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Drug overview for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
Generic name: ARTICAINE HCL/EPINEPHRINE BITARTRATE
Drug class: Beta-Adrenergic Agents
Therapeutic class: Mouth-Throat-Dental - Preparations
Epinephrine is an endogenous catecholamine that is the active principle of Local anesthetics are drugs that reversibly block nerve conduction near the adrenal medulla; epinephrine acts directly on both alpha- and their site of application or injection and thus produce temporary loss of beta-adrenergic receptors. feeling or sensation in a limited area of the body.
Parenteral local anesthetics are used for infiltration and nerve block anesthesia. Because of differences in systemic absorption and toxicity, not all of these drugs are indicated for all types of local anesthesia and the concentration of the drug used depends on the anesthetic procedure. For indications of each parenteral local anesthetic and concentrations used for various procedures, see the individual monographs in 72:00.
Infiltration anesthesia, which is frequently used in minor surgical and dental procedures, is achieved by injecting the local anesthetic solution intradermally, subcutaneously, or submucosally across the path of nerves supplying the area to be anesthetized. Field block technique, in which the local anesthetic is infiltrated subcutaneously in a circular pattern around the operative field, is a common type of infiltration anesthesia. Infiltration anesthesia has occasionally been used for cesarean section, but epidural or spinal anesthesia is generally preferred.
Nerve block (regional) anesthesia, used in surgical, dental, and diagnostic procedures and in therapeutic management of pain, is achieved by injecting a local anesthetic solution into or around nerve trunks or ganglia supplying the area to be anesthetized. Nerve block procedures require a high degree of specialization and should be performed only by clinicians experienced in local anesthetic procedures. Peripheral nerve blocks (e.g., paracervical blocks, pudendal blocks, brachial plexus nerve blocks, ulnar nerve blocks, and intercostal blocks) and sympathetic nerve blocks (e.g., stellate ganglion blocks) involve a variety of nerves.
Spinal (subarachnoid, intrathecal) and epidural (extradural, peridural) blocks are special forms of nerve block anesthesia. Spinal anesthesia is achieved by injecting local anesthetic solutions intrathecally into the subarachnoid space at the lumbar level, and epidural anesthesia is produced by injecting the drug into the epidural space. Caudal (sacral) anesthesia is a type of epidural anesthesia in which the injection is made through the sacral hiatus.
Several nerve block procedures such as epidural (including caudal), paracervical, pudendal, and low spinal (saddle) blocks are used in obstetrics; high spinal anesthesia using high or medium drug doses should not be used for normal vaginal deliveries because undue ascent of the anesthetic may result from variations in CSF pressure during labor. Local anesthetics should not be given until the cervix is well dilated and labor is progressing normally. In spinal anesthetic procedures, the drugs should not be injected during uterine contractions since undesired ascent of the anesthetic may occur.
Vasoconstrictors (e.g., epinephrine), when added to solutions of some local anesthetics, may decrease the rate of vascular absorption of the anesthetic, thereby localizing anesthesia and prolonging the duration of anesthesia; systemic toxicity of the local anesthetic is also decreased. When infiltration anesthesia is used, vasoconstrictors may also decrease bleeding in the operative field. Epinephrine appears to be the most effective vasoconstrictor.
Mepivacaine and prilocaine produce little or no vasodilation and, therefore, administration of a vasoconstrictor with these drugs is usually not necessary. Epinephrine also does not appear to affect time of onset or duration of ropivacaine anesthesia. The optimal concentration of vasoconstrictors varies with the vascularity of the injection site and with the individual anesthetic agent.
In general, 0.1 mg of epinephrine (20 mL of a 1:200,000 solution) is used and up to 0.2 mg of epinephrine (20 mL of a 1:100,000 solution) is generally well tolerated by normal patients.
If the therapeutic benefit of epinephrine administration is considered to outweigh the possible risks in high-risk patients, a lower maximum dose of 0.02-0.05 mg (2-5 mL of a 1:100,000 solution) may be considered.
Local anesthetics should be used as a component of multimodal analgesia (i.e., simultaneous use of a combination of analgesic agents and techniques that target different mechanisms of action in the peripheral and central nervous systems) in the management of postoperative pain. Studies have demonstrated that multimodal pain management strategies are associated with superior pain relief and decreased need for opiates. Experts recommend that clinicians consider the use of local anesthetic infiltration or site-specific regional analgesic techniques as part of a multimodal approach to the management of postoperative pain.
Parenteral local anesthetics (e.g., lidocaine hydrochloride) have been used to produce regional anesthesia by injecting the drug IV (Bier Block) into a limb in which circulation has been interrupted by application of a tourniquet. However, this route of administration is not recommended with some local anesthetics (e.g., bupivacaine, ropivacaine); cardiac arrest and death have been reported when bupivacaine was administered using this technique. Procaine and lidocaine have also been administered IV as systemic analgesics; however, use of these drugs for analgesia is of doubtful value and may result in serious toxic reactions.
Lidocaine hydrochloride is used IV to treat acute ventricular arrhythmias (see 24:04.04.08). For information on topical local anesthetics, see 52:16 and 84:08.
Generic name: ARTICAINE HCL/EPINEPHRINE BITARTRATE
Drug class: Beta-Adrenergic Agents
Therapeutic class: Mouth-Throat-Dental - Preparations
Epinephrine is an endogenous catecholamine that is the active principle of Local anesthetics are drugs that reversibly block nerve conduction near the adrenal medulla; epinephrine acts directly on both alpha- and their site of application or injection and thus produce temporary loss of beta-adrenergic receptors. feeling or sensation in a limited area of the body.
Parenteral local anesthetics are used for infiltration and nerve block anesthesia. Because of differences in systemic absorption and toxicity, not all of these drugs are indicated for all types of local anesthesia and the concentration of the drug used depends on the anesthetic procedure. For indications of each parenteral local anesthetic and concentrations used for various procedures, see the individual monographs in 72:00.
Infiltration anesthesia, which is frequently used in minor surgical and dental procedures, is achieved by injecting the local anesthetic solution intradermally, subcutaneously, or submucosally across the path of nerves supplying the area to be anesthetized. Field block technique, in which the local anesthetic is infiltrated subcutaneously in a circular pattern around the operative field, is a common type of infiltration anesthesia. Infiltration anesthesia has occasionally been used for cesarean section, but epidural or spinal anesthesia is generally preferred.
Nerve block (regional) anesthesia, used in surgical, dental, and diagnostic procedures and in therapeutic management of pain, is achieved by injecting a local anesthetic solution into or around nerve trunks or ganglia supplying the area to be anesthetized. Nerve block procedures require a high degree of specialization and should be performed only by clinicians experienced in local anesthetic procedures. Peripheral nerve blocks (e.g., paracervical blocks, pudendal blocks, brachial plexus nerve blocks, ulnar nerve blocks, and intercostal blocks) and sympathetic nerve blocks (e.g., stellate ganglion blocks) involve a variety of nerves.
Spinal (subarachnoid, intrathecal) and epidural (extradural, peridural) blocks are special forms of nerve block anesthesia. Spinal anesthesia is achieved by injecting local anesthetic solutions intrathecally into the subarachnoid space at the lumbar level, and epidural anesthesia is produced by injecting the drug into the epidural space. Caudal (sacral) anesthesia is a type of epidural anesthesia in which the injection is made through the sacral hiatus.
Several nerve block procedures such as epidural (including caudal), paracervical, pudendal, and low spinal (saddle) blocks are used in obstetrics; high spinal anesthesia using high or medium drug doses should not be used for normal vaginal deliveries because undue ascent of the anesthetic may result from variations in CSF pressure during labor. Local anesthetics should not be given until the cervix is well dilated and labor is progressing normally. In spinal anesthetic procedures, the drugs should not be injected during uterine contractions since undesired ascent of the anesthetic may occur.
Vasoconstrictors (e.g., epinephrine), when added to solutions of some local anesthetics, may decrease the rate of vascular absorption of the anesthetic, thereby localizing anesthesia and prolonging the duration of anesthesia; systemic toxicity of the local anesthetic is also decreased. When infiltration anesthesia is used, vasoconstrictors may also decrease bleeding in the operative field. Epinephrine appears to be the most effective vasoconstrictor.
Mepivacaine and prilocaine produce little or no vasodilation and, therefore, administration of a vasoconstrictor with these drugs is usually not necessary. Epinephrine also does not appear to affect time of onset or duration of ropivacaine anesthesia. The optimal concentration of vasoconstrictors varies with the vascularity of the injection site and with the individual anesthetic agent.
In general, 0.1 mg of epinephrine (20 mL of a 1:200,000 solution) is used and up to 0.2 mg of epinephrine (20 mL of a 1:100,000 solution) is generally well tolerated by normal patients.
If the therapeutic benefit of epinephrine administration is considered to outweigh the possible risks in high-risk patients, a lower maximum dose of 0.02-0.05 mg (2-5 mL of a 1:100,000 solution) may be considered.
