8.

General Anaesthesia, Intravenous agents - Benzodiazepines

Benzodiazepines are a class of psychoactive drugs.

Their use results in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant,

and muscle relaxant properties. High doses of many shorter-acting benzodiazepines may also
cause anterograde amnesia and dissociation. These properties make benzodiazepines useful in
treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as
a premedication for medical or dental procedures. Benzodiazepines are categorized as either short-,
intermediate-, or long-acting. Short- and intermediate-acting benzodiazepines are preferred for the
treatment of insomnia; longer-acting benzodiazepines are recommended for the treatment of anxiety.

Use

 Seizures
o Prolonged convulsive epileptic seizures are a medical emergency that can usually be
dealt with effectively by administering fast-acting benzodiazepines, which are
potent anticonvulsants. In a hospital environment, intravenous clonazepam, lorazepam,
and diazepam are first-line choices, clonazepam due to its stronger and more potent
anticonvulsant action, diazepam due to its faster onset and lorazepam for its longer
duration of action
 They can be very useful in intensive care to sedate patients receiving mechanical ventilation or
those in extreme distress. Caution is exercised in this situation due to the occasional occurrence
of respiratory depression, and it is recommended that benzodiazepine overdose treatment
facilities should be available.
 Benzodiazepines are effective as medication given a couple of hours before surgery to relieve
anxiety. They also produce amnesia, which can be useful, as patients will not be able to
remember any unpleasantness from the procedure. They are also used in patients with dental
phobia as well as some ophthalmic procedures like refractive surgery; Midazolam is the most
commonly prescribed for this use because of its strong sedative actions and fast recovery time,
as well as its water solubility, which reduces pain upon injection. Diazepam and lorazepam are
sometimes used. Lorazepam has particularly marked amnesic properties that may make it more
effective when amnesia is the desired effect

Contraindications

Because of their muscle relaxant action, benzodiazepines may cause respiratory depression in

susceptible individuals. For that reason, they are contraindicated in people with myasthenia gravis, sleep
apnea, bronchitis, and COPD.

Caution is required when benzodiazepines are used in people with personality disorders or intellectual

disability because of frequent paradoxical reactions. In major depression, they may precipitate suicidal
tendencies and are sometimes used for suicidal overdoses. Individuals with a history of
alcohol, opioid and barbiturate abuse should avoid benzodiazepines, as there is a risk of life-threatening
interactions with these drugs
Side effects

The most common side-effects of benzodiazepines are related to their sedating and muscle-relaxing
action. They include drowsiness, dizziness, and decreased alertness and concentration.  

Hypotension and suppressed breathing (hypoventilation) may be encountered with intravenous use

Examples

Diazepam –

 Pre- or postoperative sedation, anxiolysis and/or amnesia (e.g., before endoscopic or surgical
procedures)
 Intravenous diazepam or lorazepam are first-line treatments for status epilepticus. However,
lorazepam has advantages over diazepam, including a higher rate of terminating seizures and a
more prolonged anticonvulsant effect. Diazepam is rarely used for the long-term treatment
of epilepsy because tolerance to its anticonvulsant effects usually develops within six to 12
months of treatment, effectively rendering it useless for that purpose.

Lorazepam –

 Intravenous diazepam or lorazepam are first-line treatments for convulsive status

epilepticus. Lorazepam is more effective than diazepam in the treatment of status epilepticus
 Its marked anticonvulsant properties, and its pharmacokinetic profile, make intravenous
lorazepam a reliable agent for stopping acute seizures, but it has relatively prolonged sedation
after-effects
 Lorazepam is sometimes used for individuals receiving mechanical ventilation. However, in
critically ill people, propofol has been found to be superior to lorazepam both in effectiveness
and overall cost; as a result, the use of propofol for this indication is now encouraged, whereas
the use of lorazepam is discouraged.
 Its relative effectiveness in preventing new memory formation, along with its ability to reduce
agitation and anxiety, makes lorazepam useful as premedication. It is given before a general
anesthetic to reduce the amount of anesthetic required, or before unpleasant awake
procedures, such as in dentistry or endoscopies, to reduce anxiety, to increase compliance, and
to induce amnesia for the procedure. intravenous Lorazepam is given as late as 10 minutes
before procedures
  Lorazepam is sometimes used as an alternative to midazolam in palliative sedation.
  In intensive care units lorazepam is sometimes used to produce anxiolysis, hypnosis,
and amnesia.

Midazolam

 Intravenous midazolam is indicated for procedural sedation (often in combination with

an opioid, such as fentanyl), for preoperative sedation, for the induction of general anesthesia,
and for sedation of people who are ventilated in critical care units.
 Midazolam is superior to diazepam in impairing memory of endoscopy procedures,
but propofol has a quicker recovery time and a better memory-impairing effect.
  It is the most popular benzodiazepine in the intensive care unit (ICU) because of its
short elimination half-life, combined with its water solubility and its suitability for continuous
infusion.
 for long-term sedation, lorazepam is preferred due to its long duration of action, and propofol
has advantages over midazolam when used in the ICU for sedation, such as shorter weaning
time and earlier tracheal extubation.
 Midazolam is sometimes used in neonatal intensive care units. When used, additional caution is
required in newborns; midazolam should not be used for longer than 72 hours due to risks
of tachyphylaxis, and the possibility of development of a benzodiazepine withdrawal syndrome,
as well as neurological complications