Diprivan 10mg/Ml (1%) Emulsion For Injection Or Infusion
Patient Information Leaflet Diprivan® 10 mg/ml (1%) Emulsion for Injection or Infusion
(propofol)
Your medicine is available in the above name, but will be referred to as Diprivan throughout the remainder of the leaflet,
Read all of this leaflet carefully before you start having this medicine.
• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor or nurse.
• If you think you have a side effect, or if you notice any side effects not listed in this leaflet, please tell your doctor or nurse.
This product is also available in other strengths.
In this leaflet:
1. What Diprivan is and what it is used for
2. Before you have Diprivan
3. How to have Diprivan
4. Possible side effects
5. How to store Diprivan
6. Further information
1. What Diprivan is and what it is used for
Diprivan contains a medicine called propofol. This belongs to a group of medicines called ‘general anaesthetics’. General anaesthetics are used to cause unconsciousness (sleep) so that surgical operations or other procedures can be performed.
They can also be used to sedate you (so that you are sleepy but not completely asleep).
Diprivan will be given to you as an injection by a doctor.
In adults and children over 1 month of age it is used to:
• Help put you to sleep before an operation or other procedure.
• Keep you asleep during an operation or other procedure.
• Sedate you during diagnostic and surgical procedures, alone or in combination with local or regional anaesthesia.
In people over 16 years of age it is also used to:
• Sedate you when receiving artificial respiration in an Intensive Care Unit (ICU).
2. Before you have Diprivan Do not have Diprivan if:
• You are allergic (hypersensitive) to propofol or any of the other ingredients of Diprivan (listed in Section 6: Further information).
• You are allergic to peanut or soya. This is because Diprivan contains soya oil.
• You are pregnant (see the section called ‘Pregnancy and breast-feeding’).
• You are 16 years of age or younger for sedation in intensive care.
If any of the above apply to you, do not have Diprivan and tell your doctor, anaesthetist or nurse. If you are not sure, talk to one of these people before having Diprivan.
Take special care with Diprivan
The use of Diprivan is not recommended in new-born infants. Before you have this medicine, tell your doctor, anaesthetist or nurse if:
• You have ever had a fit or convulsion.
• You have ever been told that you have very high levels of fat in your blood.
• You have ever been told that your body has problems using fat.
• Your body has lost lots of water (you are dehydrated).
• You have any other health problems, such as problems with your heart, breathing, kidneys or liver.
• You have been generally unwell for some time.
If you are not sure if any of the above apply to you, talk to your doctor or nurse before having Diprivan.
Taking other medicines
Tell your doctor if you are taking or have recently taken any other medicines. This includes medicines that you buy without a prescription and herbal medicines.
Pregnancy and breast-feeding
• Do not have Diprivan if you are pregnant.
• If you are trying to get pregnant or if you are breastfeeding, talk to your doctor or nurse before having this medicine.
Driving and using machines
After having Diprivan, you may still feel sleepy for some time. Do not drive or use any tools or machines until you are sure the effects have worn off.
• If you are able to go home shortly after having Diprivan, do not drive a car or use any tools or machines.
• Ask your doctor when you can start doing these activities again and when you can go back to work.
Important information about some of the ingredients of Diprivan
Diprivan contains sodium. If you are on a sodium controlled diet, you will need to take this into account. Diprivan contains soya oil. If you are allergic to peanut or soya, do not use this medicine.
Diprivan contains disodium edetate. During prolonged use of Diprivan for intensive care, you may need to be given a zinc (a mineral) supplement.
3. How to have Diprivan
You will be given Diprivan by a doctor. It will be given to you as an injection into a vein. This is usually in the back of your hand or in your forearm.
• The doctor will give you the injection using a needle or through a fine plastic tube called a ‘cannula’.
• The doctor can also use an electric pump to control how fast the injection is given. This may be done if you are having a long operation or if you are in an Intensive Care Unit.
The dose of Diprivan varies from one patient to another. The amount of Diprivan that you need depends on your age, size, physical fitness and the level of sleepiness or sleep that you need. The doctor will give you the correct dose to start and to sustain anaesthesia or to achieve the required level of sedation, by carefully watching your responses and vital signs (pulse, blood pressure, breathing etc.).
You may need several different medicines to keep you asleep or sleepy, free from pain, breathing in a healthy way and to keep your blood pressure steady. The doctor will decide which medicines you need and when you need them.
4. Possible side effects
Like all medicines, Diprivan may cause side effects although not everybody gets them.
Side effects that can happen during anaesthesia
The following side effects can happen during anaesthesia (while the injection is being given to you or when you are sleepy or asleep). Your doctor will be looking out for these. If they happen, your doctor will give you appropriate treatment.
Very common (affects more than 1 in 10 people)
• A feeling of pain at the site of the injection (while the injection is being given, before you fall asleep).