Local anesthetics should be used as a component of multimodal analgesia (i.e., simultaneous use of a combination of analgesic agents and techniques that target different mechanisms of action in the peripheral and central nervous systems) in the management of postoperative pain. Studies have demonstrated that multimodal pain management strategies are associated with superior pain relief and decreased need for opiates. Experts recommend that clinicians consider the use of local anesthetic infiltration or site-specific regional analgesic techniques as part of a multimodal approach to the management of postoperative pain.
Parenteral local anesthetics (e.g., lidocaine hydrochloride) have been used to produce regional anesthesia by injecting the drug IV (Bier Block) into a limb in which circulation has been interrupted by application of a tourniquet. However, this route of administration is not recommended with some local anesthetics (e.g., bupivacaine, ropivacaine); cardiac arrest and death have been reported when bupivacaine was administered using this technique. Procaine and lidocaine have also been administered IV as systemic analgesics; however, use of these drugs for analgesia is of doubtful value and may result in serious toxic reactions.
Lidocaine hydrochloride is used IV to treat acute ventricular arrhythmias (see 24:04.04.08). For information on topical local anesthetics, see 52:16 and 84:08.
DRUG IMAGES
No Image Available
The following indications for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate) have been approved by the FDA:
Indications:
Administration of local anesthesia by infiltration
Administration of local anesthetic nerve block
Professional Synonyms:
None.
Indications:
Administration of local anesthesia by infiltration
Administration of local anesthetic nerve block
Professional Synonyms:
None.
The following dosing information is available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
Generally, lower concentrations of local anesthetics are used for infiltration and peripheral or sympathetic nerve block anesthesia than for epidural anesthesia; highest concentrations (but small doses) are used in spinal anesthesia. Dosage varies with the anesthetic procedure, the degree of anesthesia required, and individual patient response. The smallest dose and concentration required to produce the desired effect should be used, especially in obstetrics.
Reduced dosage is indicated in debilitated or acutely ill patients, in very young children or geriatric patients, and in patients with liver disease, arteriosclerosis, or occlusive arterial disease.
Dosage of epinephrine salts is expressed in terms of epinephrine. Dosage of racepinephrine hydrochloride is expressed in terms of racepinephrine; racepinephrine is about one-half as active as epinephrine.
For the emergency treatment of allergic reactions, including anaphylaxis, the usual adult dose of epinephrine is 0.2-0.5 mg (0.2-0.5 mL of a 1-mg/mL solution) administered IM or subcutaneously; the dose may be repeated every 5-15 minutes as necessary.
A maximum single dose of 0.5 mg in adults is recommended. IM administration is preferred since absorption and subsequent achievement of peak plasma concentrations may be slower and substantially delayed following subcutaneous administration of the drug if shock is present.
For self-administration of epinephrine using a prefilled auto-injector (e.g., EpiPen(R)), an IM or subcutaneous dose of 0.3 mg is recommended. For severe persistent anaphylaxis, repeated doses may be needed; if more than 2 sequential doses are needed, subsequent doses should be administered under direct medical supervision.
In extreme circumstances (e.g., anaphylactic shock, cardiac arrest, or no response to initial IM injections), IV administration may be necessary since absorption of epinephrine may be impaired with subcutaneous or IM administration. The usual adult IV dose of epinephrine for the treatment of anaphylaxis ranges from 0.1 to 0.25
mg (1-2.5 mL of a 0.1-mg/mL solution); the dose may be repeated every 5-15 minutes as needed. Although there is no established dosage for continuous IV infusions of epinephrine, some studies have demonstrated efficacy at IV infusion rates of 2-15 mcg/minute, titrated based on severity of the reaction and clinical response.
Patients with anaphylaxis who respond to therapy require observation for possible recurrence even if there is an intervening asymptomatic period; length of observation time has not been established. Symptoms may recur within 1-36 hours after the initial reaction. The duration of direct observation and monitoring after an episode of anaphylaxis should be individualized based on the severity and duration of the anaphylactic event as well as other factors (e.g., response to treatment, pattern of previous anaphylactic reactions, comorbidities, patient reliability, access to medical care).
Some experts suggest that patients with moderate to severe anaphylaxis should be observed for a minimum of 4-8 hours after treatment.
When used for cardiac resuscitation in adults, epinephrine doses ranging from 0.1-1 mg have been used. In ACLS guidelines, a standard dosage of epinephrine (defined as 1 mg every 3-5 minutes by IV/IO injection) is recommended during adult cardiac arrest.
Current evidence indicates that higher doses (e.g., 0.1-0.2 mg/kg) do not provide any benefits in terms of survival or neurologic outcomes compared with the standard dose and may be harmful.
The optimum dose of epinephrine during cardiac resuscitation has been a subject of controversy. Many clinicians had questioned the commonly used doses of 0.5-1 mg because of concern that these doses were not based on body weight, and thus may be lower than necessary for optimum cardiovascular effects.
Interest in high doses of epinephrine was stimulated by animal studies indicating that such doses (e.g., 0.045-0.2 mg/kg) provided optimal improvement in hemodynamics, including ROSC, and timely achievement of successful cardiopulmonary resuscitation (CPR). Results of several clinical studies, including randomized controlled studies, found no substantial improvement in survival rates to hospital discharge nor trend for improved neurologic outcomes in patients with cardiac arrest receiving higher than usual doses of epinephrine, despite evidence of increased rates of ROSC and higher initial resuscitation rates with high-dose therapy. A retrospective study of functional neurologic outcomes (assessed by measurement of cerebral performance category) of patients with ventricular fibrillation who received high IV dosages of epinephrine during cardiac resuscitation found that such dosages were independently associated with unfavorable neurologic outcomes.
Patients with unfavorable neurologic outcomes after resuscitation had received substantially higher median cumulative doses (i.e., 4 mg (range: 2-8 mg)) of epinephrine than those with favorable neurologic outcomes who received a median cumulative dose of 1 mg (range: less than 1-3 mg). These findings persisted after neurologic outcomes were stratified by duration of CPR and other potentially confounding conditions were considered. Based on the currently available evidence, the American Heart Association (AHA) states that it is reasonable to administer standard-dose epinephrine (1 mg every 3-5 minutes) during cardiac arrest in adults; high-dose epinephrine should not be used routinely, but may be considered in certain situations (e.g., overdosage of beta-adrenergic or calcium-channel blocking agents).
The optimal timing of epinephrine administration, particularly in relation to defibrillation, is not known and may vary based on patient-specific factors and resuscitation conditions. In adults with asystole or pulseless electrical activity (PEA), epinephrine may be given as soon as feasible after the onset of cardiac arrest based on studies demonstrating improved survival to hospital discharge and increased ROSC when the drug was administered early during the course of treatment for a nonshockable rhythm.
If IV or IO access cannot be established during cardiac arrest, epinephrine may be administered via the endotracheal route. Although the optimal dose of epinephrine administered via an endotracheal tube remains to be established, some experts state that typical doses should be 2-2.5 times those administered IV.
If epinephrine is used for hemodynamic support following cardiac resuscitation, the usual IV dosage in adults is 0.1-0.5 mcg/kg per minute; the infusion rate should be titrated to patient response.
If epinephrine is used for the treatment of symptomatic bradycardia in adults, an initial infusion rate of 2-10 mcg/minute has been recommended and should be titrated to patient response. Intravascular volume and support should be assessed as needed.
When used for pediatric advanced life support (PALS), the usual IV or IO dose of epinephrine is 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution), up to a maximum single dose of 1 mg, and the usual dose of epinephrine administered via an endotracheal tube is 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution), up to a maximum single dose of 2.5
mg. The same IV, IO, or endotracheal dose should be repeated every 3-5 minutes if needed. Higher doses are not recommended because of the potential for harm, particularly in cases of asphyxia, and lack of survival benefit.
AHA states, however, that high-dose epinephrine may be considered in exceptional circumstances (e.g., beta-adrenergic blocking agent overdose).
In a prospective, randomized, double-blind study of 68 children who received either 0.01 mg/kg (standard dose) or 0.1 mg/kg (high dose) of epinephrine as rescue therapy for in-hospital cardiac arrest after failure of CPR and an initial dose of 0.01
mg/kg (standard dose) of epinephrine, high-dose rescue therapy was not associated with any benefits. High-dose epinephrine rescue therapy did not improve the survival rate at 24 hours compared with standard-dose therapy, and appeared to be harmful in children with asphyxia-precipitated cardiac arrest. In addition, a trend toward reduced rate of survival at 24 hours was observed among children who received high-dose therapy as compared with standard-dose therapy.
Also, the rates of ROSC or survival to hospital discharge were not significantly different between the 2 groups.
For postresuscitation stabilization in pediatric patients, epinephrine may be administered by IV or IO infusion at a rate of 0.1-1 mcg/kg per minute; the rate of infusion should be adjusted based on patient response. Although low-dose IV infusions (less than 0.3 mcg/kg per minute) generally produce predominantly beta-adrenergic effects, while higher-dose IV infusions (exceeding 0.3 mcg/kg per minute) generally result in alpha-adrenergic vasoconstriction, there is substantial interindividual variation in response, and infusion dosage should be titrated to the desired effect.
