bupivacaine (Rx)

Brand and Other Names:Marcaine, Sensorcaine, more...Posimir
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

injectable solution

  • 0.25% (Sensorcaine, Marcaine, generic)
  • 0.5% (Sensorcaine, Marcaine, generic)
  • Contains methylparaben

injectable solution, preservative-free

  • 0.25% (Sensorcaine-MPF, Marcaine, generic)
  • 0.5% (Sensorcaine-MPF, Marcaine, generic)
  • 0.75% (Sensorcaine-MPF, Marcaine Preservative Free, generic)

injection, spinal

  • 0.75% (Sensorcaine MPF Spinal, Marcaine Spinal, generic)
  • Each 2-mL ampule contains 15 mg bupivacaine HCL with 165 mg dextrose

injection, single-dose vial

  • 660mg/5mL (Posimir)

Subarachnoid block

Marcaine spinal, Sensorcaine-MPF Spinal, generic

Indicated for the production of subarachnoid block (spinal anesthesia)

Lower extremity and perineal procedures (eg, vaginal hysterectomy): 7.5 mg or 1 mL

Lower abdominal procedures (appendectomy): 12 mg or 1.6 mL

Local Anesthesia

Marcaine, Sensorcaine, generic

Local infiltration: 0.25%; may increase up to 175 mg (70 mL) OK

Regional Anesthesia

Marcaine, Sensorcaine, generic

Sympathetic block

  • 0.25%; 50-125 mg (20-50 mL)

Retrobulbar block

  • 0.75%; 15-30 mg (2-4 mL)
  • Complete corneal anesthesia usually precedes onset of clinically acceptable external ocular muscle akinesia; determine readiness for surgery based on presence of akinesia rather than anesthesia alone

Peripheral nerve block

  • 0.25%; 12.5 -175 mg (5-70 mL) OR
  • 0.5%: 25-175 mg (5-35 mL)

Caudal block

  • Use as a test dose before caudal epidural blocks when clinical conditions permit
  • 0.25%; 15-30 mL (37.5-75 mg) OR
  • 0.5%: 15-30 mL (75-150 mg)

Lumbar epidural block

  • Use as a test dose before lumbar epidural blocks when clinical conditions permit
  • In obstetrics, use ONLY 0.5% and 0.25% concentrations; incremental doses of 3-5 mL of the 0.5% solution not exceeding 50-100 mg at any dosing interval are recommended
  • Repeat doses should be preceded by a test dose containing epinephrine if not clinically contraindicated
  • 0.25%; 10-20 mL (25-50 mg) OR
  • 0.5%: 10-20 mL (50-100 mg) OR
  • 0.75%: 10-20 mL (75-150 mg); for single-dose use; not for intermittent epidural technique or obstetrical anesthesia

Postsurgical Analgesia for Arthroscopic Subacromial Decompression

  • Posimir only
  • Indicated in adults for administration into subacromial space under direct arthroscopic visualization to produce postsurgical analgesia for up to 72 hr following arthroscopic subacromial decompression
  • 660 mg once into subacromial space

Dosage Modifications

Renal impairment

  • Pharmacokinetics not evaluated
  • Substantially excreted by the kidneys; may increase bupivacaine exposure and risk of systemic toxicities in patients with renal impairment
  • All severities: Use with caution; consider frequent monitoring for adverse reactions

Hepatic impairment

  • Pharmacokinetics not evaluated
  • Owing to inability to metabolize local anesthetics normally, patients with hepatic impairment at risk of increased bupivacaine plasma levels and systemic toxicities
  • Moderate-to-severe: Use with caution; consider reducing dosage and closely monitor

Dosing Considerations

Doses of any local anesthetic administered varies with anesthetic procedure, area to be anesthetized, vascularity of tissues, number of neuronal segments to be blocked, depth of anesthesia and degree of muscle relaxation required, duration of anesthesia desired, individual tolerance, and physical condition of patient

Use smallest dose and concentration required to produce desired result

Posimir

  • Different formulations are not bioequivalent even if dosage is the same
  • Do not substitute

Limitations of use

  • Not all blocks are indicated for use given clinically significant risks associated with use
  • Posimir
    • Safety and efficacy not established in other procedures (eg, soft tissue surgical procedures, other orthopedic procedures, boney procedures, used for neuraxial or peripheral nerve blockade)

