardia (occasionally profound) and also asystole. The intravenous administration of an anticholinergic agent before induction, or during maintenance of anaesthesia should be considered, especially in situations where vagal tone is likely to predominate, or when Diprivan 1% is used in conjunction with other agents likely to cause a bradycardia.
Appropriate care should be applied in patients with disorders of fat metabolism and in other conditions where lipid emulsions must be used cautiously.
Use is not recommended with electroconvulsive treatment.
As with other anaesthetics, sexual disinhibition may occur during recovery.
Diprivan 1% is not advised for general anaesthesia in children younger than 1 month of age. The safety and efficacy of Diprivan 1% for (background) sedation in children younger than 16 years of age have not been demonstrated. Although no causal relationship has been established, serious undesirable effects with (background) sedation in patients younger than 16 years of age (including cases with fatal outcome) have been reported during unlicensed use. In particular these effects concerned occurrence of metabolic acidosis, hyperlipidemia, rhabdomyolysis and/or cardiac failure. These effects were most frequently seen in children with respiratory tract infections who received dosages in excess of those advised in adults for sedation in the intensive care unit.
The use of Diprivan 1% is not recommended for newborn infants for induction and maintenance of anaesthesia as this patient population has not been fully investigated. Pharmacokinetic data (see Section 5.2) indicate that clearance is considerably reduced in neonates with a very high inter-individual variability. Relative overdose could occur administering doses recommended for older children resulting in severe cardiovascular depression.
Very rare reports have been received of occurrence of metabolic acidosis, rhabdomyolysis, hyperkalaemia and/or rapidly progressive cardiac failure (in some cases with fatal outcome) in adults who were treated for more than 58 hours with dosages in excess of 5 mg/kg/h. This exceeds the maximum dosage of 4 mg/kg/h currently advised for sedation in the intensive care unit. The patients affected were mainly (but not only) seriously head-injured patients with raised ICP. The cardiac failure in such cases was usually unresponsive to inotropic supportive treatment. Treating physicians are reminded if possible not to exceed the dosage of 4 mg/kg/h. Prescribers should be alert to these possible undesirable effects and consider decreasing the Diprivan 1% dosage or switching to an alternative sedative at the first sign of occurrence of symptoms. Patients with raised ICP should be given appropriate treatment to support the cerebral perfusion pressure during these treatment modifications.
Diprivan 1% contains 0.0018 mmol sodium per ml.
EDTA is a chelator of metal ions, including zinc. The need for supplemental zinc should be considered during prolonged administration of Diprivan, particularly in patients who are predisposed to zinc deficiency, such as those with burns, diarrhoea and/or major sepsis.
Additional Precautions
Diprivan 1% contains no antimicrobial preservatives and supports growth of micro-organisms. When Diprivan 1% is to be aspirated, it must be drawn aseptically into a sterile syringe or giving set immediately after opening the ampoule or breaking the vial seal. Administration must commence without delay. Asepsis must be maintained for both Diprivan 1% and infusion equipment throughout the infusion period. Any drugs or fluids added to the Diprivan 1% line must be administered close to the cannula site. Diprivan 1% must not be administered via a microbiological filter.
Diprivan 1% and any syringe containing Diprivan 1% are for single use in an individual patient. For use in long term maintenance of anaesthesia or sedation in intensive care it is recommended that the infusion line and reservoir of Diprivan 1% be discarded and replaced at regular intervals.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Diprivan 1% has been used in association with spinal and epidural anaesthesia and with commonly used premedicants, neuromuscular blocking drugs, inhalational agents and analgesic agents; no pharmacological incompatibility has been encountered. Lower doses of Diprivan 1% may be required where general anaesthesia is used as an adjunct to regional anaesthetic techniques.
The concurrent administration of other CNS depressants such as pre-medication drugs, inhalation agents, analgesic agents may add to the sedative, anaesthetic and cardiorespiratory depressant effects of propofol (see Section 4.4).
4.6 Pregnancy And Lactation
Pregnancy
The safety of Diprivan during pregnancy has not been established. Therefore Diprivan should not be used in pregnancy unless clearly necessary. Diprivan has been used, however, during termination of pregnancy in the first trimester.
Obstetrics
Diprivan 1% crosses the placenta and may be associated with neonatal depression. It should not be used for obstetric anaesthesia unless clearly necessary.
Lactation
Safety to the neonate has not been established following the use of Diprivan 1% in mothers who are breast feeding.
4.7 Effects On Ability To Drive And Use Machines
Patients should be advised that performance at skilled tasks, such as driving and operating machinery, may be impaired for some time after general anaesthesia.