The usual neonatal IV dose of epinephrine is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of a 0.1-mg/mL solution).
AHA states that higher IV doses are not recommended; in pediatric and animal studies, administration of IV doses in the range of 0.1 mg/kg have been associated with exaggerated hypertension, decreased myocardial function, and worsening neurologic function. In addition, the sequence of hypotension followed by hypertension is likely to increase the risk of intracranial hemorrhage, especially in neonates.
IV administration of epinephrine (0.01-0.03 mg/kg per dose) is the preferred route in neonates, since there are limited data available on endotracheal administration of epinephrine. If the endotracheal route is used, doses of 0.01 or 0.03
mg/kg will likely be ineffective. Although safety and efficacy have not been established, endotracheal administration of a higher dose (0.05-0.1 mg/kg) while IV access is being obtained may be considered.
In one retrospective study in children and neonates who received either mean doses of 0.01 mg/kg (standard dose) or 0.12 mg/kg (high dose) of epinephrine administered IV, via an endotracheal tube, or by IO infusion during CPR after cardiac arrest occurring during a hospital stay, high doses of the drug were not associated with improvements in rates of ROSC, short- or long-term survival rates, or overall outcome scores.
In this study, the time to ROSC was substantially shorter in patients receiving standard doses of epinephrine than in those receiving higher doses. In addition, high-dose epinephrine may be associated with adverse effects such as increased myocardial oxygen consumption during cardiac resuscitation, a postarrest hyperadrenergic state with tachycardia, hypertension and ventricular ectopy, myocardial necrosis, and worse postarrest myocardial dysfunction. Additional clinical studies are needed to evaluate fully the optimum dosage regimen of epinephrine in pediatric patients.
For the emergency treatment of infants and children with bradycardia and cardiorespiratory compromise (with a palpable pulse), epinephrine may be given at a dose of 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution) by IV/IO injection, and repeated every 3-5 minutes as needed; alternatively, an endotracheal dose of 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution) may be given if IV/IO access is not available.
For the treatment of severe asthma exacerbations when orally inhaled, selective short-acting beta2-adrenergic agonists are not available, an expert panel of the National Asthma Education and Prevention Program (NAEPP) states that epinephrine 0.3-0.5 mg may be given subcutaneously every 20 minutes for 3 doses in adults and adolescents older than 12 years of age.
Alternatively, some clinicians recommend a subcutaneous epinephrine dose of 0.01 mg/kg (using a 1-mg/mL solution), divided into 3 doses of approximately 0.3 mg each, administered at 20-minute intervals.
For the treatment of severe asthma exacerbations in children 12 years of age or younger, 0.01 mg/kg of epinephrine (0.01 mL/kg using a 1-mg/mL solution), but no more than 0.3-0.5
mg per dose, may be administered by subcutaneous injection at 20-minute intervals for 3 doses.
For the treatment of bronchospasm in adults, some manufacturers recommend an epinephrine dose of 0.1-0.25 mg (1-2.5 mL of a 0.1-mg/mL solution) by slow IV injection.
If IV administration of epinephrine is required for the management of asthma attacks in pediatric patients, some clinicians recommend a slow IV injection of 0.01 mg/kg in neonates and an initial IV dose of 0.05 mg (which may be repeated at 20- to 30-minute intervals) in infants.
For the temporary relief of mild symptoms of intermittent asthma, the usual dose of 2.25% racepinephrine inhalation solution (equivalent to 1% epinephrine) in adults and children 4 years of age or older is 1-3 inhalations; doses should not be repeated more often than every 3 hours. Patients should be advised to seek medical assistance immediately if symptoms are not relieved within 20 minutes or become worse.
Reduced dosage is indicated in debilitated or acutely ill patients, in very young children or geriatric patients, and in patients with liver disease, arteriosclerosis, or occlusive arterial disease.
Dosage of epinephrine salts is expressed in terms of epinephrine. Dosage of racepinephrine hydrochloride is expressed in terms of racepinephrine; racepinephrine is about one-half as active as epinephrine.
For the emergency treatment of allergic reactions, including anaphylaxis, the usual adult dose of epinephrine is 0.2-0.5 mg (0.2-0.5 mL of a 1-mg/mL solution) administered IM or subcutaneously; the dose may be repeated every 5-15 minutes as necessary.
A maximum single dose of 0.5 mg in adults is recommended. IM administration is preferred since absorption and subsequent achievement of peak plasma concentrations may be slower and substantially delayed following subcutaneous administration of the drug if shock is present.
For self-administration of epinephrine using a prefilled auto-injector (e.g., EpiPen(R)), an IM or subcutaneous dose of 0.3 mg is recommended. For severe persistent anaphylaxis, repeated doses may be needed; if more than 2 sequential doses are needed, subsequent doses should be administered under direct medical supervision.
In extreme circumstances (e.g., anaphylactic shock, cardiac arrest, or no response to initial IM injections), IV administration may be necessary since absorption of epinephrine may be impaired with subcutaneous or IM administration. The usual adult IV dose of epinephrine for the treatment of anaphylaxis ranges from 0.1 to 0.25
mg (1-2.5 mL of a 0.1-mg/mL solution); the dose may be repeated every 5-15 minutes as needed. Although there is no established dosage for continuous IV infusions of epinephrine, some studies have demonstrated efficacy at IV infusion rates of 2-15 mcg/minute, titrated based on severity of the reaction and clinical response.
Patients with anaphylaxis who respond to therapy require observation for possible recurrence even if there is an intervening asymptomatic period; length of observation time has not been established. Symptoms may recur within 1-36 hours after the initial reaction. The duration of direct observation and monitoring after an episode of anaphylaxis should be individualized based on the severity and duration of the anaphylactic event as well as other factors (e.g., response to treatment, pattern of previous anaphylactic reactions, comorbidities, patient reliability, access to medical care).
Some experts suggest that patients with moderate to severe anaphylaxis should be observed for a minimum of 4-8 hours after treatment.
When used for cardiac resuscitation in adults, epinephrine doses ranging from 0.1-1 mg have been used. In ACLS guidelines, a standard dosage of epinephrine (defined as 1 mg every 3-5 minutes by IV/IO injection) is recommended during adult cardiac arrest.
Current evidence indicates that higher doses (e.g., 0.1-0.2 mg/kg) do not provide any benefits in terms of survival or neurologic outcomes compared with the standard dose and may be harmful.
The optimum dose of epinephrine during cardiac resuscitation has been a subject of controversy. Many clinicians had questioned the commonly used doses of 0.5-1 mg because of concern that these doses were not based on body weight, and thus may be lower than necessary for optimum cardiovascular effects.
Interest in high doses of epinephrine was stimulated by animal studies indicating that such doses (e.g., 0.045-0.2 mg/kg) provided optimal improvement in hemodynamics, including ROSC, and timely achievement of successful cardiopulmonary resuscitation (CPR). Results of several clinical studies, including randomized controlled studies, found no substantial improvement in survival rates to hospital discharge nor trend for improved neurologic outcomes in patients with cardiac arrest receiving higher than usual doses of epinephrine, despite evidence of increased rates of ROSC and higher initial resuscitation rates with high-dose therapy. A retrospective study of functional neurologic outcomes (assessed by measurement of cerebral performance category) of patients with ventricular fibrillation who received high IV dosages of epinephrine during cardiac resuscitation found that such dosages were independently associated with unfavorable neurologic outcomes.
Patients with unfavorable neurologic outcomes after resuscitation had received substantially higher median cumulative doses (i.e., 4 mg (range: 2-8 mg)) of epinephrine than those with favorable neurologic outcomes who received a median cumulative dose of 1 mg (range: less than 1-3 mg). These findings persisted after neurologic outcomes were stratified by duration of CPR and other potentially confounding conditions were considered. Based on the currently available evidence, the American Heart Association (AHA) states that it is reasonable to administer standard-dose epinephrine (1 mg every 3-5 minutes) during cardiac arrest in adults; high-dose epinephrine should not be used routinely, but may be considered in certain situations (e.g., overdosage of beta-adrenergic or calcium-channel blocking agents).
The optimal timing of epinephrine administration, particularly in relation to defibrillation, is not known and may vary based on patient-specific factors and resuscitation conditions. In adults with asystole or pulseless electrical activity (PEA), epinephrine may be given as soon as feasible after the onset of cardiac arrest based on studies demonstrating improved survival to hospital discharge and increased ROSC when the drug was administered early during the course of treatment for a nonshockable rhythm.
If IV or IO access cannot be established during cardiac arrest, epinephrine may be administered via the endotracheal route. Although the optimal dose of epinephrine administered via an endotracheal tube remains to be established, some experts state that typical doses should be 2-2.5 times those administered IV.
If epinephrine is used for hemodynamic support following cardiac resuscitation, the usual IV dosage in adults is 0.1-0.5 mcg/kg per minute; the infusion rate should be titrated to patient response.