Common (affects less than 1 in 10 people)
• Low blood pressure.
• Changes in your breathing pattern.
• Slow heart beat.
Rare (affects less than 1 in 1,000 people)
• Twitching and shaking of your body, or a fit (may also happen when you wake up).
• Unusual colour of urine (may also happen when you wake up).
Very rare (affects less than 1 in 10,000 people)
• Allergic reactions.
• Stopping of your heart beat.
• Build-up of fluid in the lungs which can make you very breathless (may also happen when you wake up).
Side effects that can happen after anaesthesia
The following side effects can happen after anaesthesia (when you are waking up or after you have woken up).
Common (affects less than 1 in 10 people)
• Feeling sick (nausea).
• Being sick (vomiting).
• Headache.
Uncommon (affects less than 1 in 100 people)
• Swelling and redness along a vein or blood clots.
Very rare (affects less than 1 in 10,000 people)
• Feeling sexually aroused.
• High temperature (fever).
• Redness or soreness where the injection was given.
• Being unconscious after the operation. (When this has happened, the patients have recovered without problems.)
Other possible side effects
The following side effects have been seen when Diprivan is used in intensive care at higher doses than recommended.
Very rare (affects less than 1 in 10,000 people)
• Heart failure.
• Inflamed pancreas (pancreatitis) which causes severe stomach pain.
• Too much acid in your blood. This may make you breathe more quickly.
• Increased amount of potassium in your blood.
• High blood level of a type of fat called lipids.
• Abnormal heart beat.
• Enlargement of the liver.
• Kidney failure.
The following side effects have been seen in children in intensive care when Diprivan has been stopped suddenly.
Common (affects less than 1 in 10 people)
• ‘Withdrawal symptoms’. These include unusual behaviour, sweating, shaking and feeling anxious.
• Flushing of the skin.
Do not be concerned by this list of possible side effects. You may not get any of them.
Side effects of unknown frequency may include
• Euphoric mood.
• Involuntary movements.
• Drug abuse, mostly by healthcare professionals.
• Abnormal ECG.
• Breakdown of muscle cells (rhabdomyolysis).
If you think you have a side effect or if you notice any side effects not listed in this leaflet, please tell your doctor or nurse.
Reporting of side effects
If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard. By reporting side effects, you can help provide more information on the safety of this medicine.
5. How to store Diprivan
• The doctor and hospital pharmacist are responsible for storing, using and disposing of Diprivan correctly.
• Store Diprivan between 2°C and 25°C. Do not freeze.
• Do not use Diprivan after the expiry date which is stated on the carton.
6. Further information What Dipravin 1% contains
The active substance is propofol. There is 10 mg of propofol in each millilitre.
Each ampoule contains 200mg of propofol.
The other ingredients are glycerol, purified egg phosphatide, sodium hydroxide, soya bean oil refined, water for injections and disodium edetate.
What Dipravin 1% looks like and contents of the pack
Diprivan 1% is a milky, white liquid. It comes in 5 x 20ml glass ampoules.
PL 20774/1469 Diprivan 10 mg/ml (1%) Emulsion for Injection or Infusion POM
Manufacturer and Product Licence Holder
Manufactured by: AstraZeneca SA, 4 Theotokopoulou & Astronafton Street, Maroussi, Athens, GR-151 25, Greece. Procured from within the EU. Product Licence Holder: Quadrant Pharmaceuticals Ltd, Lynstock House, Lynstock Way, Lostock, Bolton BL6 4SA. Repackaged by Maxearn Ltd, Bolton BL6 4SA.
Diprivan is a registered trademark of AstraZeneca UK Limited
Date of preparation 26th April 2016
Medical Information Leaflet
Diprivan 1%
(Issued to the Medical Professions Only)
1. Trade 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 age in 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 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 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 special 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 ml of Diprivan 1% contains approximately 0.1 g 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 administration 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).
QL1469/1
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 siphoning 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 microgram/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 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 1-2 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 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 |
Preparation |
|
Pre-mixing |
Dextrose 5% intravenous infusion |
Mix 1 part of Diprivan 1% with up to 4 parts of dextrose 5% intravenous infusion 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. The abuse of Diprivan 1%, predominantly by health care professionals, has been reported. As with other general anaesthetics, the administration of Diprivan 1% without airway care may result in fatal respiratory complications.
When Diprivan 1% is administered for conscious 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 1% 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.
An adequate period is needed prior to discharge of the patient to ensure full recovery after use of Diprivan 1 %. Very rarely the use of Diprivan 1% 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.
