Version May 2024
Dosage guidance:
Dosing: Use the smallest dose and concentration required to produce the desired result. Dosage varies with anesthetic procedure, area to be anesthetized, vascularity of the tissues, number of neuronal segments to be blocked, depth of anesthesia and degree of muscle relaxation required, duration of anesthesia, and tolerance and physical condition of the patient. During epidural administration, a test dose (45 to 50 mg) is recommended prior to induction of complete block and all reinforcing doses with continuous catheter technique. The test dose should contain epinephrine to serve as a warning of unintended intravascular injection.
Local or regional anesthesia (eg, epidural, caudal, or peripheral nerve blocks): Note: Maximum daily dose: 1,000 mg per 24 hours.
Caudal and epidural block (preservative free solutions only): 15 to 30 mL of a 1% solution (maximum total dose: 300 mg) or 10 to 25 mL of a 1.5% solution (maximum total dose: 375 mg) or 10 to 20 mL of a 2% solution (maximum total dose: 400 mg).
Cervical, brachial, intercostal, pudendal nerve block: 5 to 40 mL of a 1% solution (maximum total dose: 400 mg) or 5 to 20 mL of a 2% solution (maximum total dose: 400 mg). For pudendal block, inject one-half the total dose to each side.
Infiltration: Up to 40 mL of a 1% solution (maximum total dose: 400 mg); up to 50 mL of a 1% solution if epinephrine has been added (maximum total dose: 500 mg) (Gropper 2020); an equivalent amount of a 0.5% solution (prepared by diluting the 1% solution with NS) may be used for large areas.
Paracervical block: Up to 20 mL (total for both sides) of a 1% solution (maximum total dose: 200 mg). Inject one-half the total dose to each side. This is the maximum recommended dose per 90-minute procedure; inject slowly with 5 minutes between sides.
Peripheral nerve block to provide a surgical level of anesthesia (off-label):
Major nerve block (blockade of 2 or more distinct nerves, a nerve plexus, or very large nerves at more proximal sites): 30 to 50 mL of a 1% or 1.5% solution (maximum total dose: 350 mg; if epinephrine has been added, maximum total dose: 500 mg) (Gropper 2020).
Minor nerve block (blockade of a single nerve [eg, ulnar or radial]): 5 to 20 mL of a 1% solution (maximum total dose: 200 mg) (Gropper 2020).
Therapeutic block: 1 to 5 mL of 1% solution (maximum total dose: 50 mg) or 1 to 5 mL of 2% solution (maximum total dose: 100 mg).
Transvaginal block (paracervical plus pudendal): Up to 30 mL (total for both sides) of a 1% solution (maximum total dose: 300 mg). Inject one-half the total dose to each side.
Dental anesthesia:
Single site in upper or lower jaw: 51 mg as a 3% solution.
Infiltration and nerve block of entire oral cavity: 270 mg as a 3% solution. Maximum total dose: 400 mg.
|
Number of cartridges (1.7 mL) |
Mepivacaine mg (3%) |
|---|---|
|
1 |
51 |
|
2 |
102 |
|
3 |
153 |
|
4 |
204 |
|
5 |
255 |
|
6 |
306 |
|
7 |
357 |
|
8 |
408 |
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; consider a reduced dose (especially with repeated dosing) in patients with moderate to severe impairment.
There are no dosage adjustments provided in the manufacturer's labeling; consider a reduced dose (especially with repeated dosing) in patients with moderate to severe impairment.
Refer to adult dosing; reduce dose consistent with age and physical status.
(For additional information see "Mepivacaine: Pediatric drug information")
Note: Dose varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient. The smallest dose and concentration required to produce the desired effect should be used. Consider incremental administration with negative aspiration prior to each injection; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided (Mulroy 2010). Should only be administered under the supervision of a qualified physician experienced in the use of anesthetics.
Dental anesthesia: Children and Adolescents: 3% solution: Injection:
Manufacturer's labeling: Maximum dose: 5 to 6 mg/kg; maximum total dose: 270 mg. In adults, the dose for single site in upper or lower jaw is 51 mg (one 1.7 mL cartridge).
Alternate dosing: American Academy Pediatric Dentistry (AAPD 2015): Maximum dose: 4.4 mg/kg; maximum total dose: 300 mg in any single dental sitting.
Local or regional anesthesia (eg, epidural, caudal, or peripheral nerve blocks): Maximum single or total dose given for one procedure: 5 to 6 mg/kg (maximum adult dose per manufacturer: 400 mg); only concentrations <2% should be used in patients <3 years or <14 kg to ensure adequate drug volume for area and to decrease the potential for local anesthetic systemic toxicity.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations.
The following adverse drug reactions are derived from product labeling unless otherwise specified. Reactions listed may be based on reports for other agents in this same pharmacologic class and may not be specifically reported for mepivacaine.