If epinephrine is used for the treatment of symptomatic bradycardia in adults, an initial infusion rate of 2-10 mcg/minute has been recommended and should be titrated to patient response. Intravascular volume and support should be assessed as needed.
When used for pediatric advanced life support (PALS), the usual IV or IO dose of epinephrine is 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution), up to a maximum single dose of 1 mg, and the usual dose of epinephrine administered via an endotracheal tube is 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution), up to a maximum single dose of 2.5
mg. The same IV, IO, or endotracheal dose should be repeated every 3-5 minutes if needed. Higher doses are not recommended because of the potential for harm, particularly in cases of asphyxia, and lack of survival benefit.
AHA states, however, that high-dose epinephrine may be considered in exceptional circumstances (e.g., beta-adrenergic blocking agent overdose).
In a prospective, randomized, double-blind study of 68 children who received either 0.01 mg/kg (standard dose) or 0.1 mg/kg (high dose) of epinephrine as rescue therapy for in-hospital cardiac arrest after failure of CPR and an initial dose of 0.01
mg/kg (standard dose) of epinephrine, high-dose rescue therapy was not associated with any benefits. High-dose epinephrine rescue therapy did not improve the survival rate at 24 hours compared with standard-dose therapy, and appeared to be harmful in children with asphyxia-precipitated cardiac arrest. In addition, a trend toward reduced rate of survival at 24 hours was observed among children who received high-dose therapy as compared with standard-dose therapy.
Also, the rates of ROSC or survival to hospital discharge were not significantly different between the 2 groups.
For postresuscitation stabilization in pediatric patients, epinephrine may be administered by IV or IO infusion at a rate of 0.1-1 mcg/kg per minute; the rate of infusion should be adjusted based on patient response. Although low-dose IV infusions (less than 0.3 mcg/kg per minute) generally produce predominantly beta-adrenergic effects, while higher-dose IV infusions (exceeding 0.3 mcg/kg per minute) generally result in alpha-adrenergic vasoconstriction, there is substantial interindividual variation in response, and infusion dosage should be titrated to the desired effect.
The usual neonatal IV dose of epinephrine is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of a 0.1-mg/mL solution).
AHA states that higher IV doses are not recommended; in pediatric and animal studies, administration of IV doses in the range of 0.1 mg/kg have been associated with exaggerated hypertension, decreased myocardial function, and worsening neurologic function. In addition, the sequence of hypotension followed by hypertension is likely to increase the risk of intracranial hemorrhage, especially in neonates.
IV administration of epinephrine (0.01-0.03 mg/kg per dose) is the preferred route in neonates, since there are limited data available on endotracheal administration of epinephrine. If the endotracheal route is used, doses of 0.01 or 0.03
mg/kg will likely be ineffective. Although safety and efficacy have not been established, endotracheal administration of a higher dose (0.05-0.1 mg/kg) while IV access is being obtained may be considered.
In one retrospective study in children and neonates who received either mean doses of 0.01 mg/kg (standard dose) or 0.12 mg/kg (high dose) of epinephrine administered IV, via an endotracheal tube, or by IO infusion during CPR after cardiac arrest occurring during a hospital stay, high doses of the drug were not associated with improvements in rates of ROSC, short- or long-term survival rates, or overall outcome scores.
In this study, the time to ROSC was substantially shorter in patients receiving standard doses of epinephrine than in those receiving higher doses. In addition, high-dose epinephrine may be associated with adverse effects such as increased myocardial oxygen consumption during cardiac resuscitation, a postarrest hyperadrenergic state with tachycardia, hypertension and ventricular ectopy, myocardial necrosis, and worse postarrest myocardial dysfunction. Additional clinical studies are needed to evaluate fully the optimum dosage regimen of epinephrine in pediatric patients.
For the emergency treatment of infants and children with bradycardia and cardiorespiratory compromise (with a palpable pulse), epinephrine may be given at a dose of 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution) by IV/IO injection, and repeated every 3-5 minutes as needed; alternatively, an endotracheal dose of 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution) may be given if IV/IO access is not available.
For the treatment of severe asthma exacerbations when orally inhaled, selective short-acting beta2-adrenergic agonists are not available, an expert panel of the National Asthma Education and Prevention Program (NAEPP) states that epinephrine 0.3-0.5 mg may be given subcutaneously every 20 minutes for 3 doses in adults and adolescents older than 12 years of age.
Alternatively, some clinicians recommend a subcutaneous epinephrine dose of 0.01 mg/kg (using a 1-mg/mL solution), divided into 3 doses of approximately 0.3 mg each, administered at 20-minute intervals.
For the treatment of severe asthma exacerbations in children 12 years of age or younger, 0.01 mg/kg of epinephrine (0.01 mL/kg using a 1-mg/mL solution), but no more than 0.3-0.5
mg per dose, may be administered by subcutaneous injection at 20-minute intervals for 3 doses.
For the treatment of bronchospasm in adults, some manufacturers recommend an epinephrine dose of 0.1-0.25 mg (1-2.5 mL of a 0.1-mg/mL solution) by slow IV injection.
If IV administration of epinephrine is required for the management of asthma attacks in pediatric patients, some clinicians recommend a slow IV injection of 0.01 mg/kg in neonates and an initial IV dose of 0.05 mg (which may be repeated at 20- to 30-minute intervals) in infants.
For the temporary relief of mild symptoms of intermittent asthma, the usual dose of 2.25% racepinephrine inhalation solution (equivalent to 1% epinephrine) in adults and children 4 years of age or older is 1-3 inhalations; doses should not be repeated more often than every 3 hours. Patients should be advised to seek medical assistance immediately if symptoms are not relieved within 20 minutes or become worse.
Parenteral local anesthetics may be administered by local infiltration or by epidural (including caudal), spinal (subarachnoid, intrathecal), retrobulbar, dental, peripheral, or sympathetic block. The drugs may be given by single injection or continuous block techniques in which repeat injections are given through a catheter inserted into the area being anesthetized. Local anesthetics have been administered by continuous intra-articular infusion+ using elastomeric infusion devices (e.g., for control of postoperative pain); however, such use has been associated with chondrolysis.(See
Cautions: Musculoskeletal Effects.) Local anesthetic solutions containing preservatives should not be used for spinal or epidural (including caudal) anesthesia. Partially used bottles of solutions which do not contain preservatives should be discarded. Because of the risk of hypotension, the patient's blood pressure should be monitored during spinal anesthesia.
Resuscitative equipment, oxygen, drugs, and personnel required for treatment of adverse reactions should be immediately available when local anesthetics are used. (See Cautions: Precautions and Contraindications.) Proper positioning of the patient is extremely important in spinal anesthesia. For specific procedures and techniques of administration, specialized references should be consulted.
Local anesthetics should be administered slowly in incremental doses to reduce the risk of adverse effects (e.g., local anesthetic systemic toxicity). Frequent aspirations for blood or cerebrospinal fluid (when applicable) should be performed to avoid intravascular administration and to either confirm entry into the subarachnoid space (for spinal anesthesia) or avoid inadvertent subarachnoid injection. USP has changed its labeling standard for single-entity drug products to no longer allow the use of ratios to express drug concentrations.
This labeling change was prompted by numerous reports of serious medication errors caused by confusion with different ratio expressions. Effective May 1, 2016, all single-entity preparations of epinephrine injection, USP should be labeled only in terms of strength per mL (i.e., mg/mL). While concentrations of some epinephrine preparations were historically expressed in ratios (e.g., 1:1000 or 1:10,000), such designation is no longer acceptable because of the risk of dosing errors.
Epinephrine usually is administered by IM, subcutaneous, or IV injection, or by continuous IV infusion. Epinephrine also has been administered by intraosseous (IO) injection+ in the setting of advanced cardiovascular life support (ACLS), generally when IV access is not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration. If vascular access (IV or IO) cannot be established during cardiac arrest, epinephrine may be administered endotracheally; however, this method of administration results in lower plasma concentrations compared with the same dose given intravascularly.
Epinephrine also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration is not recommended in current ACLS guidelines. The appropriate concentration and route of administration of epinephrine should be selected carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV. Because of the risks associated with IV use, epinephrine generally should be administered by the IV route only in extreme situations (such as in the treatment of septic or anaphylactic shock, cardiac arrest, or when the patient is unresponsive to multiple IM injections).
Dilute solutions of epinephrine (e.g., 0.1 mg/mL) should always be used when administering the drug IV. Commercially available epinephrine solutions for IM or subcutaneous injection are tenfold more concentrated (1 mg/mL) and should not be administered IV without dilution. Solutions of epinephrine should be inspected visually for particulate matter and discoloration prior to administration. Epinephrine injection must not be used if it is discolored or cloudy or contains any particulate matter.
Cautions: Musculoskeletal Effects.) Local anesthetic solutions containing preservatives should not be used for spinal or epidural (including caudal) anesthesia. Partially used bottles of solutions which do not contain preservatives should be discarded. Because of the risk of hypotension, the patient's blood pressure should be monitored during spinal anesthesia.