Diprivan 1% induced impairment is not generally detectable beyond 12 hours. The effects of Diprivan 1%, the procedure, concomitant medications, the age and the condition of the patient should be considered when advising patients on:
• The advisability of being accompanied on leaving the place of administration
• The timing of recommencement of skilled or hazardous tasks such as driving
• The use of other agents that may sedate (Eg, benzodiazepines, opiates, alcohol.)
As with other intravenous anaesthetic agents, caution should be applied in patients with cardiac, respiratory, renal or hepatic impairment or in hypovolaemic or debilitated patients. Diprivan 1% clearance is blood flow dependent, therefore, concomitant medication that reduces cardiac output will also reduce Diprivan 1% clearance.
Diprivan 1 % lacks vagolytic activity and 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.
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%.
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 eg., 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.
When Diprivan 1% is administered to an epileptic patient, there may be a risk of convulsion.
Appropriate care should be applied in patients with disorders of fat metabolism and in other conditions where lipid emulsions must be used cautiously (see section 4.2).
It is recommended that blood lipid levels should be monitored if Diprivan 1 % is administered to patients thought to be at particular risk of fat overload. Administration of propofol 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 contains approximately 0.1 g of fat.
Use is not recommended with electroconvulsive treatment.
As with other anaesthetics, sexual disinhibition may occur during recovery.
The use of Diprivan is not recommended in newborn infants as this patient population has not been fully investigated. Pharmacokinetic data (see section 5.2) indicate that clearance is considerably reduced in neonates and has a very high inter-individual variability. Relative overdose could occur on administering doses recommended for older children and result in severe cardiovascular depression. Diprivan 2% is not recommended for use in children < 3 years of age due to difficulty in titrating small volumes.
Advisory statements concerning Intensive Care Unit management
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.
Reports have been received of combinations of the following: Metabolic acidosis, Rhabdomyolysis, Hyperkalaemia, Hepatomegaly, Renal failure, Hyperlipidaemia, Cardiac arrhythmia, Brugada-type ECG (elevated ST-segment and coved T-wave) and rapidly progressive Cardiac failure usually unresponsive to inotropic supportive treatment (in some cases with fatal outcome) in adults. Combinations of these events have been referred to as the Propofol Infusion Syndrome.
The following appear to be the major risk factors for the development of these events: decreased oxygen delivery to tissues; serious neurological injury and/or sepsis; high dosages of one or more of the following pharmacological agents - vasoconstrictors, steroids, inotropes and/or Diprivan 1% (usually following extended dosing at dose rates greater than 4mg/kg/h).
Prescribers should be alert to these events and consider decreasing the Diprivan 1% dosage or switching to an alternative sedative at the first sign of occurrence of symptoms. All sedative and therapeutic agents used in the intensive care unit (ICU), including Diprivan 1%, should be titrated to maintain optimal oxygen delivery and haemodynamic parameters. Patients with raised intra-cranial pressure (ICP) should be given appropriate treatment to support the cerebral perfusion pressure during these treatment modifications. Treating physicians are reminded if possible not to exceed the dosage of 4 mg/kg/h.
Diprivan 1% contains 0.0018 mmol sodium per ml.
Additional precautions
Diprivan 1% contains no antimicrobial preservatives and supports growth of micro-organisms.
EDTA chelates metal ions, including zinc, and reduces microbial growth rates.
The need for supplemental zinc should be considered during prolonged administration of Diprivan 1%, particularly in patients who are predisposed to zinc deficiency, such as those with burns, diarrhoea and/or major sepsis.
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 infusion 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. In accordance with established guidelines for other lipid emulsions, a single infusion of Diprivan 1% must not exceed 12 hours. At the end of the procedure or at 12 hours, whichever is the sooner, both the reservoir of Diprivan 1% and the infusion line must be discarded and replaced as appropriate.
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 Diprivan 1% (see Section 4.4).
4.6 Pregnancy and lactation
Pregnancy The safety of Diprivan 1% during pregnancy has not been established. Diprivan 1% should not be given to pregnant women except when absolutely necessary. Diprivan 1% can, however, be used during an induced abortion.
Obstetrics Diprivan 1% crosses the placenta and can cause neonatal depression. It should not be used for obstetric anaesthesia unless clearly necessary.
Lactation
Studies of breastfeeding mothers showed that small quantities of Diprivan 1% are excreted in human milk. Women should therefore not breastfeed for 24 hours after administration of Diprivan 1%. Milk produced during this period should be discarded.
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.
Diprivan 1% induced impairment is not generally detectable beyond 12 hours (Section 4.4).
4.8 Undesirable effects General
Induction and maintenance of anaesthesia or sedation is generally smooth with minimal evidence of excitation. The most commonly reported ADRs are pharmacologically predictable side effects of an anaesthetic/sedative agent, such as hypotension. The nature, severity and incidence of adverse events observed in patients receiving Diprivan 1% may be related to the condition of the recipients and the operative or therapeutic procedures being undertaken.
