l INDICATIONS AND DOSE CITANEST

1% ® Infiltration anaesthesia | Nerve block

 BY REGIONAL ADMINISTRATION

 Adult: 100–200 mg/minute, alternatively may be given in incremental doses; dose adjusted according to site of administration and response, and in elderly and debilitated patients (smaller doses may be required); maximum 400 mg per course PRILOTEKAL ® Spinal anaesthesia

BY INTRATHECAL INJECTION

 Adult: Usual dose 40–60 mg (max. per dose 80 mg), dose may need to be reduced in elderly or debilitated patients, or in late pregnancy 

DOSES AT EXTREMES OF BODY-WEIGHT

 To avoid excessive dosage in obese patients, dose should be calculated on the basis of ideal body-weight.

IMPORTANT SAFETY INFORMATION

Should only be administered by, or under the direct supervision of, personnel experienced in their use, with adequate training in anaesthesia and airway management, and should not be administered parenterally unless adequate resuscitation equipment is available.

l CONTRA-INDICATIONS GENERAL CONTRA-INDICATIONS

Acquired methaemoglobinaemia . anaemia . avoid injection into infected tissues . avoid injection into inflamed tissues . congenital methaemoglobinaemia . preparations containing preservatives should not be used for caudal, epidural, or spinal block

SPECIFIC CONTRA-INDICATIONS

 With intrathecal use Serious cardiac conduction disorders

CONTRA-INDICATIONS, FURTHER INFORMATION

 Injection site Manufacturer advises local anaesthetics should not be injected into inflamed or infected tissues. Increased absorption into the blood increases the possibility of systemic side-effects, and the local anaesthetic effect may also be reduced by altered local pH.

l CAUTIONS

Cardiovascular disease . debilitated patients (consider dose reduction). elderly (consider dose reduction). epilepsy . hypovolaemia . impaired cardiac conduction . impaired respiratory function . myasthenia gravis . severe or untreated hypertension . shock

l INTERACTIONS → Appendix 1:

anaesthetics, local

l SIDE-EFFECTS

 Common or very common Arrhythmias . dizziness . hypertension . hypotension . nausea . paraesthesia . vomiting  Uncommon Neurotoxicity  Rare or very rare Cardiac arrest. methaemoglobinaemia . nerve disorders ? Frequency not known Diplopia .respiratory depression

SIDE-EFFECTS, FURTHER INFORMATION

Toxic effects Toxic effects after administration of local anaesthetics are a result of excessively high plasma concentrations; severe toxicity usually results from inadvertent intravascular injection or too rapid injection. The systemic toxicity of local anaesthetics mainly involves the central nervous and cardiovascular systems. The onset of toxicity can be unpredictable and delayed. Monitor as per local protocol for at least 30 minutes after administration. Methaemoglobinaemia Methaemoglobinaemia can be treated with an intravenous injection of methylthioninium chloride.

l ALLERGY AND CROSS-SENSITIVITY

 Hypersensitivity and cross-sensitivity Hypersensitivity reactions occur mainly with the ester-type local anaesthetics, such as tetracaine; reactions are less frequent with the amide types, such as articaine, bupivacaine, levobupivacaine, lidocaine, mepivacaine, prilocaine, and ropivacaine. Cross-sensitivity reactions may be avoided by using the alternative chemical type.

l PREGNANCY

Large doses during delivery can cause neonatal respiratory depression, hypotonia, and bradycardia after epidural block. Avoid paracervical or pudendal block in obstetrics (neonatal methaemoglobinaemia reported). Dose adjustments Use lower doses for intrathecal use during late pregnancy.

l BREAST FEEDING

Present in milk but not known to be harmful. 

l HEPATIC IMPAIRMENT

Manufacturer advises caution. Dose adjustments With intrathecal use Manufacturer advises consider dose reduction.

l RENAL IMPAIRMENT

Use with caution. Dose adjustments Lower doses may be required for intrathecal anaesthesia.

l NATIONAL FUNDING/ACCESS DECISIONS PRILOTEKAL

 Scottish Medicines Consortium (SMC) decisions  With intrathecal use The Scottish Medicines Consortium has advised (December 2010) that prilocaine 2% hyperbaric solution for injection (Prilotekal ®) is accepted for restricted use within NHS Scotland for use in spinal anaesthesia in ambulatory surgery settings.