Resuscitative equipment, oxygen, drugs, and personnel required for treatment of adverse reactions should be immediately available when local anesthetics are used. (See Cautions: Precautions and Contraindications.) Proper positioning of the patient is extremely important in spinal anesthesia. For specific procedures and techniques of administration, specialized references should be consulted.
Local anesthetics should be administered slowly in incremental doses to reduce the risk of adverse effects (e.g., local anesthetic systemic toxicity). Frequent aspirations for blood or cerebrospinal fluid (when applicable) should be performed to avoid intravascular administration and to either confirm entry into the subarachnoid space (for spinal anesthesia) or avoid inadvertent subarachnoid injection. USP has changed its labeling standard for single-entity drug products to no longer allow the use of ratios to express drug concentrations.
This labeling change was prompted by numerous reports of serious medication errors caused by confusion with different ratio expressions. Effective May 1, 2016, all single-entity preparations of epinephrine injection, USP should be labeled only in terms of strength per mL (i.e., mg/mL). While concentrations of some epinephrine preparations were historically expressed in ratios (e.g., 1:1000 or 1:10,000), such designation is no longer acceptable because of the risk of dosing errors.
Epinephrine usually is administered by IM, subcutaneous, or IV injection, or by continuous IV infusion. Epinephrine also has been administered by intraosseous (IO) injection+ in the setting of advanced cardiovascular life support (ACLS), generally when IV access is not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration. If vascular access (IV or IO) cannot be established during cardiac arrest, epinephrine may be administered endotracheally; however, this method of administration results in lower plasma concentrations compared with the same dose given intravascularly.
Epinephrine also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration is not recommended in current ACLS guidelines. The appropriate concentration and route of administration of epinephrine should be selected carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV. Because of the risks associated with IV use, epinephrine generally should be administered by the IV route only in extreme situations (such as in the treatment of septic or anaphylactic shock, cardiac arrest, or when the patient is unresponsive to multiple IM injections).
Dilute solutions of epinephrine (e.g., 0.1 mg/mL) should always be used when administering the drug IV. Commercially available epinephrine solutions for IM or subcutaneous injection are tenfold more concentrated (1 mg/mL) and should not be administered IV without dilution. Solutions of epinephrine should be inspected visually for particulate matter and discoloration prior to administration. Epinephrine injection must not be used if it is discolored or cloudy or contains any particulate matter.
No dosing information available.
No generic dosing information available.
The following drug interaction information is available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
There are 1 contraindications.
These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.
| Drug Interaction | Drug Names |
|---|---|
| Dihydroergotamine/Sympathomimetics SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Concurrent use of dihydroergotamine and sympathomimetics may result in additive or synergistic effect on peripheral blood vessels.(1) CLINICAL EFFECTS: Concurrent use of dihydroergotamine and sympathomimetics may result in increased blood pressure due to peripheral vasoconstriction.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Dihydroergotamine is contraindicated with sympathomimetics because the combination may result in additive or synergistic elevation of blood pressure.(1) DISCUSSION: Significant elevation in blood pressure has been reported in patients treated with dihydroergotamine.(1) Sympathomimetics can be expected to have additional effects on blood pressure. |
DIHYDROERGOTAMINE MESYLATE, MIGRANAL, TRUDHESA |
There are 6 severe interactions.
These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.
| Drug Interaction | Drug Names |
|---|---|
| Epinephrine/Non-Cardioselective Beta-Blockers SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of beta-blockers also block the beta effects of epinephrine, which results in predomination of alpha effects. The plasma clearance of epinephrine is decreased. CLINICAL EFFECTS: Concurrent use of epinephrine with beta-blockers may result in hypertension with reflex bradycardia. Epinephrine resistance in patients with anaphylaxis has been reported. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Avoid concomitant administration of epinephrine and beta-blockers if possible. If both drugs are administered, monitor blood pressure carefully. Hypertension and bradycardia are less likely to occur with cardioselective beta-blockers. Use caution when treating anaphylaxis with epinephrine since response may be poor. DISCUSSION: In a study of 6 subjects, an increase in mean arterial pressure (MAP) of 15.1% (p < 0.05) was observed after an infusion of epinephrine (10 ng/kg/min) followed by an intravenous injection of propranolol (40 mcg/kg). In addition, plasma clearance of epinephrine decreased to 54.7% of the control value after the dose of propranolol.(1) In another study of 6 subjects, patients were intravenously administered 15 mcg epinephrine, followed by propranolol 0.04 mg/kg, and then another dose of epinephrine. A mean decrease in heart rate of 37% (p < 0.001) was observed following the second dose of epinephrine.(2) In a study in 10 healthy subjects, an increase in MAP was observed after infusion of epinephrine (5 mcg/min) followed by infusion of propranolol (10 mg).(5) In a study in 1 healthy subject, marked bradycardia and atrioventricular block occurred after administration of propranolol (40 mg orally) with epinephrine (17 mcg/min intravenously).(6) In a study in 7 healthy subjects, and increase in MAP (8% increase in systolic blood pressure, 10% increase in diastolic blood pressure) was observed after injection of epinephrine (45 mcg in lidocaine) in to the maxilla after pretreatment with pindolol (5 mg).(7) A retrospective analysis of sinus surgery patients found that 9.1% had exaggerated intraoperative hypertensive events during the first surgical hour (defined as relative increase greater than 20% of systolic blood pressure or single systolic blood pressure value above 200 mmHg). Subjects with established beta blockade were found to be three times as likely to experience an exaggerated hypertensive event during the first intraoperative hour.(8) In a study, intraoral injection with 2% lidocaine containing epinephrine (45 mcg) after pretreatment with pindolol (5 mg) resulted reduced stroke volume, increase in afterload, decreased myocardial contractility, decreased heart rate, and an increase in blood pressure.(9) In a study in 8 subjects, a comparison of propranolol (80 mg three times daily) or metoprolol (100 mg three times daily) with epinephrine (8 mcg/min for 6 minutes) showed that propranolol significantly increases MAP while metoprolol, a beta1-selective beta-blocker, does not.(10) There are several case reports of significant hypertension with reflex bradycardia.(9-12) In some of these case reports patients had strokes.(12) |
BETAPACE, BETAPACE AF, CORGARD, HEMANGEOL, INDERAL LA, INDERAL XL, INNOPRAN XL, LABETALOL HCL, LABETALOL HCL-WATER, NADOLOL, PINDOLOL, PROPRANOLOL HCL, PROPRANOLOL HCL ER, PROPRANOLOL-HYDROCHLOROTHIAZID, SOTALOL, SOTALOL AF, SOTALOL HCL, SOTYLIZE, TIMOLOL MALEATE |
| Ergot Alkaloids/Sympathomimetics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of ergot alkaloids and sympathomimetics may result in additive or synergistic effect on peripheral blood vessels. CLINICAL EFFECTS: Concurrent use of ergot alkaloids and sympathomimetics may result in increased blood pressure due to peripheral vasoconstriction. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: When possible, avoid the concurrent use of ergot alkaloids and sympathomimetics. If concurrent use is warranted, monitor blood pressure and for signs of vasoconstriction. Decreasing the dose of one or both drugs may be necessary. DISCUSSION: There have been reports of severe vasoconstriction resulting in gangrene in patients receiving intravenous ergonovine with dopamine or norepinephrine. |
ERGOLOID MESYLATES, ERGOMAR, ERGOTAMINE TARTRATE, ERGOTAMINE-CAFFEINE, METHYLERGONOVINE MALEATE, METHYSERGIDE MALEATE, MIGERGOT |
