Carmin injector

American Regent launched indigo carmine in July Indigo carmine is indigotindisulfonate sodium, a marker dye used during cystoscopy and ureteral catheterization.

Indigo carmine is an unapproved drug without FDA approved labeling. There is no single dye that can replace indigo carmine.

Many of the marker dyes are on nationwide shortage. Table 2 summarizes the published primary literature for intravenous use of marker dyes to evaluate ureter patency during intraoperative cystoscopy. Table 3 summarizes the use of these products given by direct instillation for urologic or gynecologic procedures. Possible oral options for staining the urine during cystoscopy include phenazopyridine and vitamin B complex.

Hui et al[8] published a case report of 32 women who received single-dose oral phenazopyridine mg to mg one hour prior to pelvic reconstructive surgery. Intraoperative cystoscopy was performed to confirm ureteric patency. Bilateral ureteric patency was confirmed in all 32 cases and bladder mucosa was also adequately inspected in all women.

No postoperative ureteric injuries were identified. Fernando et al[9] administered 3 tablets of vitamin B complex 1 to 4 hours prior to surgery and cystoscopy. Amniocentesis with transabdominal instillation of indigo carmine may be used in cases where the diagnosis of suspected premature rupture of membranes remains difficult despite use of standard non-invasive methods. There are several case reports of adverse neonatal outcome when methylene blue was given by intra-amniotic injection.

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The authors concluded that both intra-amniotic indigo carmine infusion and noninvasive placental alpha microglobulin-1 immunoassay methods were comparable for diagnosing ROM. During the shortage of indigo carmine, use of placental alpha microglobulin-1 immunoassay AmniSure may be an option. Consult with a specialist in obstetrics and gynecology.

Table 1. Serotonin syndrome can occur in patients taking other serotonergic agents. Metabolism Renal excretion Renal excretion Not metabolized. Indocyanine green is bound to plasma proteins, taken up by hepatocytes, and excreted unaltered into bile 20 minutes after injection.

None Half-life, intravenous 4 to 5 minutes blue urine usually appears within 10 minutes of intravenous administration 4 5 to 6. Harris et al 28 used indigo carmine 5 mL intravenously prior to intraoperative cystoscopy in women undergoing reconstructive pelvic surgery. Jelovsek et al 30 reported the results of intraoperative cystoscopy with intravenous indigo carmine in patients undergoing total laparoscopic hysterectomy.

The dose of indigo carmine was 1 ampule 5 mL intravenous. Song and Kim 31 used indigo carmine 5 mL intravenously one hour prior to operation and then repeated at time of skin incision to help identify ureters in 37 patients with ureteral obstruction.

There are 3 published reports of intravenous methylene blue used to confirm ureteral patency. No methylene blue was visualized after administration. Authors speculate the methylene blue was metabolized to leukomethylene, which is colorless. Both patients received subsequent doses of indigo carmine and blue urine was observed. The dose was 6 mL 0. Delayed emission of the dye was observed in one patient with a right ureter stricture. Verbeek et al 35 evaluated the use of methylene blue in 12 patients undergoing lower abdominal surgery exposing the ureters.

Methylene blue was given intravenously at a dose of 0.During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection EMR and endoscopic submucosal dissection ESD.

Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them.

For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages.

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Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.

Core tip: In this work, we review the importance of submucosal injection and present some of the most commonly used solutions, comparing them taking into account their advantages and disadvantages. Unlike most of the previous papers about this subject, we organized this review in a more practical point of view. For that, we try to answer some essential questions like: what is the need for submucosal injection, when should we use it, what type of solution is more suitable for each endoscopic resection technique and how should we use them.

During the past decades, endoscopic resection techniques have gradually improved and gained more importance in the management of premalignant lesions and early cancers of the digestive tract[ 12 ]. Injection lifts the lesion and separates it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding, while also facilitating en-bloc resection by improving technical feasibility[ 34 ].

An additional important aspect of injection is that if dyes are incorporated, lesion margins may become more clearly defined, especially in the colon. Several solutions have been used for submucosal injection, although there is still no consensus about which one is the best. The ideal injection solution should provide a thick submucosal fluid cushion that remains in the submucosal space long enough to avoid the need of multiple injectionsshould be inexpensive, widely available, improve outcomes, reduce adverse events, and should not damage tissue specimens in order to allow an accurate pathologic staging[ 56 ].

Taking into account the different types of solutions, normal saline NS has been the most widely used solution. It is simple to use and available at a low-cost, although the mucosal protrusion created by the submucosal injection of NS is only maintained for a short period of time.