4.8 Undesirable Effects
General
Induction of anaesthesia is generally smooth with minimal evidence of excitation. The most commonly reported ADRs are pharmacologically predictable side effects of an anaesthetic agent, such as hypotension. Given the nature of anaesthesia and those patients receiving intensive care, events reported in association with anaesthesia and intensive care may also be related to the procedures being undertaken or the recipient's condition.
Very common
(>1/10)
|
General disorders and administration site conditions:
|
Local pain on induction (1)
|
Common
(>1/100, <1/10)
|
Vascular disorder:
|
Hypotension (2)
|
|
Cardiac disorders:
|
Bradycardia (3)
|
|
Respiratory, thoracic and mediastinal disorders:
|
Transient apnoea during induction
|
|
Gastrointestinal disorders:
|
Nausea and vomiting during recovery phase
|
|
Nervous system disorders:
|
Headache during recovery phase
|
|
General disorders and administration site conditions:
|
Withdrawal symptoms in children (4)
|
|
Vascular disorders:
|
Flushing in children (4)
|
Uncommon
(>1/1000, <1/100)
|
Vascular disorders:
|
Thrombosis and phlebitis
|
Rare
(>1/10 000, <1/1000)
|
Nervous system disorders:
|
Epileptiform movements, including convulsions and opisthotonus during induction, maintenance and recovery
|
Very rare
(<1/10 000)
|
Musculoskeletal and connective tissue disorders:
|
Rhabdomyolysis (5)
|
|
Gastrointestinal disorders:
|
Pancreatitis
|
|
Injury, poisoning and procedural complications:
|
Post-operative fever
|
|
Renal and urinary disorders:
|
Discolouration of urine following prolonged administration
|
|
Immune system disorders:
|
Anaphylaxis – may include angioedema, bronchospasm, erythema and hypotension
|
|
Reproductive system and breast disorders:
|
Sexual disinhibition
|
|
Cardiac disorders:
|
Pulmonary oedema
|
|
Nervous system disorders:
|
Postoperative unconsciousness
|
(1) May be minimised by using the larger veins of the forearm and antecubital fossa. With Diprivan 1% local pain can also be minimised by the co-administration of lidocaine.
(2) Occasionally, hypotension may require use of intravenous fluids and reduction of the administration rate of Diprivan.
(3) Serious bradycardias are rare. There have been isolated reports of progression to asystole.
(4) Following abrupt discontinuation of Diprivan during intensive care.
(5) Very rare reports of rhadbomyolysis have been received where Diprivan has been given at doses greater than 4 mg/kg/hr for ICU sedation.
Pulmonary oedema, hypotension, asystole, bradycardia, and convulsions, have been reported. In very rare cases rhabdomyolysis, metabolic acidosis, hyperkalaemia or cardiac failure, sometimes with fatal outcome, have been observed when propofol was administered at dosages in excess of 4 mg/kg/h for sedation in the intensive care unit (see 4.4 Special warnings and precautions for use). Dystonia/dyskinesia have been reported.
Reports from off-label use of Diprivan for induction of anaesthesia in neonates indicates that cardio-respiratory depression may occur if the paediatric dose regimen is applied.
Local
The local pain which may occur during the induction phase of Diprivan 1% anaesthesia can be minimised by the co-administration of lidocaine (see "Dosage and Administration") and by the use of the larger veins of the forearm and antecubital fossa. Thrombosis and phlebitis are rare. Accidental clinical extravasation and animal studies showed minimal tissue reaction. Intra-arterial injection in animals did not induce local tissue effects.
4.9 Overdose
Accidental overdosage is likely to cause cardiorespiratory depression. Respiratory depression should be treated by artificial ventilation with oxygen. Cardiovascular depression would require lowering of the patient's head and, if severe, use of plasma expanders and pressor agents.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Propofol (2, 6-diisopropylphenol) is a short-acting general anaesthetic agent with a rapid onset of action of approximately 30 seconds. Recovery from anaesthesia is usually rapid. The mechanism of action, like all general anaesthetics, is poorly understood. However, propofol is thought to produce its sedative/anaesthetic effects by the positive modulation of the inhibitory function of the neurotransmitter GABA through the ligand-gated GABAA receptors.
In general, falls in mean arterial blood pressure and slight changes in heart rate are observed when Diprivan 1% is administered for induction and maintenance of anaesthesia. However, the haemodynamic parameters normally remain relatively stable during maintenance and the incidence of untoward haemodynamic changes is low.