Dosage Forms & Strengths

injectable solution

  • 0.25% (Sensorcaine, Marcaine, generic)
  • 0.5% (Sensorcaine, Marcaine, generic)
  • Contains methylparaben

injectable solution, preservative-free

  • 0.25% (Sensorcaine-MPF, Marcaine, generic)
  • 0.5% (Sensorcaine-MPF, Marcaine, generic)
  • 0.75% (Sensorcaine-MPF, Marcaine Preservative Free, generic)

Local Anesthesia

Marcaine, Sensorcaine, generic

<12 years: Not recommended; decreased dose by 30% in infants <6 mo, if necessary

≥12 years

  • Local infiltration: 0.25%; may increase up to 2.5 mg/kg

Regional Anesthesia

Marcaine, Sensorcaine, generic

<12 years: Limited date available; usual concentration <0.25% and dose decreased by 30% in infants <6 mo

≥12 years

  • Sympathetic block
    • 0.25%; 50-125 mg (20-50 mL)
  • Peripheral nerve block
    • 0.25%; 12.5 -175 mg (5-70 mL) OR
    • 0.5%: 25-175 mg (5-35 mL)
  • Caudal block
    • Use as a test dose before caudal epidural blocks when clinical conditions permit
    • 0.25%; 15-30 mg (37.5-75 mL) OR
    • 0.5%: 15-30 mg (75-150 mL)
  • Lumbar epidural block
    • Use as a test dose before lumbar epidural blocks when clinical conditions permit
    • In obstetrics, use ONLY 0.5% and 0.25% concentrations; incremental doses of 3-5 mL of the 0.5% solution not exceeding 50-100 mg at any dosing interval are recommended.
    • Repeat doses should be preceded by a test dose containing epinephrine if not clinically contraindicated
    • 0.25%; 10-20 mL (25-50 mg) OR
    • 0.5%: 10-20 mL (50-100 mg) OR
    • 0.75%: 10-20 mL (75-150 mg); for single-dose use; not for intermittent epidural technique or obstetrical anesthesia
  • Retrobulbar block
    • 0.75%; 15-30 mg (2-4 mL)
    • Complete corneal anesthesia usually precedes onset of clinically acceptable external ocular muscle akinesia; determine readiness for surgery based on presence of akinesia rather than anesthesia alone

Dosage Modifications

Renal impairment

  • Pharmacokinetics not evaluated
  • Substantially excreted by the kidneys; may increase bupivacaine exposure and risk of systemic toxicities in patients with renal impairment
  • All severities: Use with caution; consider frequent monitoring for adverse reactions

Hepatic impairment

  • Pharmacokinetics not evaluated
  • Owing to their inability to metabolize local anesthetics normally, patients with hepatic impairment at risk of increased bupivacaine plasma levels and systemic toxicities
  • Moderate-to-severe: Use with caution; consider reducing dosage and closely monitor

Dosing Considerations

Continuous infusions in pediatric patients reported to result in high systemic levels of bupivacaine and seizures; high plasma levels may also be associated with cardiovascular abnormalities

Doses of any local anesthetic administered varies with anesthetic procedure, area to be anesthetized, vascularity of tissues, number of neuronal segments to be blocked, depth of anesthesia and degree of muscle relaxation required, duration of anesthesia desired, individual tolerance, and physical condition of patient

Use smallest dose and concentration required to produce desired result

Duration of action is dependent on concentration, total dose, and site of administration, use of epinephrine, and age

Limitations of use

  • Marcaine
    • Not all blocks are indicated for use given clinically significant risks associated with use

In clinical studies, differences in pharmacokinetics have been observed in older adults compare to younger adults

Bupivacaine is substantially excreted by kidneys

Older adults may have decreased renal function and are at greater risk of adverse reactions to bupivacaine

