Administration Precautions

• MARCAINE SPINAL is to be administered in carefully adjusted dosages by or under the supervision of experienced clinicians who are well versed in the diagnosis and management of dose-related toxicity and other acute emergencies which might arise from the block to be employed.
• Use MARCAINE SPINAL only if the following are immediately available: oxygen, cardiopulmonary resuscitative equipment and drugs, and the personnel resources needed for proper management of toxic reactions and related emergencies [see Warnings and Precautions (5.3), Adverse Reactions (6), Overdosage (10)].
• The toxic effects of local anesthetics are additive. Monitor for neurologic and cardiovascular effects related to local anesthetic systemic toxicity when additional local anesthetics are administered with MARCAINE SPINAL [see Warnings and Precautions (5.3), Drug Interactions (7.1), Overdosage (10)].
• Aspirate for blood and cerebrospinal fluid prior to injecting MARCAINE SPINAL, for both the initial dose and all subsequent doses (where applicable), to avoid intravascular injection and to confirm entry into the subarachnoid space. Aspiration of cerebrospinal fluid into a MARCAINE SPINAL-filled syringe will result in an identifiable swirl in the solution. A negative aspiration for blood does not ensure against an intravascular injection [see Warnings and Precautions (5.4)].
• Avoid rapid injection of MARCAINE SPINAL.
• The patient should have an indwelling intravenous catheter to assure adequate intravenous access. The lowest dosage of MARCAINE SPINAL that results in effective spinal anesthesia should be used to avoid a high motor block and serious adverse reactions.
• Perform careful and constant monitoring of cardiovascular and respiratory (adequacy of oxygenation and ventilation) vital signs and the patient's level of consciousness during spinal anesthesia.

Conditions Which May Preclude Use of Spinal Anesthesia

The following conditions may preclude the use of spinal anesthesia, depending upon the physician's evaluation of the patient:

• Pre-existing diseases of the central nervous system (CNS), such as those attributable to pernicious anemia, poliomyelitis, syphilis, or tumor.
• Hematological disorders predisposing to coagulopathies or patients on anticoagulant therapy. Trauma to a blood vessel during the conduct of spinal anesthesia may, in some instances, result in uncontrollable CNS hemorrhage, soft tissue hemorrhage, or development of a hematoma.
• Chronic backache and preoperative headache.
• Hypotension and hypertension.
• Technical problems (persistent paresthesias, persistent bloody tap).
• Arthritis or spinal deformity.
• Extremes of age.
• Psychosis, dementia, or other illnesses resulting in poor patient cooperation.