Although ventilatory depression can occur following administration of Diprivan 1%, any effects are qualitatively similar to those of other intravenous anaesthetic agents and are readily manageable in clinical practice.
Diprivan 1% reduces cerebral blood flow, intracranial pressure and cerebral metabolism. The reduction in intracranial pressure is greater in patients with an elevated baseline intracranial pressure.
Recovery from anaesthesia is usually rapid and clear headed with a low incidence of headache and post-operative nausea and vomiting.
In general, there is less post-operative nausea and vomiting following anaesthesia with Diprivan 1% than following anaesthesia with inhalational agents. There is evidence that this may be related to a reduced emetic potential of propofol.
Diprivan 1%, at the concentrations likely to occur clinically, does not inhibit the synthesis of adrenocortical hormones.
Limited studies on the duration of propofol based anaesthesia in children indicate safety and efficacy is unchanged up to duration of 4 hours. Literature evidence of use in children documents use for prolonged procedures without changes in safety or efficacy.
5.2 Pharmacokinetic Properties
The decline in propofol concentrations following a bolus dose or following the termination of an infusion can be described by a three compartment open model with very rapid distribution (half-life 2 –4 minutes), rapid elimination (half-life 30 – 60 minutes), and a slower final phase, representative of redistribution of propofol from poorly perfused tissue.
Propofol is extensively distributed and rapidly cleared from the body (total body clearance 1.5–2 litres/minute). Clearance occurs by metabolic processes, mainly in the liver where it is blood flow dependent, to form inactive conjugates of propofol and its corresponding quinol, which are excreted in urine.
When Diprivan 1% is used to maintain anaesthesia, blood concentrations asymptotically approach the steady-state value for the given administration rate. The pharmacokinetics are linear over the recommended range of infusion rates of Diprivan 1%.
After a single dose of 3 mg/kg intravenously, propofol clearance/kg body weight increased with age as follows: Median clearance was considerably lower in neonates <1 month old (n=25) (20 ml/kg/min) compared to older children (n= 36, age range 4 months–7 years). Additionally inter-individual variability was considerable in neonates (range 3.7–78 ml/kg/min). Due to this limited trial data that indicates a large variability, no dose recommendations can be given for this age group.
Median propofol clearance in older aged children after a single 3 mg/kg bolus was 37.5 ml/min/kg (4-24 months) (n=8), 38.7 ml/min/kg (11–43 months) (n=6), 48 ml/min/kg (1–3 years)(n=12), 28.2 ml/min/kg (4–7 years)(n=10) as compared with 23.6 ml/min/kg in adults (n=6).
5.3 Preclinical Safety Data
Propofol is a drug on which extensive clinical experience has been obtained. All relevant information for the prescriber is provided elsewhere in the Summary of Product Characteristics.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Glycerol Ph Eur
Purified Egg Phosphatide
Sodium Hydroxide Ph Eur
Soya-bean Oil, Refined Ph Eur
Water for Injections Ph Eur
Nitrogen Ph Eur
Disodium Edetate Ph Eur
6.2 Incompatibilities
The neuromuscular blocking agents, atracurium and mivacurium should not be given through the same intravenous line as Diprivan 1% without prior flushing.
6.3 Shelf Life
6.3.1 Shelf life of the product as packaged for sale
Ampoules
|
-
|
3 years
|
Vials
|
-
|
3 years
|
Pre-filled syringe
|
-
|
2 years.
|
6.3.2 Shelf life after dilution
Use of diluted Diprivan must begin immediately following dilution.
6.4 Special Precautions For Storage
Store between 2°C and 25°C.
Do not freeze.
6.5 Nature And Contents Of Container
a) Clear neutral glass ampoules of 20 ml in boxes of 5
b) Clear neutral glass vials of 50 ml and 100 ml
c) Type 1 glass pre-filled syringe of 50 ml
6.6 Special Precautions For Disposal And Other Handling
In-use precautions
Containers should be shaken before use.
Any portion of the contents remaining after use should be discarded.
Diprivan 1% should not be mixed prior to administration with injections or infusion fluids other than 5% Dextrose or Lidocaine Injection (see Section 4.2.5).
7. Marketing Authorisation Holder
AstraZeneca UK Limited,
600 Capability Green,
Luton, LU1 3LU, UK.
8. Marketing Authorisation Number(S)
PL 17901/0007
9. Date Of First Authorisation/Renewal Of The Authorisation
8th July 2000 / 24th September 2004
10. Date Of Revision Of The Text
7th September 2010