Consider a lower dose and closely monitor for toxicities

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Interactions

Interaction Checker

and bupivacaine

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            Adverse Effects

            >10%

            Posimir

            • Visible bruising (91.1%)
            • Postprocedural contusion (14-71.2%)
            • Nausea (20-55.8%)
            • Surgical site bleeding (8.7-48.9%)
            • Dizziness (15-40.3%)
            • Somnolence (8.3-40%)
            • Constipation (30.4%)
            • Vomiting (4.4-29%)
            • Bradycardia (22.9%)
            • Headache (11.1-27.2%)
            • Pruritus generalized (2.2-21.6%)
            • Paresthesia (7.5-18.4%)
            • Dysgeusia (13-17.6%)
            • Hypoesthesia (17.3%)
            • Anemia (4.5-16.7%)
            • Tinnitus (13.2%)
            • C-reactive protein increased (11.7%)
            • Pyrexia (6-11.7%)
            • Procedural pain (<11.4%)
            • Dysuria (10.1%)

            1-10%

            Posimir

            • Diarrhea (9.8%)
            • Abdominal distension (8.2%)
            • Incision site erythema (4.1-8.1%)
            • Postprocedural discharge (7.5%)
            • Insomnia (3.9-7.1%)
            • Blood potassium decreased (6.7%)
            • Hypertension (6.7%)
            • Hypokalemia (5.9%)
            • Headache (5.7%)
            • Contusion (5.7%)
            • Dyspepsia (3.8-5.7%)
            • Incision site hematoma (5-5.2%)
            • Oropharyngeal pain (3.5-4.6%)
            • Tachycardia (4.6%)
            • Flatulence (4.6%)
            • Hypertension (2.8-4.6%)
            • Incision site infection (4.5%)
            • Drainage from surgical incision (4.4%)
            • Abdominal pain (4.4%)
            • Musculoskeletal pain (4.2%)
            • Viral infection (4.1%)
            • Back pain (4.1%)
            • Electrocardiogram (ECG) T wave inversion (3.8%)
            • Hypoesthesia (3.8%)
            • Dyspnea (3.8%)
            • Muscle twitching (3.8%)
            • Wound dehiscence (3.6%)
            • Cough (3.6%)
            • Peripheral swelling (3.9%)
            • ECG change (3.3%)
            • Procedural hemorrhage (3.3%)
            • Vaginal hematoma (3.3%)
            • Dry throat (3.2%)
            • Testicular swelling (3.2%)
            • Hyperhidrosis (3%)
            • Local swelling (3%)
            • Upper respiratory tract infection (3%)
            • Chest pain (2.9%)
            • Ileus (2.7%)
            • Urinary retention (2.7-2.8%)
            • Dysmenorrhea (2.7%)
            • Incision site pruritus (2.7%)
            • Abdominal pain upper (2.5%)
            • Nasal congestion (2.5%)
            • Pruritus generalized (2.5%)
            • Contusion (2.5%)
            • Body temperature increased (2.4%)
            • Dry mouth (2.2%)
            • Rash (2.1%)
            • Pain in extremity (2.1%)
            • Nasopharyngitis (2.1%)
            • Angina pectoris (<2%)
            • Blepharospasm (<2%)
            • ECG T-wave amplitude decreased (<2%)
            • Fatigue (<2%)
            • Osteoarthritis (<2%)
            • Procedural nausea (<2%)
            • Pulmonary arterial hypertension (<2%)

            Frequency Not Defined

            Respiratory: Respiratory paralysis, underventilation

            Cardiovascular: Myocardium depression, decreased cardiac output, bradycardia, heart block, ventricular arrhythmias, possible cardiac arrest

            Neurologic: Excitement and/or depression, restlessness, anxiety, dizziness, tinnitus, blurred vision, tremors, convulsions, loss of perineal sensation and sexual function, persistent anesthesia, paresthesia, weakness and paralysis of the lower extremities, loss of sphincter control, high or total spinal block, urinary retention, septic meningitis, meningismus, arachnoiditis, shivering, cranial nerve palsies, fecal and urinary incontinence

            Labor and delivery: Slowing of labor, increased incidence of forceps delivery. Allergic:

            Immune system disorders: Urticaria, pruritus, erythema, angioneurotic edema (including laryngeal edema), tachycardia, sneezing, nausea, vomiting, dizziness, syncope, excessive sweating, elevated temperature, anaphylactoid-like symptomatology (including severe hypotension)