Postmarketing:
Cardiovascular: Bradycardia, cardiac insufficiency, cardiovascular depression, cardiovascular stimulation, heart block, hypertension, hypotension, low cardiac output, ventricular arrhythmia
Gastrointestinal: Fecal incontinence, loss of anal sphincter control, nausea, vomiting
Genitourinary: Sexual disorder (sexual function), urinary incontinence, urinary retention
Hematologic & oncologic: Methemoglobinemia
Hypersensitivity: Hypersensitivity reaction (including anaphylactic shock, anaphylaxis, angioedema, and nonimmune anaphylaxis) (Estrada 2011; Nam 2023; Takahashi 2019)
Infection: Septic meningitis
Nervous system: Anxiety, asthenia, central nervous system depression, chills, confusion, cranial nerve palsy, dizziness, drowsiness, excitement, headache, loss of consciousness, meningism, paralysis, paresthesia, persistent anesthesia, restlessness, seizure, sensation disorder (loss of perineal sensation), tremor
Neuromuscular & skeletal: Back pain
Ophthalmic: Blurred vision, miosis
Otic: Tinnitus
Respiratory: Apnea, hypoventilation, respiratory depression, respiratory paralysis
Hypersensitivity to mepivacaine, other amide-type local anesthetics, or any component of the formulation
Concerns related to adverse effects:
• CNS toxicity: Careful and constant monitoring of the patient's state of consciousness should be done following each local anesthetic injection; at such times, restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness may be early warning signs of CNS toxicity. Use extreme caution in patients with existing neurological disease. Seizures due to systemic toxicity leading to cardiac arrest have also been reported, presumably following unintentional intravascular injection. In the event of cardiovascular collapse and/or severe CNS toxicity, treatment in accordance with the American Society of Regional Anesthesia and Pain Medicine’s Checklist for Treatment of Local Anesthetic Toxicity is recommended (ASRA [Neal 2021]).
• Familial malignant hyperthermia: Although product labeling suggests that mepivacaine may potentially trigger malignant hyperthermia, evidence and expert consensus do not support and use is considered to be safe (MHAUS 2023).
• Intra-articular infusion related chondrolysis: Continuous intra-articular infusion of local anesthetics after arthroscopic or other surgical procedures is not an approved use; chondrolysis (primarily in the shoulder joint) has occurred following infusion, with some cases requiring arthroplasty or shoulder replacement.
• Methemoglobinemia: Has been reported with local anesthetics; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months of age are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue).
• Respiratory arrest: Local anesthetics have been associated with rare occurrences of sudden respiratory arrest. Careful and constant monitoring of the patient's respiratory (adequacy of ventilation) vital signs should be done following each local anesthetic injection.
• Seizures: Convulsions due to systemic toxicity leading to cardiac arrest have also been reported, presumably following unintentional intravascular injection.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular disease, including rhythm disturbances, hypotension/shock, and heart block; consider a reduced dose.
• Hepatic impairment: Use with caution in patients with hepatic impairment. Because of the inability to metabolize local anesthetics, patients with severe hepatic disease are at a greater risk of developing toxic plasma concentrations.
• Kidney impairment: Use with caution in patients with kidney impairment.
Special populations:
• Acutely ill patients: Use with caution in acutely ill patients; reduce dose consistent with age and physical status.
• Debilitated patients: Use with caution in debilitated patients; reduce dose consistent with age and physical status.
• Older adult: Use with caution in older adults; reduce dose consistent with age and physical status.
• Pediatric: Use with caution in children; reduce dose consistent with age and physical status.
Dosage form specific issues:
• Preservative-containing solutions: Do not use solutions containing preservatives for caudal or epidural block.
Other warnings/precautions:
• Administration: Intravascular injections should be avoided; aspiration should be performed prior to administration; the needle must be repositioned until no return of blood can be elicited by aspiration; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided. Use with caution when there is inflammation and/or sepsis in the region of the proposed injection.
• Appropriate dosing: To avoid serious adverse effects and high plasma levels, the lowest dosage resulting in effective anesthesia should be administered. Repeated doses may cause significant increases in blood levels with each repeated dose due to the possibility of accumulation of the drug or its metabolites. Tolerance to elevated blood levels varies with patient status.
• Test dose: A test dose is recommended prior to epidural administration and all reinforcing doses with continuous catheter technique.
