Markain appoint for carrying out different types of local anesthesia (anesthesia at injuries, holding painful diagnostic procedures (for example, an arthroscopy), at surgical interventions (including Cesarean section), a labor pain relief):

Conduction anesthesia, including intercostal blockade, blockade of small and big nerves, blockade of nerves in a neck and the head;
Regional (retrobulbar) anesthesia;
Local infiltration anesthesia;
Lumbar or caudal epidural blockade.

Contraindications

Absolute:

Arterial hypotonia;
Diseases of the central nervous system;
Age up to 2 years;
Hypersensitivity to drug components, and also to local anesthetics of amide type.

At accidental penetration of bupivacaine into a circulatory bed development of acute system toxic reactions therefore drug is not used when carrying out intravenous regional anesthesia is possible (blockade on Bira).

Relative (it is necessary to be careful at the following diseases / states):

General serious condition;
Heart blocks;
Cardiovascular insufficiency (because of probability of progressing of a disease);
Deficit of cholinesterase;
Inflammatory diseases or infection of the place of an injection (at an infiltration anesthesia);
Renal failure, decrease in a hepatic blood-groove (for example, at diseases of a liver, chronic heart failure);
Septicaemia, the previous neurologic diseases, zatrudnennost of carrying out a puncture owing to deformation of a backbone (at caudal and lumbar anesthesia);
Carrying out paracervical anesthesia;
Co-administration with antiarrhytmic drugs, including beta adrenoblockers;
Simultaneous use with other local anesthetics or drugs structurally similar to local anesthetics of amide type (for example, lidocaine, meksiletiny);
The age up to 12 years is also more senior than 65 years;
III trimester of pregnancy.

Route of administration and dosage

When calculating a necessary dose of Markain it is important to be based on assessment of the physical status of the patient and clinical experience.

When performing of the prolonged blockade by means of the prolonged infusion or fractional administration of drug it is necessary to consider a possibility of increase in its concentration in a blood plasma to toxic or probability of development of local damage of nerve fibrils. The available experience shows that introduction to the adult patient for 24 hours of 400 mg of Markain is usually transferred well.

When using large volumes of solution with the content of adrenaline it is necessary to consider risk of emergence of its system effects.

At the choice of dosing by the adult and to children of 12 years during execution of techniques it is most often recommended to be guided by the following data (the dose/beginning of action/duration of the anesthesia/indication and comments):

Infiltration: ≤30 ml, or ≤150 mg / 1-10 minutes / 3-8 hours / when carrying out surgical interventions and for a postoperative analgesia;
Retrobulbar anesthesia: 2-4 ml, ili10-20 / 5 minutes / 4-8 hours / are applied by mg in an ophthalmosurgery;
Peribulbarny anesthesia: 6-10 ml, or 30-50 mg / 10 minutes / 4-8 hours / are applied in an ophthalmosurgery;
Intercostal anesthesia (counting on a nerve): 2-3 ml, ili10-15 mg / 3-5 minutes / 4-8 hours / when carrying out surgical interventions and for a postoperative analgesia and anesthesia at injuries;
Interplevralny blockade: 20 ml, ili100 mg / 10-20 minutes / 4-8 hours / for a postoperative analgesia;
Axillary supraclavicular blockade of a brachial plexus: 30-40 ml, or 150-200 mg / 15-30 minutes / 4-8 hours;
Subclavial and interladder perivascular blockade of a brachial plexus: 20-30 ml, or 100-150 mg / 15-30 minutes / 4-8 hours;
Blockade of a sciatic nerve: 10-35 ml, or 50-200 mg / 15-30 minutes / 4-8 hours / when carrying out surgical interventions;
Blockade of a locking nerve, femoral nerve and lateral cutaneous nerve of a hip (3 in 1): 10-35 ml, or 50-200 mg / 15-30 minutes / 4-8 hours / when carrying out surgical interventions;
Epidural blockade (lumbar level): 15-30 ml, or 75-150 mg / 15-30 minutes / 2-3 hours / when carrying out surgical interventions, including a labor pain relief, Cesarean section and postoperative anesthesia (taking into account sample test);
Epidural blockade (chest level): 5-10 ml, or 25-50 mg / 10-15 minutes / 2-3 hour / when carrying out surgical interventions (taking into account sample test);
Caudal anesthesia: 20-30 ml, or 100-150 mg / 15-30 minutes / 2-3 hour / for intraoperative and postoperative anesthesia, when performing therapy of pain syndromes and anesthesia at diagnostic procedures (taking into account sample test).

Markain it is necessary to enter with care to avoid accidental intravascular administration of solution and emergence of acute toxic reactions. To and in the course of administration of drug it is recommended to carry out aspiration test carefully.

In need of introduction of high doses, for example, at epidural blockade, previously it is recommended to carry out the test: 3-5 ml of Markain with adrenaline. At accidental intravascular administration of solution the tranzitorny tachycardia which is easily revealed by the doctor can develop.

The main dose of Markain should be entered slowly with a speed of 25-50 mg a minute or fractionally bolyusno, supporting continuous verbal contact with the patient. If symptoms of intoxication are observed, it is necessary to interrupt administration of solution immediately.

Children up to 12 years should calculate a dose taking into account body weight (on average – to 2 mg/kg):

Lumbosacral blockade: 1,5-2 mg/kg;
Thoracolumbar blockade: 1,5-2,5 mg/kg.

Epinephrinum increases anesthesia duration by 50-100%.

