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Epinephrine may cause local toxicity, including ischemic injury or necrosis.

Local anesthetics containing a vasoconstrictor may cause methemoglobinemia, especially in combination with methemoglobin-inducing agents. Do not use in patients with congenital or idiopathic methemoglobinemia, or in patients who are receiving treatment with methemoglobin-inducing agents.

May occur. Systemic absorption of local anesthetics may produce cardiovascular and/or CNS effects. Toxic blood concentrations of local anesthetics depress cardiac conduction and excitability, which may lead to AV block, ventricular arrhythmias, and cardiac arrest (sometimes resulting in death). In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading to decreased cardiac output and arterial blood pressure. Restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness may be early warning signs of CNS toxicity. Small doses of local anesthetics injected into dental blocks may produce adverse reactions similar to systemic toxicity, including confusion, convulsions, respiratory depression and/or respiratory arrest, and cardiovascular stimulation or depression; these reactions may be due to intra-arterial injection of the local anesthetic with retrograde flow to the cerebral circulation. Constantly monitor cardiovascular and respiratory vital signs and patient’s state of consciousness carefully following each injection. Disease-related concerns:

Use with caution in patients with impaired cardiovascular function, including patients with heart block. Use local anesthetics containing a vasoconstrictor with caution in patients with vascular disease; patients with peripheral vascular disease or hypertensive vascular disease may exhibit exaggerated vasoconstrictor response, possibly resulting in ischemic injury or necrosis. Dosages should be reduced for patients with cardiac disease.

Use with caution in patients with severe hepatic disease (has not been studied). Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

Administer reduced dosages, commensurate with age and physical condition, to debilitated and/or acutely-ill patients.

Use with caution in the elderly; administer reduced dosages to commensurate with age and physical condition.

Administer reduced dosages, commensurate with age and physical condition, to pediatric patients. Dosage form specific issues:

May contain sodium metabisulfite, which may cause allergic-type reactions (including anaphylactic symptoms, and life-threatening or less severe asthmatic episodes) in certain susceptible patients. The overall prevalence of the sulfite sensitivity in the general population is unknown, and is seen more frequently in asthmatic than in nonasthmatic persons. Other warnings/precautions:

Avoid intravascular injection; accidental intravascular injection may be associated with convulsions, followed by CNS or cardiorespiratory depression and coma, progressing ultimately to respiratory arrest. 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.

To avoid serious adverse effects and high plasma levels, use the lowest dosage resulting in effective anesthesia. Repeated doses may cause significant increases in blood levels due to the possibility of accumulation of the drug or its metabolites. Dosage recommendations should not be exceeded.

Health care providers 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.