Mepivacaine (mepivacaine HCl)

Mepivacaine hydrochloride may be administered by infiltration, by epidural (including caudal) block, or by peripheral or sympathetic nerve block. Local anesthetics, including mepivacaine hydrochloride, have been administered by continuous intra-articular infusion+ (e.g., for control of postoperative pain); however, such use has been associated with chondrolysis. (See Cautions: Musculoskeletal Effects in the Local Anesthetics, Parenteral, General Statement 72:00.) Mepivacaine hydrochloride solutions containing preservatives should not be used for epidural or caudal block. Partially used bottles of solutions that do not contain preservatives should be discarded.

Aspiration for blood should be performed prior to injection of mepivacaine hydrochloride to avoid intravascular administration; however, a negative aspiration does not ensure protection against inadvertent intravascular injection.

Local anesthetics should only be administered by clinicians who are experienced in the diagnosis and management of dose-related toxicities and other acute emergencies associated with these agents. Resuscitative equipment, oxygen, drugs, and personnel required for treatment of adverse reactions should be immediately available when mepivacaine is administered. For specific procedures and techniques of administration, specialized references should be consulted.

Dosage of mepivacaine hydrochloride varies with the anesthetic procedure, the degree of anesthesia required, and the individual patient response. The usual dosages should generally be reduced in children and in geriatric, debilitated, or acutely ill patients. The smallest dose and lowest concentration required to produce the desired effect should be used. The maximum single dose (or the total of a series of doses given in one procedure) of mepivacaine hydrochloride for unsedated, healthy normal-sized adults should usually not exceed 400 mg. Maximum doses of 7 mg/kg (550 mg) have been administered without adverse effects, but these doses are not recommended except in unusual circumstances, and such doses should not be repeated at intervals of less than 1.5 hours. The total dose for any 24-hour period should not exceed 1 g. The pediatric dose should not exceed 5-6 mg/kg, especially in children weighing less than 13.6 kg. In children younger than 3 years of age or weighing less than 13.6 kg, concentrations less than 2% (e.g., 0.5-1.5%) should be used.

For infiltration anesthesia, up to 40 mL of a 1% solution (400 mg) of mepivacaine hydrochloride or 80 mL of a 0.5% solution (400 mg) may be given; a 0.5% solution may be prepared by diluting the 1% solution with 0.9% sodium chloride injection.

For cervical, brachial, intercostal, or pudendal nerve block, 5-40 mL of a 1% solution (50-400 mg) or 5-20 mL of a 2% solution (100-400 mg) may be given depending on the area and degree of anesthesia required; for pudendal block, one-half the total dose is injected on each side. For combined paracervical and pudendal block by the transvaginal route, up to 15 mL of a 1% solution (150 mg) is injected on each side. For paracervical block, up to 10 mL of a 1% solution (100 mg) may be injected on each side every 90 minutes; injections should be made slowly, with an interval of 5 minutes between sides. For therapeutic nerve block in the management of pain, 1-5 mL of a 1 or 2% solution (10-100 mg) may be given.

Solutions of 1, 1.5, or 2% mepivacaine hydrochloride containing no preservatives may be used in epidural or caudal anesthesia. To prevent intravascular or subarachnoid injection of a large epidural dose of mepivacaine hydrochloride, a test dose of anesthetic solution should be injected at least 5 minutes prior to administering the total dose; when a continuous block technique is used, a test dose should be administered prior to each dose to ensure that the catheter has not been displaced. Each test dose should contain 45-50 mg of mepivacaine hydrochloride to detect inadvertent subarachnoid injection and, when clinical conditions permit, epinephrine (e.g., 10-15 mcg) to detect inadvertent intravascular injection. For caudal epidural block, the usual dose of mepivacaine hydrochloride is 15-30 mL of a 1% solution (150-300 mg), 10-25 mL of a 1.5% solution (150-375 mg), or 10-20 mL of a 2% solution (200-400 mg) of mepivacaine hydrochloride.

In dental infiltration or nerve block procedures, the usual dose is 1.8 mL (36 mg) of a 2% solution also containing levonordefrin or 1.8 mL (54 mg) of a 3% solution. Infiltration or injection should be performed slowly with frequent aspiration. In adults, a total dose of 9 mL (180 mg as the 2% solution or 270 mg as the 3% solution) is usually adequate to produce local anesthesia of the entire oral cavity; however, a dose of up to 6.6 mg/kg (3 mg/lb) may administered. The total dose for all injection sites in a single dental sitting should not exceed 400 mg in adults. In children, the maximum dose for dental blocks must be carefully calculated and should not exceed 9 mL (180 mg as the 2% solution or 270 mg as the 3% solution). The manufacturer recommends that the maximum pediatric dose be calculated as follows:

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There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Local Anesthetics/Long-Acting Bupivacaine

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)

There are no moderate interactions for this drug.

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• Methemoglobinemia

• Atrial fibrillation
• Bradycardia
• Butyrylcholinesterase deficiency
• Glucose-6-phosphate dehydrogenase (g6Pd) deficiency
• Hemolytic anemia from pyruvate kinase and g6PD deficiencies
• Myasthenia gravis
• Structural disorder of heart

• Disease of liver
• Hypotension
• Kidney disease with reduction in glomerular filtration rate (GFr)

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Less Frequent

• Hypotension

Rare or Very Rare

• Anaphylaxis
• Bradycardia
• Cardiac arrhythmia
• Chondrolysis of articular cartilage
• CNS toxicity
• Hemiparesis
• Hypertension
• Methemoglobinemia
• Myocardial dysfunction
• Respiratory depression
• Seizure disorder
• Status asthmaticus
• Tachycardia
• Unconsciousness
• Urticaria
• Vasodilation of blood vessels
• Ventricular arrhythmias

Less Frequent

• Chills
• Headache disorder

Rare or Very Rare

• Acute cognitive impairment
• Apprehension
• Blurred vision
• Diplopia
• Dizziness
• Drowsy
• Dysgeusia
• Edema
• Euphoria
• Hypoesthesia
• Injection site sequelae
• Miosis
• Muscle fasciculation
• Nausea
• Nervousness
• Oral hypoesthesia
• Sensation of cold
• Sensation of warmth
• Skin rash
• Symptoms of anxiety
• Tinnitus
• Tremor
• Visual changes
• Vomiting

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