Table of Adverse Drug Reactions
|
System Organ |
Class Frequency |
Undesirable Effects |
|
Immune system disorders: |
Very rare (<1/10 000) |
Anaphylaxis - may include angioedema, bronchospasm, erythema and hypotension |
|
Metabolism and Nutritional disorder: |
Frequency not known (9) |
Metabolic acidosis (5), hyperkalaemia (5), hyperlipidaemia (5) |
|
Psychiatric disorders: |
Frequency not known (9) |
Euphoric mood, drug abuse (8) |
|
Nervous system disorders: |
Common (>1/100, <1/10) |
Headache during recovery phase |
|
Rare (>1/10 000, <1/1000) |
Epileptiform movements, including convulsions and opisthotonus during induction, maintenance and recovery | |
|
Very rare (<1/10 000) |
Postoperative unconsciousness | |
|
Frequency not known (9) |
Involuntary movements | |
|
Cardiac disorders: |
Common (>1/100, <1/10) |
Bradycardia (1) |
|
Very rare (<1/10 000) |
Pulmonary oedema | |
|
Frequency not known (9) |
Cardiac arrhythmia (5), cardiac failure (5), (7) |
|
Vascular disorders: |
Common (>1/100, <1/10) |
Hypotension (2) |
|
Uncommon (>1/1000, <1/100) |
Thrombosis and phlebitis | |
|
Respiratory, thoracic and mediastinal disorders: |
Common (>1/100, <1/10) |
Transient apnoea during induction |
|
Gastrointestinal disorders: |
Common (>1/100, <1/10) |
Nausea and vomiting during recovery phase |
|
Very rare (<1/10 000) |
Pancreatitis | |
|
Hepatobiliary disorders |
Frequency not known (9) |
Hepatomegaly (5) |
|
Musculoskeletal and connective tissue disorders: |
Frequency not known (9) |
Rhabdomyolysis (3), (5) |
|
Renal and urinary disorders |
Very rare (<1/10 000) |
Discolouration of urine following prolonged administration |
|
Frequency not known (9) |
Renal failure(5) | |
|
Reproductive system and breast |
Very rare (<1/10 000) |
Sexual disinhibition |
|
General disorders and administration site conditions: |
Very common (>1/10) |
Local pain on induction (4) |
|
Investigations |
Frequency not known (9) |
Brugada type ECG (5), (6) |
|
Injury, poisoning and procedural complications: |
Very rare (<1/10 000) |
Postoperative fever |
(1) Serious bradycardias are rare. There have been isolated reports of progression to asystole.
(2) Occasionally, hypotension may require use of intravenous fluids and reduction of the administration rate of Diprivan.
(3) Very rare reports of rhabdomyolysis have been received where Diprivan has been given at doses greater than 4 mg/kg/hr for ICU sedation.
(4) 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.
(5) Combinations of these events, reported as “Propofol Infusion Syndrome”, may be seen in seriously ill patients who often have multiple risk factors for the development of the events, see section 4.4.
(6) Brugada-type ECG - elevated ST-segment and coved T-wave in ECG.
(7) Rapidly progressive cardiac failure (in some cases with fatal outcome) in adults. The cardiac failure in such cases was usually unresponsive to inotropic supportive treatment.
(8) Drug abuse, predominantly by health care professionals.
(9) Not known as it cannot be estimated from the available clinical trial data.
Dystonia/dyskinesia have been reported.
Local
The local pain which may occur during the induction phase of Diprivan 1 % anaesthesia can be minimised by the coadministration 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 postoperative nausea and vomiting. In general, there is less postoperative 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 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
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
6.6 Instructions for use and 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. Product licence holder:
Procured from within the EU. Product Licence Holder: Quadrant Pharmaceuticals Ltd, Lynstock House, Lynstock Way, Lostock, Bolton, BL6 4SA.
PL 20774/1469 pom
26th April 2016
QL1469/1
Diprivan 10mg/ml (1%) Emulsion for Injection or Infusion PL 20774/1469 - sOp - Insertion of the leaflets
When the leaflets are printed and folded, they will be stored in 2 separate tubs, each with lid closures to prevent cross-contamination.
When the job is in the process room, the process worker will work in job lots of 10 packs. 10 leaflets will be taken from each tub and placed in 2 piles on the table a strip of 10 over labels and a strip of a 50 ampoule labels, 10 packs will be removed from the outer, and opened. The foreign leaflets will be discarded, and the process worker will label each of the packs, taking the required components of each pack from each of the piles. Working in this way minimises the risk of having 2 of the same leaflet in a pack and also minimises the risk of packs being released without one or more of the leaflets.
Once 10 packs have been processed, there will be a clear worktop ready for the next job lot of 10 packs.