• Trained personnel: Clinicians using local anesthetic agents should be well trained in diagnosis and management of emergencies that may arise from the use of these agents. Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Injection, as hydrochloride:
Carbocaine: 1% (50 mL); 2% (50 mL) [contains methylparaben]
Polocaine: 1% (50 mL); 2% (50 mL) [contains methylparaben]
Solution, Injection, as hydrochloride [preservative free]:
Carbocaine Preservative-Free: 1% (30 mL); 1.5% (30 mL); 2% (20 mL)
Polocaine-MPF: 1% (30 mL); 1.5% (30 mL); 2% (20 mL) [methylparaben free]
Solution, Injection, as hydrochloride [dental use]:
Carbocaine: 3% (1.7 mL)
Polocaine Dental: 3% (1.7 mL)
Scandonest 3% Plain: 3% (1.7 mL)
Yes
Solution (Polocaine Injection)
1% (per mL): $0.29
2% (per mL): $0.30
Solution (Polocaine-MPF Injection)
1% (per mL): $0.34
1.5% (per mL): $0.46
2% (per mL): $0.57
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Not for intrathecal use. Intravascular or subarachnoid injections should be avoided. Have resuscitative equipment and medications readily available during administration. Administer slowly in small, incremental doses; avoid rapid injection of a large volume. Use an indwelling IV catheter during major regional nerve block (eg, brachial plexus, lower extremity). Aspirate for blood or cerebrospinal fluid (if applicable) before administration of all doses; absence of blood or cerebrospinal fluid in the syringe does not guarantee that intravascular or intrathecal injection has been avoided. Avoid puncturing the skin when there is inflammation and/or infection in the region of the proposed injection. Do not use injections containing preservatives (eg, methylparaben in multiple-dose vials) for epidural or caudal anesthesia.
Parenteral: Before injecting, withdraw syringe plunger to ensure injection is not into vein or artery. Administer slowly in small incremental doses, with frequent aspirations before and during the injection to avoid intravascular injection. Use with caution when there is inflammation and/or sepsis in the region of the proposed injection.
Dental: Aspirate the syringe after tissue penetration and before injection to minimize chance of direct vascular injection.
Dental anesthesia: Production of local anesthesia for dental procedures by infiltration or nerve block in adult and pediatric patients.
Local or regional anesthesia (eg, epidural, caudal, or peripheral nerve blocks): Production of local or regional analgesia and anesthesia by local infiltration, peripheral nerve block techniques, and central neural techniques (epidural and caudal) in adult and pediatric patients. Not for use in spinal anesthesia.
Mepivacaine may be confused with BUPivacaine
Polocaine may be confused with prilocaine
The Institute for Safe Medication Practices (ISMP) includes this medication (epidural administration) among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
BUPivacaine: Local Anesthetics may enhance the adverse/toxic effect of BUPivacaine. Management: Avoid using any additional local anesthetics within 96 hours after insertion of the bupivacaine implant (Xaracoll) or bupivacaine and meloxicam periarticular solution (Zynrelef) or within 168 hours after subacromial infiltration (Posimir brand). Risk C: Monitor therapy
BUPivacaine (Liposomal): Local Anesthetics may enhance the adverse/toxic effect of BUPivacaine (Liposomal). Management: Liposomal bupivacaine should not be administered with local anesthetics, but may be administered 20 minutes or more after lidocaine. Avoid all local anesthetics within 96 hours after administration of liposomal bupivacaine. Risk X: Avoid combination
Hyaluronidase: May enhance the adverse/toxic effect of Local Anesthetics. Risk C: Monitor therapy
Methemoglobinemia Associated Agents: May enhance the adverse/toxic effect of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor therapy
Neuromuscular-Blocking Agents: Local Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Propranolol: May increase the serum concentration of Mepivacaine. Risk C: Monitor therapy
Technetium Tc 99m Tilmanocept: Local Anesthetics may diminish the diagnostic effect of Technetium Tc 99m Tilmanocept. Management: Avoid mixing and simultaneously co-injecting technetium Tc 99m tilmanocept with local anesthetics. This interaction does not appear to apply to other uses of these agents in combination. Risk C: Monitor therapy
Animal reproduction studies have not been conducted. Mepivacaine has been used in obstetrical analgesia.
It is not known if mepivacaine is present in breast milk. The manufacturer recommends that caution be exercised when administering mepivacaine to breastfeeding women. Usual infiltration doses of mepivacaine dental anesthetic given to breastfeeding mothers has not been shown to affect the health of the breastfeeding infant.
Cardiovascular and respiratory status; vital signs (eg, BP, heart rate, oxygen saturation); mental status changes; signs of CNS toxicity (eg, seizures, visual changes, muscle twitching); systemic toxicity, especially in patients with moderate to severe hepatic or kidney impairment.
Mepivacaine is an amide local anesthetic similar to lidocaine. Local anesthetics bind selectively to the intracellular surface of sodium channels to block influx of sodium into the axon. As a result, depolarization necessary for action potential propagation and subsequent nerve function is prevented. The block at the sodium channel is reversible. When drug diffuses away from the axon, sodium channel function is restored and nerve propagation returns.
Onset of action (route and dose dependent): Range: 3 to 20 minutes; Dental: Upper jaw: 30 to 120 seconds; Lower jaw: 1 to 4 minutes
Duration (route and dose dependent): 2 to 2.5 hours; Dental: Upper jaw: 20 minutes; Lower jaw: 40 minutes
Protein binding: ~75%
Metabolism: Primarily hepatic via N-demethylation, hydroxylation, and glucuronidation
Half-life elimination: Neonates: 8.7 to 9 hours; Adults: 1.9 to 3.2 hours
Excretion: Urine (90% to 95% as metabolites)
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