| Selected Inhalation Anesthetic Agents/Sympathomimetics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: The exact mechanism is unknown. The anesthetics produce conduction changes that increase impulse re-entry into the myocardial tissue.(1) The anesthetics' ability to precipitate arrhythmias is enhanced by elevated arterial blood pressure, tachycardia, hypercapnia, and/or hypoxia, events that stimulate the release of endogenous catecholamines.(1) CLINICAL EFFECTS: Concurrent use of inhalation anesthetic agents and sympathomimetics may result in ventricular arrhythmias or sudden blood pressure and heart rate increase during surgery.(2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Monitor blood pressure and avoid use of sympathomimetics in patients being treated with anesthetics on the day of surgery.(2) Intravenous use of epinephrine during surgery with halothane and related halogenated general anesthetics should be strongly discouraged. When intravenous epinephrine is necessary, nitrous oxide anesthesia supplemented with ether, muscle relaxants, or opioids should be used instead of halothane.(3,4) Epinephrine may safely be used subcutaneously with the following precautions: the patient is adequately ventilated to prevent hypoxia or respiratory acidosis; the total dose of epinephrine is limited to 100 mcg/10 minute period or 300 mcg/hour in adults, 3.5 mcg/Kg in infants, 2.5 mcg/Kg in children up to two years of age, and 1.45 mcg/Kg in children over two years of age; a minimum effective concentration of anesthetic is maintained; the drugs are not co-administered in patients with hypertension or other cardiovascular disorders; and the cardiac rhythm is continuously monitored during and after injection.(3-10) If arrhythmias occur after the administration of the epinephrine, the drugs of choice are lidocaine or propranolol, depending on the type of arrhythmia.(1) DISCUSSION: Administration of epinephrine during halothane anesthesia may may lead to serious ventricular arrhythmias.(3-6,11-18) This has occurred when epinephrine was administered intravenously,(6) when it was administered with lidocaine as a dental block,(11,14) or when it was administered supraperiosteally.(5) Norepinephrine has been shown to interact with halothane in a manner similar to epinephrine.(1) In two case reports, patients were given terbutaline (0.25 to 0.35 mg) for wheezing following induction of anesthesia with halothane. One patient's heart rate increased from 68 to 100 beats/minute, and the ECG showed premature ventricular contractions and bigeminy, while the other patient developed multiple unifocal premature ventricular contractions and bigeminy. The arrhythmias resolved in both patients following lidocaine administration.(19) Although not documented, isoproterenol causes effects on the heart similar to terbutaline(20) and would probably interact with halothane in a similar manner. Other inhalation anesthetics that increase the incidence of arrhythmias with epinephrine include chloroform,(20) methoxyflurane,(20) and enflurane.(12) A similar interaction may be expected between the other inhalation anesthetics and sympathomimetics. |
DESFLURANE, FORANE, ISOFLURANE, SEVOFLURANE, SUPRANE, TERRELL, ULTANE |
| Selected Direct-Acting Sympathomimetics/Tricyclic Compounds SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Unknown. However, it is speculated that direct-acting sympathomimetic amines have an enhanced effect due to tricyclic blockage of norepinephrine reuptake. CLINICAL EFFECTS: Increased effect of direct acting sympathomimetics. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Consider avoiding the concurrent use of direct-acting sympathomimetics and tricyclic compounds. If concurrent use of direct-acting sympathomimetics and tricyclic compounds is warranted, the initial dose of the sympathomimetic should be lowered and the patient should be monitored for adverse cardiovascular effects. Use of tricyclic compounds and other sympathomimetics should be approached with caution. DISCUSSION: Epinephrine and other direct-acting sympathomimetic amines exert enhanced cardiovascular effects (e.g., arrhythmias, hypertension, and tachycardia) in individuals concurrently receiving or previously treated with tricyclic antidepressants. Other direct and mixed acting sympathomimetic amines have also been reported to interact with tricyclic antidepressants. These include norepinephrine, phenylephrine, dopamine, and methoxamine. Protriptyline, amitriptyline, and desipramine have also been reported to interact with direct-acting sympathomimetics. |
AMITRIPTYLINE HCL, AMOXAPINE, ANAFRANIL, CHLORDIAZEPOXIDE-AMITRIPTYLINE, CLOMIPRAMINE HCL, DESIPRAMINE HCL, DOXEPIN HCL, IMIPRAMINE HCL, IMIPRAMINE PAMOATE, NORPRAMIN, NORTRIPTYLINE HCL, PAMELOR, PERPHENAZINE-AMITRIPTYLINE, PROTRIPTYLINE HCL, SILENOR, TRIMIPRAMINE MALEATE |
| Iobenguane I 123/Agents that Affect Catecholamines SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Many compounds that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells.(1) CLINICAL EFFECTS: Compounds that reduce catecholamine uptake or that deplete catecholamine stores may interfere with imaging completed with iobenguane.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Discuss the use of agents that affect catecholamines. Discontinue drugs that reduce catecholamine uptake or deplete catecholamine stores prior to imaging with iobenguane. Before imaging with iobenguane, discontinue agents that affect catecholamines for at least 5 biological half-lives, as clinically tolerated.(1) DISCUSSION: Many agents may reduce catecholamine uptake or deplete catecholamine stores.(1) Examples include: - CNS stimulants or amphetamines (e.g. cocaine, methylphenidate, dextroamphetamine) - norepinephrine and dopamine reuptake inhibitors (e.g. phentermine) - norepinephrine and serotonin reuptake inhibitors (e.g. tramadol) - monoamine oxidase inhibitors (e.g. phenelzine, linezolid) - central monoamine depleting drugs (e.g. reserpine) - non-select beta adrenergic blocking drugs (e.g. labetalol) - alpha agonists or alpha/beta agonists (e.g. pseudoephedrine, phenylephrine, ephedrine, phenylpropanolamine, naphazoline) - tricyclic antidepressants or norepinephrine reuptake inhibitors (e.g. amitriptyline, bupropion, duloxetine, mirtazapine, venlafaxine) - botanicals that may inhibit reuptake of norepinephrine, serotonin or dopamine (e.g. ephedra, ma huang, St. John's Wort, yohimbine) |
ADREVIEW |
| Long-acting Bupivacaine/Local Anesthetics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of other local anesthetics or use of other local anesthetics within 96 hours following long-acting bupivacaine may result in additive neurologic and cardiovascular effects. Use of articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, and tetracaine may also increase the risk of methemoglobinemia.(1,2) Non-liposomal bupivacaine may impact the pharmacokinetic and/or physicochemical properties of the liposomal formulation when administered in the same syringe or used simultaneously unless the ratio of mg of non-liposomal bupivacaine to mg of bupivacaine liposomal does not exceed 1:2.(1) Local anesthetics other than bupivacaine may trigger the immediate release of bupivacaine from the liposomal formulation when administered together locally.(1) CLINICAL EFFECTS: Concurrent or use of local anesthetics with 96 hours of use of long-acting bupivacaine may result in neurologic and cardiovascular toxicity. Use of articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, and tetracaine may also result in methemoglobinemia.(1,2) Non-liposomal bupivacaine may impact the pharmacokinetic and/or physicochemical properties of the liposomal formulation when administered in the same syringe or used simultaneously unless the ratio of mg of non-liposomal bupivacaine to mg of bupivacaine liposomal does not exceed 1:2.(1) Local anesthetics other than bupivacaine may trigger the immediate release of bupivacaine from the liposomal formulation when administered together locally.(1) PREDISPOSING FACTORS: Use of additional agents that are associated with methemoglobinemia may further increase the risk of methemoglobinemia.(1) Patients who are at increased risk of developing methemoglobinemia include those with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended.(1) PATIENT MANAGEMENT: Avoid the use of other local anesthetics within 96 hours following the administration of long-acting bupivacaine. In patients for whom use is required, monitor for neurologic and cardiovascular effects. Also monitor for methemoglobinemia with use of articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, and tetracaine.(1,2) Non-liposomal bupivacaine may be administered in the same syringe as bupivacaine liposomal or injected immediately before bupivacaine liposomal as long as the ratio of mg of non-liposomal bupivacaine to mg of bupivacaine liposomal does not exceed 1:2.(1) Lidocaine may be administered 20 minutes or more prior to bupivacaine. It is unknown if other local anesthetics may be used without compromising the release characteristic of bupivacaine liposomal.(1) DISCUSSION: Concurrent use of other local anesthetics or use of other local anesthetics within 96 hours following long-acting bupivacaine may result in additive neurologic and cardiovascular effects. Use of articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, and tetracaine may also increase the risk of methemoglobinemia.(1,2) Non-liposome bupivacaine may impact the pharmacokinetic and/or physicochemical properties of the liposomal formulation when administered in the same syringe or used simultaneously unless the ratio of mg of non-liposomal bupivacaine to mg of bupivacaine liposomal does not exceed 1:2.(1) Local anesthetics other than bupivacaine may trigger the immediate release of bupivacaine from the liposomal formulation when administered together locally. Lidocaine may be administered 20 minutes or more prior to bupivacaine. It is unknown if other local anesthetics may be used without compromising the release characteristic of bupivacaine liposomal.(1) |
BUPIVACAINE LIPOSOME, EXPAREL, XARACOLL, ZYNRELEF |
There are 6 moderate interactions.