            Other: Nausea, vomiting

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            Warnings

            Black Box Warnings

            Risk of cardiac arrest in obstetrical anesthesia

            • Marcaine only
            • Cardiac arrest with difficult resuscitation or death reported during use for epidural anesthesia in obstetrical patients
            • Most cases occurred following use of 0.75% (7.5 mg/mL) concentration
            • Resuscitation has been difficult or impossible despite adequate preparation and appropriate management
            • Cardiac arrest reported after convulsions resulting from systemic toxicity, presumably following unintentional intravascular injection
            • Marcaine 0.75% concentration is not recommended for obstetrical anesthesia and should be reserved for surgical procedures where a high degree of muscle relaxation and prolonged effect are necessary

            Risk of potential adverse embolic effects

            • Posimir only
            • Inadvertent intravascular injection may cause droplets to deposit in pulmonary and other capillary beds
            • Administer into subacromial space at end of arthroscopic shoulder surgery
            • Use direct arthroscopic visualization to confirm proper placement of needle tip before injecting drug

            Contraindications

            Hypersensitivity to any amide local anesthetics, or other product components

            Marcaine

            • Undergoing obstetrical paracervical block anesthesia
            • IV regional anesthesia (Bier Block)

            Bupivacaine spinal

            • Severe hemorrhage, severe hypotension or shock and arrhythmias (eg, complete heart block)
            • Local infection at the site of proposed lumbar puncture
            • Septicemia

            Posimir

            • Undergoing obstetrical paracervical block anesthesia; use of bupivacaine HCl with this technique has resulted in fetal bradycardia and death

            Cautions

            Safety and effectiveness of local anesthetics depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies; resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use

            Caution with impaired cardiovascular function (eg, hypotension, heart block), as patients may be unable to compensate for functional changes associated with prolongation of AV conduction produced by bupivacaine; consider reduced dosing; closely monitor for blood pressure, heart rate, and ECG changes

            Many drugs used during anesthesia may trigger malignant familial hyperthermia; potential for amide-type local anesthetics to also trigger such a response is unknown; consider a standard protocol for therapeutic management to be available

            Avoid solutions containing antimicrobial preservatives, (ie, multiple-dose vials), for epidural or caudal anesthesia; safety not established for use

            Infants and neonates are at greater risk for bupivacaine toxicity owing to a lower amount of serum alpha-1-acid-glycoprotein concentration compared with older children; this protein is the major binding site for bupivacaine, therefore, infants and neonates may have an increase of free fraction of local anesthetics

            Methemoglobinemia

            • Use of local anesthetics may cause methemoglobinemia
            • Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants ≤6 months, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition
            • Advise patient to seek immediate medical attention if they experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue
            • Discontinue any other oxidizing agents
            • Depending on severity of signs and symptoms, patients may respond to supportive care, including oxygen therapy and hydration
            • More severe clinical presentations may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen

            Chondrolysis

            • Chondrolysis associated with intra-articular infusions following arthroscopic and other surgical procedure; majority of reported cases involved the shoulder joint
            • Information on determining whether shorter infusion periods are not associated with these findings is insufficient
            • Time of onset of symptoms (eg, joint pain, stiffness, loss of motion) varies; may begin as early as 2nd month postsurgery
            • Currently, there is no effective treatment; may require additional diagnostic and therapeutic procedures (eg, arthroplasty or shoulder replacement)
            • Use of bupivacaine for spinal anesthesia and Posimir are not recommend in patients <18 years

            Risk of system toxicity

            • Marcaine, Posimir
            • Unintended intravascular injection may be associated with systemic toxicities, including CNS or cardiorespiratory depression and coma, progressing ultimately to respiratory arrest
            • Safety and effectiveness of bupivacaine depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies
            • Closely monitor cardiovascular and respiratory (adequacy of ventilation) vital signs and mental status after injection
            • Avoid additional use of local anesthetics within 168 hr following administration
            • Repeated doses may cause significant increases in plasma levels owing slow accumulation of drug or metabolites, or because of slow metabolic degradation
            • Consider increased monitoring for systemic toxicity in debilitated, elderly, or acutely ill patients

