Marcain Spinal Heavy Special Precautions

Intrathecal anaesthesia should only be undertaken by or under the supervision of clinicians with the necessary knowledge and experience.
Regional anaesthetic procedures should always be performed in a properly equipped and staffed area with equipment and drugs necessary for monitoring and emergency resuscitation immediately available.
Intravenous access, e.g. an i.v. infusion, should be in place before starting the intrathecal anaesthesia.
Clinicians should have received adequate and appropriate training in the procedure to be performed and should be familiar with the diagnosis and treatment of side effects, systemic toxicity or other complications (see Overdosage).
Patients in poor general condition due to ageing or other compromising factors such as partial or complete heart conduction block, advanced liver or renal dysfunction require special attention although regional anaesthesia may be the optimal choice for surgery in these patients. Patients treated with anti-arrhythmic drugs class III (e.g. amiodarone) should be under close surveillance and ECG monitoring considered, since cardiac effects may be additive (see Interactions).
Like all local anaesthetic drugs, bupivacaine may cause acute toxicity effects on the central nervous and cardiovascular systems, if utilised for local anaesthetic procedures resulting in high blood concentrations of the drug. This is especially the case after unintentional intravascular administration. Ventricular arrhythmia, ventricular fibrillation, sudden cardiovascular collapse and death have been reported in connection with high systemic concentrations of bupivacaine. However, high systemic concentrations are not expected with doses normally used for intrathecal anaesthesia.
A rare, though severe, adverse reaction following spinal anaesthesia is high or total spinal blockade resulting in cardiovascular and respiratory depression. The cardiovascular depression is caused by extensive sympathetic blockade which may result in profound hypotension and bradycardia, or even cardiac arrest. Respiratory depression may be caused by blockade of the innervation of the respiratory muscles, including the diaphragm.
There is an increased risk for high or total spinal blockade in the elderly and in patients in the late stages of pregnancy. The dose should therefore be reduced in these patients (see also Dosage & Administration).
Patients with hypovolaemia can develop sudden and severe hypotension during intrathecal anaesthesia, regardless of the local anaesthetic used. The hypotension usually seen after intrathecal blocks in adults is uncommon in children under the age of 8.
Neurological injury is a rare consequence of intrathecal anaesthesia and may result in paraesthesia, anaesthesia, motor weakness and paralysis. Occasionally these are permanent.
Neurological disorders, such as multiple sclerosis, haemiplegia, paraplegia and neuromuscular disorders are not thought to be adversely affected by intrathecal anaesthesia, but call for caution. Before treatment is instituted, consideration should be taken if the benefits outweigh the possible risks for the patient.
Effects on ability to drive and use machines: Besides the direct anaesthetic effect, local anaesthetics may have a very mild effect on mental function and coordination even in the absence of overt CNS toxicity and may temporarily impair locomotion and alertness.