The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.
| Drug Interaction | Drug Names |
|---|---|
| Antidiabetics/Epinephrine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Gluconeogenesis, glycogenolysis, and lipolysis are increased by epinephrine. Also, insulin secretion and glucose uptake by peripheral tissues are decreased by epinephrine. CLINICAL EFFECTS: Increased blood glucose resulting in decreased effectiveness of the antidiabetic agent. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Caution when starting or stopping epinephrine in diabetic patients. Adjust the antidiabetic dose as needed based on blood glucose levels. DISCUSSION: This interaction is likely to occur based upon well documented properties of the interacting drugs. However, there is individual variability in its occurrence. |
ACARBOSE, ADMELOG, ADMELOG SOLOSTAR, AFREZZA, APIDRA, APIDRA SOLOSTAR, BASAGLAR KWIKPEN U-100, BASAGLAR TEMPO PEN U-100, DUETACT, FIASP, FIASP FLEXTOUCH, FIASP PENFILL, FIASP PUMPCART, GLIMEPIRIDE, GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLUCOTROL XL, GLYBURIDE, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, HUMALOG, HUMALOG JUNIOR KWIKPEN, HUMALOG KWIKPEN U-100, HUMALOG KWIKPEN U-200, HUMALOG MIX 50-50 KWIKPEN, HUMALOG MIX 75-25, HUMALOG MIX 75-25 KWIKPEN, HUMALOG TEMPO PEN U-100, HUMULIN R U-500, HUMULIN R U-500 KWIKPEN, INSULIN ASPART, INSULIN ASPART FLEXPEN, INSULIN ASPART PENFILL, INSULIN ASPART PROT MIX 70-30, INSULIN DEGLUDEC, INSULIN DEGLUDEC PEN (U-100), INSULIN DEGLUDEC PEN (U-200), INSULIN GLARGINE MAX SOLOSTAR, INSULIN GLARGINE SOLOSTAR, INSULIN GLARGINE-YFGN, INSULIN LISPRO, INSULIN LISPRO JUNIOR KWIKPEN, INSULIN LISPRO KWIKPEN U-100, INSULIN LISPRO PROTAMINE MIX, LANTUS, LANTUS SOLOSTAR, LYUMJEV, LYUMJEV KWIKPEN U-100, LYUMJEV KWIKPEN U-200, LYUMJEV TEMPO PEN U-100, MERILOG, MERILOG SOLOSTAR, MIGLITOL, MYXREDLIN, NATEGLINIDE, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30, NOVOLOG MIX 70-30 FLEXPEN, NOVOLOG PENFILL, PIOGLITAZONE-GLIMEPIRIDE, PRECOSE, REZVOGLAR KWIKPEN, SEMGLEE (YFGN), SEMGLEE (YFGN) PEN, SOLIQUA 100-33, TOUJEO MAX SOLOSTAR, TOUJEO SOLOSTAR, TRESIBA, TRESIBA FLEXTOUCH U-100, TRESIBA FLEXTOUCH U-200, XULTOPHY 100-3.6 |
| Sympathomimetics (Direct, Mixed-Acting)/Guanethidine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Direct or mixed-acting sympathomimetics may inhibit uptake of guanethidine at the adrenergic neuron. CLINICAL EFFECTS: Decreased antihypertensive effectiveness. Effects may be seen for several days after discontinuation of the direct or mixed-acting sympathomimetic. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Avoid concomitant administration of these drugs. If both drugs are administered, adjust the guanethidine dose as needed based on blood pressure. DISCUSSION: Documentation supports routine monitoring of this interaction. It should be noted that this interaction can occur quickly. |
GUANETHIDINE HEMISULFATE |
| Sympathomimetics/Rauwolfia Alkaloids SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Reserpine depletes catecholamine stores within the peripheral vascular adrenergic nerve endings, thus indirect acting sympathomimetics are unable to trigger the release of catecholamines. The reserpine-induced catecholamine release increases sensitivity to the effects of direct acting sympathomimetics. CLINICAL EFFECTS: Increased effects of direct acting sympathomimetics. Decreased effects of indirect acting sympathomimetics. Mixed acting sympathomimetics will show effects based on the predominance of either direct or indirect activity. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: If these agents are administered concurrently, monitor blood pressure. The dose of the sympathomimetic may need to be adjusted. DISCUSSION: This interaction has been well documented in animal studies and human case reports have confirmed the interaction. Reserpine has been shown to decrease the response to epinephrine administered for hypotension. Reserpine has also been shown to decrease the effectiveness of ophthalmic epinephrine, a direct acting sympathomimetic. Ophthalmic phenylephrine has been shown to decrease the hypotensive effects of reserpine. |
RESERPINE |
| Sympathomimetics (Direct, Mixed-Acting)/Methyldopa SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Unknown. CLINICAL EFFECTS: The pressor response to sympathomimetics may be increased. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Start with low doses of sympathomimetics and monitor blood pressure of patients during concurrent administration of sympathomimetics and methyldopa. DISCUSSION: The pressor response to sympathomimetics has been reported to be increased during methyldopa administration. In addition to increased duration of pressor response, severe hypertension has been reported. |
METHYLDOPA, METHYLDOPA-HYDROCHLOROTHIAZIDE, METHYLDOPATE HCL |
| Entacapone; Opicapone/COMT-Metabolized Agents SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Entacapone and opicapone are selective and reversible inhibitors of catechol-O-methyltransferase (COMT) and drugs that are metabolized by COMT can not be fully metabolized when given with entacapone or opicapone.(1) CLINICAL EFFECTS: COMT-metabolized agents can interact with entacapone or opicapone and may result in an increased heart rates, arrhythmias, or an excessive change in blood pressure.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The manufacturers of entacapone and opicapone recommend using caution when administering entacapone or opicapone and a COMT-metabolized agent regardless of the route of administration (including inhalation).(1-3) DISCUSSION: In an interaction study, ventricular tachycardia was observed after epinephrine and entacapone administration.(1) Another study on the effect of entacapone given with isoproterenol and epinephrine concluded that entacapone may potentiate the chronotropic and arrhythmogenic effects of isoproterenol and epinephrine.(4) |
CARBIDOPA-LEVODOPA-ENTACAPONE, ENTACAPONE, ONGENTYS |
| Epinephrine/Cardioselective Beta-Blockers SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Concurrent use of beta-blockers also block the beta effects of epinephrine, which results in predomination of alpha effects. The plasma clearance of epinephrine is decreased. CLINICAL EFFECTS: Concurrent use of epinephrine with beta-blockers may result in hypertension with reflex bradycardia. Epinephrine resistance in patients with anaphylaxis has been reported. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Hypertension and bradycardia are less likely to occur with cardioselective beta-blockers. If both drugs are administered, monitor blood pressure carefully. Use caution when treating anaphylaxis with epinephrine since response may be poor. DISCUSSION: A 29-year-old male undergoing elective nasal septoplasty developed severe hypertension with a blood pressure of 207/123 mmHg after topical epinephrine (1:1000) was applied to the nasal mucosa. Intravenous metoprolol was administered but the patient went into cardiogenic shock thought to be a result of unopposed alpha stimulation by the combination of epinephrine and metoprolol.(1) A study observed the differences in cardiovascular responses to subcutaneous epinephrine (given to provide hemostasis during scalp incision for craniotomy) between patients who received propranolol vs. metoprolol vs. no pretreatment. While metoprolol prevented the cardiovascular effects of epinephrine infiltration, propranolol pretreatment was associated with a highly significant increase (P less than 0.01) in mean arterial pressure and a significant decrease (P less than 0.05) in heart rate.(2) A double-blind cross-over trial studied the effects of epinephrine infusion during treatment with propranolol vs. metoprolol in 8 hypertensive patients. Patients on propranolol experienced significant increases in blood pressure and systemic vascular resistance (SVR), whereas patients on metoprolol had less increase in systolic blood pressure while the diastolic pressure remained unchanged and SVR decreased.(3) In spontaneously hypertensive rats, epinephrine in combination with pindolol induced remarkable hemodynamic changes (in particular, increase in diastolic blood pressure), which were prevented by phentolamine pretreatment, whereas epinephrine with acebutolol pretreatment induced no significant hemodynamic changes.(4) |
ACEBUTOLOL HCL, ATENOLOL, ATENOLOL-CHLORTHALIDONE, BETAXOLOL HCL, BISOPROLOL FUMARATE, BISOPROLOL-HYDROCHLOROTHIAZIDE, BREVIBLOC, BYSTOLIC, CARVEDILOL, CARVEDILOL ER, COREG, COREG CR, ESMOLOL HCL, ESMOLOL HCL-SODIUM CHLORIDE, ESMOLOL HCL-WATER, KAPSPARGO SPRINKLE, LOPRESSOR, METOPROLOL SUCCINATE, METOPROLOL TARTRATE, METOPROLOL-HYDROCHLOROTHIAZIDE, NEBIVOLOL HCL, RAPIBLYK, TENORETIC 100, TENORETIC 50, TENORMIN, TOPROL XL |
The following contraindication information is available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
Drug contraindication overview.
No enhanced Contraindications information available for this drug.
No enhanced Contraindications information available for this drug.
There are 1 contraindications.
Absolute contraindication.
| Contraindication List |
|---|
| Methemoglobinemia |
There are 19 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Angina |
| Angle-closure glaucoma |
| Atrial fibrillation |
| Bradycardia |
| Butyrylcholinesterase deficiency |
| Cardiac arrhythmia |
| Cardiogenic shock |
| Cerebral arteriosclerosis |
| Congenital long QT syndrome |
| Coronary artery disease |
| Dilated cardiomyopathy |
| Glucose-6-phosphate dehydrogenase (g6Pd) deficiency |
| Hemolytic anemia from pyruvate kinase and g6PD deficiencies |
| Hemorrhagic shock |
| Hypertension |
| Hyperthyroidism |
| Myasthenia gravis |
| Sinus tachycardia |
| Structural disorder of heart |
There are 3 moderate contraindications.
Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.
| Moderate List |
|---|
| Diabetes mellitus |
| Disease of liver |
| Kidney disease with reduction in glomerular filtration rate (GFr) |
The following adverse reaction information is available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
Adverse reaction overview.