            Spinal anesthetics

            • Use with caution in patient with severe disturbances of cardiac rhythm, shock, or heart block
            • Sympathetic blockade occurring during spinal anesthesia may result in peripheral vasodilation and hypotension, depending on number of dermatomes blocked
            • Patients >65 years, especially with hypertension, may be at an increased risk of hypotensive effects
            • Carefully monitor blood pressure and level of anesthesia
            • Conditions preventing use of spinal anesthesia
              • Depending upon clinician’s evaluation and ability to manage potential complications, conditions may include:
              • Preexisting CNS disease (eg, disease associated with pernicious anemia, poliomyelitis, syphilis, tumor)
              • Hematological disorders predisposing to coagulopathies or concurrent anticoagulant therapy
              • Chronic backache and preoperative headache
              • Hypotension or hypertension
              • Technical problems (persistent paresthesias, persistent bloody tap)
              • Arthritis or spinal deformity; extremes of age
              • Psychosis or other causes of poor patient cooperation

            Posimir only

            • Inadvertent intravascular injection may deposit droplets into pulmonary and other capillary beds
            • Confirm proper needle placement with direct arthroscopic visualization; administer into subacromial space at end of arthroscopic shoulder surgery
            • In a study, use in dogs following intra-articular administration demonstrated joint cartilage necrosis; not approved for use via intra-articular injection
            • Safety and effectiveness in surgical procedures other than subacromial decompression not established

            Drug interaction overview

            • Drugs associated with methemoglobinemia
              • Use of drugs associated with methemoglobinemia (eg, nitrates, local anesthetics) with bupivacaine may exacerbate the risk of methemoglobinemia
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            Pregnancy & Lactation

            Pregnancy

            Contraindicated for obstetrical paracervical block anesthesia; use has resulted in fetal bradycardia and death

            Data are unavailable on use in pregnant women to inform a drug-associated risks of adverse developmental outcomes

            Local anesthetics rapidly cross placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity

            Incidence and degree of toxicity depend upon procedure performed, type, and amount of drug used, and technique of drug administration

            Adverse reactions in parturient, fetus, and neonate involve alterations of CNS, peripheral vascular tone, and cardiac function

            Maternal hypotension has resulted from regional anesthesia; avoid supine position and maintain left lateral decubitus position, if possible

            Animal data

            • Embryofetal lethality was noted when administered SC to pregnant rabbits during organogenesis at clinically relevant doses
            • Decreased pup survival was observed in rat pre-and postnatal developmental study at a dose level comparable to daily maximum recommended human dose on body surface area basis
            • Advise pregnant women of potential risks to fetus

            Labor or delivery

            • Epidural, caudal, or pudendal anesthesia may alter forces of parturition through changes in uterine contractility or maternal expulsive efforts
            • Epidural anesthesia reported to prolong second stage of labor by removing reflex urge to bear down or by interfering with motor function; use of obstetrical anesthesia may increase need for forceps assistance
            • Avoid aortocaval compression by gravid uterus during administration of regional block to parturients; advise to maintain left lateral decubitus position or a blanket roll or place sandbag beneath right hip and gravid uterus displaced to the left
            • Use of some local anesthetic drug products during labor and delivery may be followed by diminished muscle strength and tone for first day or two of life; not reported with bupivacaine

            Lactation

            Not studied in nursing mothers

            Bupivacaine can persist in plasma for up to 168 hr and benzyl alcohol, a Posimir excipient, for up to 12 hr after administration

            Bupivacaine and benzyl alcohol (in Posimir only) reported to be excreted in human milk

            Consider developmental and health benefits of breastfeeding along with mother’s clinical need for bupivacaine and any potential adverse effects on breastfed child from drug or underlying maternal condition

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Blocks initiation and conduction of nerve impulses by decreasing permeability of neuronal membrane to sodium ions, resulting in inhibition of depolarization with resultant blockade of conduction

            Absorption

            Onset of action

            • Marcaine Spinal: Very rapid (within 1 minute); achieves maximum motor blockade and dermatome level within 15 minutes in most cases
            • Marcaine Spinal
              • Time of complete sensation returns in operative site or regression of two dermatomes: ~2 hr (12-mg dose) averages
              • Time to complete motor ability returns: ~3.5 hr (12-mg dose)

            Mean peak plasma concentration

            • Posimir: 593-1,006 ng/mL

            Peak plasma time

            • Posimir: 5.9-8 hr
            • Marcaine, Sensorcaine, generic: 30-45 min (caudal, epidural, or peripheral nerve block)