Side effects

Side reactions at Markain's use are similar to the disturbances arising at intrathecal administration of other local anesthetics of long action.

The side effects caused by drug, trudnootlichima from physiological manifestations of blockade of nerves (for example, bradycardia, arterial hypotension, a temporary ischuria, etc.), from the reactions caused by introduction of a needle (indirectly (for example, epidural abscess, meningitis) or directly (for example, a spinal hematoma)), and also reactions which are connected with leak of cerebrospinal fluid (for example, a post-puncture headache).

During Markain's use the following disturbances can develop (> 1/10 – very often;> 1/100 and 1/1000 and < 1/100 – нечасто; <1/1000 – редко):

Nervous system: often – paresthesia, dizziness; infrequently – symptoms of toxicity of the central nervous and cardiovascular systems (in the form of spasms, paresthesia, numbness of language, visual disturbances, a fever, a tremor, a loss of consciousness, a ring and a sonitus, a dysarthtia, a headache); seldom – neuropathy, the inadvertent total spinal block, paralysis, a paraplegia, an arachnoiditis;
Cardiovascular system: very often – hypotension; often – increase in arterial pressure, bradycardia; seldom – a cardiac standstill;
Urinogenital system: often – an urine incontience, an ischuria;
Respiratory system: seldom – respiratory depression;
Digestive tract: very often – nausea; often – vomiting;
Organ of sight: seldom – a diplopia;
The general: seldom – allergic reactions; in hard cases – an acute anaphylaxis.

Special instructions

There are data on a cardiac standstill or death during Markain's introduction for peripheral blockade or epidural anesthesia. Sometimes performing resuscitation was complicated or it is impossible, despite good preparation and the correct carrying out anesthesia.

At high concentration of bupivacaine in plasma cases of development of fibrillation of ventricles, ventricular arrhythmia, a sudden cardiovascular collapse and death were recorded.

Except holding small procedures, experienced specialists in the room equipped as appropriate at availability have to carry out regional and local anesthesia ready to immediate use of the equipment and the medicines necessary for holding resuscitation actions and cardiomonitoring. When performing big blockade before Markain's introduction it is recommended to establish an intravenous catheter.

When carrying out peripheral nervous blockade the large volume of solution is entered into the area of high vascular vascularization, it is frequent near large vessels because of what the risk of its inadvertent intravascular introduction or system absorption of a high dose of Markain increases that, in turn, can lead to increase in plasma concentration of drug.

During regional anesthesia it is necessary to be especially attentive to the following groups of patients:

The patients receiving antiarrhytmic drugs III of a class (because of possible risk of development of complications from cardiovascular system careful medical control is necessary);
The weakened patients and patients of advanced age;
Patients with total or partial cordial block (because of probability of deterioration in conductivity of a myocardium);
Patients with a heavy renal failure or the progressing liver diseases.

When carrying out some types of blockade development of serious adverse reactions is possible:

The central blockade (in particular at patients with a hypovolemia): oppression of work of cardiovascular system is possible;
Big peripheral blockade: use of a large amount of local anesthetic can be required that can result in high concentration of Markain in plasma;
Injections in the head or a neck: hit of solution in an artery is possible that even at introduction of low doses can entail serious adverse reactions;
Retrobulbar and peribulbarny introduction: there is a risk of emergence of permanent dysfunction of eye muscles. Weight of these reactions is defined by injury degree, Markain's concentration and duration of exposure of fabric drug. It is recommended to use the minimum effective concentration and a dose of solution. At simultaneous use with vasoconstrictors and other additives strengthening of fabric reactions therefore they need to be used strictly according to indications is possible;
Paracervical blockade: development of tachycardia and/or bradycardia in a fruit in this connection it is necessary to carry out careful monitoring of a cordial rhythm of a fruit is possible;
Retrobulbar injections: Markain can accidentally get to a cranial subarachnoid space that can lead to development of a temporary blindness, an apnoea, spasms, a collapse and other side effects (the arisen disturbances should be diagnosed and stopped timely);
Epidural anesthesia: development of hypotension and bradycardia is possible. For reduction of probability of development of these complications previously enter crystalloid and colloidal solutions. When developing hypotension intravenous administration of sympathomimetics is shown (in case of need carry out repeated introduction). At children the applied doses have to correspond to the weight and age.

Preservatives therefore it has to be used immediately after opening of a bottle are not a part of solution of Markain.

Medicinal interaction

At simultaneous use of Markain with some medicines there can be following effects:

Other local anesthetics or medicines having structure, similar to local anesthetics of amide type (for example, lidocaine, мексилетин): development of the additive toxic effect (it is necessary to be careful at use of a combination of these medicines);
Tricyclic antidepressants, monoamine oxidase inhibitors: increase in risk of emergence of the expressed increase in arterial pressure;
Drugs with the maintenance of oxytocin or ergotamine: development of steady increase in arterial pressure with development further complications from cardiovascular system;
Inhalation anesthesia halothane: increase in risk of development of arrhythmia;
Disinfecting solutions with the content of heavy metals (when processing the place of an injection): increase in risk of development of local reactions in the form of hypostasis and morbidity;
The drugs having similar structure with local anesthetics (for example, токаинид): increase in risk of development of the additive toxic effect;
The drugs oppressing the central nervous system: strengthening of its oppression.

Markain's solubility decreases at рН> 6,5 that needs to be considered at addition of alkaline solutions (because of possible formation of precipitated calcium superphosphate).