No enhanced Common Adverse Effects information available for this drug.
No enhanced Common Adverse Effects information available for this drug.
There are 38 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
| None. |
Hypertension Hypotension |
| Rare/Very Rare |
|---|
|
Acute myocardial infarction Anaphylaxis Angina Bradycardia Cardiac arrhythmia Cardiomyopathy Cerebrovascular accident Chest pain Chondrolysis of articular cartilage CNS toxicity Extravasation injury Gangrene Hemiparesis Hyperglycemia Hypertension Hypokalemia Intracranial bleeding Kidney disease with reduction in glomerular filtration rate (GFr) Lactic acidosis Methemoglobinemia Myocardial dysfunction Myocardial ischemia Necrotizing fasciitis Paradoxical bronchospasm Pulmonary edema Respiratory depression Seizure disorder Status asthmaticus Supraventricular tachycardia Tachycardia Unconsciousness Urticaria Vasodilation of blood vessels Ventricular arrhythmias Ventricular fibrillation Ventricular premature beats |
There are 46 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Dizziness General weakness Headache disorder Nausea Nervousness Pallor Palpitations Symptoms of anxiety Tachycardia Tremor Vomiting |
Chills Headache disorder |
| Rare/Very Rare |
|---|
|
Acute cognitive impairment Agitation Apprehension Blanching of skin Blurred vision Diplopia Dizziness Drowsy Dysgeusia Edema Euphoria Hyperhidrosis Hypoesthesia Injection site infection Injection site sequelae Memory impairment Miosis Muscle fasciculation Nausea Nervousness Oliguria Oral hypoesthesia Panic disorder Paresthesia Sensation of cold Sensation of warmth Skin rash Symptoms of anxiety Tinnitus Tremor Visual changes Vomiting Xerostomia |
The following precautions are available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
No enhanced Pediatric Use information available for this drug.
Contraindicated
Severe Precaution
Management or Monitoring Precaution
Contraindicated
| None |
Severe Precaution
| None |
Management or Monitoring Precaution
| None |
Local anesthetics generally cross the placenta rapidly, and when used for epidural, paracervical, pudendal, or caudal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity. The incidence and degree of toxicity depend on the procedure performed, the type and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the CNS, peripheral vascular tone, and cardiac function.
Maternal hypotension has resulted from regional anesthesia. Elevating the patient's legs and positioning her on her left side may help prevent hypotension. Fetal heart rate should be monitored continuously, especially during paracervical block, and electronic fetal monitoring is advisable.
Epidural, spinal, paracervical, or pudendal anesthesia may alter the forces of parturition through changes in uterine contractility or maternal expulsive efforts. Use of obstetric anesthesia may increase the need for forceps assistance during delivery. Administration of local anesthetics by paracervical nerve block during labor has been associated with a high incidence of fetal acidosis and bradycardia and has occasionally resulted in perinatal death.
Fetal bradycardia may occur in 20-30% of patients receiving paracervical block anesthesia with the amide-type local anesthetics and may be associated with fetal acidosis. The risk of fetal bradycardia appears to be increased with prematurity, toxemia of pregnancy, and fetal distress. Changes in fetal heart rate and blood pH have been reported following epidural anesthesia.
Use of bupivacaine for obstetrical paracervical block anesthesia is contraindicated. Possible inadvertent intracranial injection of local anesthetic solution into the fetus has reportedly occurred following attempted paracervical and/or pudendal block. Such inadvertent injection has resulted in unexplained neonatal depression at birth which was associated with high serum concentration of the anesthetic; seizures usually occurred within 6 hours after birth.
Prompt use of supportive measures and forced urinary excretion of the local anesthetic has reportedly been effective for managing this complication. Systemic absorption of some local anesthetics during paracervical block in early pregnancy (anesthesia for elective abortion) may be rapid, since maternal seizures and cardiovascular collapse have occurred under these conditions. Therefore, the recommended maximum dose of the drug should not be exceeded and injection should be made slowly and with frequent aspiration, allowing a 5-minute interval between sides.
In obstetrics, low spinal (saddle block) and caudal anesthesia are contraindicated in psychologically unsuited patients and in those with pelvic disproportion, abruptio placentae, unengaged or floating fetal head and placenta praevia, unless cesarean section is contemplated after induction of caudal anesthesia. In addition, these anesthetic procedures should not be used when intrauterine manipulations are required. Safe use of local anesthetics during pregnancy prior to labor has not been established with respect to adverse effects on fetal development.
Careful consideration should be given to this fact before administering these drugs in pregnant women. Epinephrine usually inhibits spontaneous or oxytocin-induced contractions of the pregnant human uterus and may delay the second stage of labor. In dosages sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage.
If used during pregnancy, epinephrine may cause anoxia to the fetus and/or spontaneous abortion. When administered in advanced cardiovascular life support (ACLS) during cardiac resuscitation, epinephrine may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus. Some manufacturers state that epinephrine should be avoided during the second stage of labor; parenteral administration of the drug to maintain blood pressure during spinal anesthesia for delivery can cause acceleration of fetal heart rate and should not be used in obstetric patients when maternal systolic/diastolic blood pressure exceeds 130/80 mm Hg.
Epinephrine should be administered cautiously by oral inhalation to pregnant patients. Epinephrine should be used during pregnancy only if the potential benefits justify the possible risks to the fetus. There is some evidence to support that epidural administration of some local anesthetics (e.g., lidocaine) with epinephrine during labor is safe.
Maternal hypotension has resulted from regional anesthesia. Elevating the patient's legs and positioning her on her left side may help prevent hypotension. Fetal heart rate should be monitored continuously, especially during paracervical block, and electronic fetal monitoring is advisable.
Epidural, spinal, paracervical, or pudendal anesthesia may alter the forces of parturition through changes in uterine contractility or maternal expulsive efforts. Use of obstetric anesthesia may increase the need for forceps assistance during delivery. Administration of local anesthetics by paracervical nerve block during labor has been associated with a high incidence of fetal acidosis and bradycardia and has occasionally resulted in perinatal death.
Fetal bradycardia may occur in 20-30% of patients receiving paracervical block anesthesia with the amide-type local anesthetics and may be associated with fetal acidosis. The risk of fetal bradycardia appears to be increased with prematurity, toxemia of pregnancy, and fetal distress. Changes in fetal heart rate and blood pH have been reported following epidural anesthesia.
Use of bupivacaine for obstetrical paracervical block anesthesia is contraindicated. Possible inadvertent intracranial injection of local anesthetic solution into the fetus has reportedly occurred following attempted paracervical and/or pudendal block. Such inadvertent injection has resulted in unexplained neonatal depression at birth which was associated with high serum concentration of the anesthetic; seizures usually occurred within 6 hours after birth.
Prompt use of supportive measures and forced urinary excretion of the local anesthetic has reportedly been effective for managing this complication. Systemic absorption of some local anesthetics during paracervical block in early pregnancy (anesthesia for elective abortion) may be rapid, since maternal seizures and cardiovascular collapse have occurred under these conditions. Therefore, the recommended maximum dose of the drug should not be exceeded and injection should be made slowly and with frequent aspiration, allowing a 5-minute interval between sides.
In obstetrics, low spinal (saddle block) and caudal anesthesia are contraindicated in psychologically unsuited patients and in those with pelvic disproportion, abruptio placentae, unengaged or floating fetal head and placenta praevia, unless cesarean section is contemplated after induction of caudal anesthesia. In addition, these anesthetic procedures should not be used when intrauterine manipulations are required. Safe use of local anesthetics during pregnancy prior to labor has not been established with respect to adverse effects on fetal development.
Careful consideration should be given to this fact before administering these drugs in pregnant women. Epinephrine usually inhibits spontaneous or oxytocin-induced contractions of the pregnant human uterus and may delay the second stage of labor. In dosages sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage.
If used during pregnancy, epinephrine may cause anoxia to the fetus and/or spontaneous abortion. When administered in advanced cardiovascular life support (ACLS) during cardiac resuscitation, epinephrine may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus. Some manufacturers state that epinephrine should be avoided during the second stage of labor; parenteral administration of the drug to maintain blood pressure during spinal anesthesia for delivery can cause acceleration of fetal heart rate and should not be used in obstetric patients when maternal systolic/diastolic blood pressure exceeds 130/80 mm Hg.
Epinephrine should be administered cautiously by oral inhalation to pregnant patients. Epinephrine should be used during pregnancy only if the potential benefits justify the possible risks to the fetus. There is some evidence to support that epidural administration of some local anesthetics (e.g., lidocaine) with epinephrine during labor is safe.
No enhanced Lactation information available for this drug.
No enhanced Geriatric Use information available for this drug.
The following prioritized warning is available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate):
No warning message for this drug.
No warning message for this drug.
The following icd codes are available for ARTICAINE-EPINEPHRINE BIT (articaine hcl/epinephrine bitartrate)'s list of indications:
No ICD codes found for this drug.
No ICD codes found for this drug.
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