            AUC

            • Posimir: 19,395-47,015 ng⋅h/mL

            Distribution

            Depending upon route of administration, distribution to some extent to all body tissues, with high concentrations found in highly perfused organs such as the liver, lungs, heart, and brain

            Protein bound: 95%

            Crosses the placenta via passive diffusion

            Fetal/maternal ratio: 0.2-0.4

            Metabolism

            Primarily metabolized in the liver via conjugation with glucuronic acid

            Major metabolite: Pipecoloxylidine

            Elimination

            Excretion: Urine (6% as unchanged)

            Half-life

            • Posimir: 16.4-26.1 hr
            • Marcaine, Sensorcaine, generic: 2.7 hr (adults); 8.1 hr (neonates)
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            Administration

            Compatibilities

            Posimir

            • Commonly implantable materials, such as polypropylene and polyester
            • Silk, nylon, gut, polypropylene, polydioxanone, and polyglycolic acid sutures

            Precautions

            Administer in carefully adjusted dosages by or under supervision of clinicians experienced in diagnosis and management dose-related toxicity and other acute emergencies

            Toxic effects of local anesthetics are additive; monitor for neurologic and cardiovascular effects related to local anesthetic systemic toxicity when administering additional local anesthetics

            Marcaine, Sensorcaine, or generic injection

            • Aspirate for blood or cerebrospinal fluid (when applicable before administration) before administration, both initial and all subsequent doses, to avoid intravascular or intrathecal use
            • Use only if the following are immediately available
              • Oxygen, cardiopulmonary resuscitative equipment and drugs, and the personnel resources needed for proper management of toxic reactions and related emergencies

            Administration

            Marcaine, Sensorcaine, generic

            • Not for intrathecal use
            • Epidural or caudal anesthesia: Avoid use of solutions containing antimicrobial preservatives (ie, multiple-dose vials)
            • Avoid rapid injection of large volumes; use incremental doses when possible
            • For major regional nerve blocks (eg, brachial plexus, lower extremity), an indwelling IV catheter should be placed to assure adequate IV access
            • Closely monitor cardiovascular and respiratory (adequacy of oxygenation and ventilation) vital signs and level of consciousness after each local anesthetic injection
            • Carefully restrict quantities in areas of body supplied by end arteries or having otherwise compromised blood supply (eg, digits, nose, external ear, penis)

            Posimir

            • Subacromial space administration
            • Single-dose administration only
            • Do NOT dilute or mix with local anesthetics, other drugs, or diluents
            • Avoid additional use of local anesthetics within 168 hr following administration
            • Administer in a setting where trained personnel and equipment are available to promptly treat any evidence of neurological or cardiac toxicity
            • Not indicated for following administrations
              • Epidural
              • Intrathecal
              • Intravascular; avoid administration owing to convulsions and cardiac arrests reported with accidental intravascular injection
              • Intra-articular use
              • Regional nerve blocks
              • Pre-incisional or pre-procedural locoregional anesthetic techniques requiring deep and complete sensory block in area of administration
            • Administration and dosing instructions

              • Ready-to-use; no dilution or mixing required
              • Draw up dose into a 5-mL syringe using a large bore needle (16 gauge or larger); discard needle after 5 mL is drawn
              • At the end of surgery, administer entire 5-mL (660-mg) dose into subacromial space using an 18-gauge or larger bore-needle
              • May insert needle through an existing arthroscopic port or through intact skin to reach subacromial space
              • Use direct arthroscopic visualization to confirm correct placement of needle tip within subacromial space
              • Do not administer into glenohumeral intra-articular space

            Storage

            Protect from light

            Product is clear and colorless; do not use solution if discolored or contains a precipitate

            Vials

            • Store at 20-25ºC (68-77ºF); excursions permitted to 15-30ºC (59-86ºF)
            • May be autoclaved once at 15 pound pressure, 121ºC (250ºF) for 15 min
            • Discard any unused portion
            Single-dose ampules
            • Store at 20-25ºC (68-77ºF); excursions permitted to 15-30ºC (59-86ºF)
            • May be autoclaved once at 15 pound pressure, 121ºC (250ºF) for 15 min
            • Discard any unused portion

            Posimir

            • Store at a controlled room temperature (20-25ºC [68-77ºF]), excursions permitted to 15-30ºC (59-86ºF)
            • Keep in carton until time of use
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            Images

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
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