Submucosal injection of glucose solution, glycerol, sodium hyaluronate SHcolloids, hydroxypropyl methylcellulose, fibrinogen solution and other alternatives have been investigated in different contexts. However, these solutions also have some disadvantages: they can be difficult to prepare or administer, may not readily available or only available at a high cost, and may induce tissue damage that can impair histological assessment or even be associated with toxicity.

The aim of this article was to review the indications of submucosal injection and to present some of the most commonly used solutions, comparing them taking into account their advantages and disadvantages. We organized this review to share information in a practical point of view, sharing also our own experience in this field.

For that, we will try to answer some essential questions: what is the need for submucosal injection, when should we use it, what type of solution is more suitable for each endoscopic resection technique and how should we use them. The main objective of submucosal injection is to separate the mucosal layer from the muscularis propria by filling the submucosal layer with fluid in order to decrease the risk of adverse events.

This submucosal cushion reduces thermal injury and the risk of perforation and haemorrhage by separating the mucosa from large submucosal vessels and also by vasoconstriction when adrenaline is part of the solution while also facilitates en-bloc resection.

Decision algorithm.

carmin injector

This technique has high rates of complete resection, adequate tissue sampling for histology and low rates of adverse events. ESGE guidelines also suggest CSP for sessile polyps mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polipectomy HSP is lacking.

On the other hand, HSP is recommended for removal of sessile polyps mm in size.

Life-threatening reaction to indigo carmine--a sulfa allergy?

In most cases, especially in the right colon, deep thermal injury with HSP is a potential risk and thus submucosal injection prior to HSP is generally advised. EMR is an endoscopic technique developed for the removal of sessile or flat neoplasms confined to the superficial layers mucosa and submucosa of the gastrointestinal tract by excising through the middle or deeper portion of the submucosa. In ligation-assisted EMR, a band ligation device is attached to the endoscope, and the banding cap is positioned over the target lesion.

In this technique, although some endoscopists use submucosal injection prior to band placement, submucosal injection is not mandatory as the resection can be safely without this step[ 351011 ]. Inject-and-cut EMR is also often called saline solution lift-assisted polipectomy.

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The procedure starts with injection of a solution into the submucosal space under the lesion creating a safety cushion. The cushion lifts the lesion, facilitating capture and removal by using a snare while minimizing mechanical or electrocautery damage to the deeper layers of the gastrointestinal wall.

Recently, cold snare EMR was also described, and ESGE guidelines suggest that it can be an option in cases where the risk of deep thermal injury is high or unable to be tolerated, although evidence is still scarce.

In this case, submucosal injection may still be needed.ProvayBlue is approved for use in children and adults with acquired methemoglobinemia. Methylene blue has also been used to treat methemoglobinemia due to toxic chemicals or substance abuse. Consider reserving a supply of methylene blue for the treatment of methemoglobinemia. Table 1 summarizes potential alternatives to methylene blue for selected clinical scenarios.

Table 2 compares indigo carmine, methylene blue, and indocyanine green with regard to indication for use, dosing, metabolism and drug interactions. Table 3 summarizes the published primary literature for intravenous use of marker dyes to evaluate ureter patency during intraoperative cystoscopy. Table 4 summarizes the use of these products given by direct instillation for urologic or gynecologic procedures.

Table 1. Sentinel lymph node biopsy for patients with neoplasms such as breast cancer or other delineation of lymphatic vessels such as patients with lymphedema or chyluria.

Repeat one time if needed. Consider alternative management if second dose does not resolve symptoms. Serotonin syndrome can occur in patients taking other serotonergic agents. Metabolism Renal excretion Renal excretion Not metabolized.

Indocyanine green is bound to plasma proteins, taken up by hepatocytes, and excreted unaltered into bile 20 minutes after injection. Azure B which is 8 times less potent than the parent compound. None Half-life, intravenous 4 to 5 minutes blue urine usually appears within 10 minutes of intravenous administration 9 Approximately 24 hours 3.

The dose of indigo carmine was 1 ampule 5 mL intravenous. No methylene blue was visualized after administration. Authors speculate the methylene blue was metabolized to leukomethylene, which is colorless. Both patients received subsequent doses of indigo carmine and blue urine was observed. The dose was 6 mL 0. Delayed emission of the dye was observed in one patient with a right ureter stricture.

Methylene blue was given intravenously at a dose of 0. Patients underwent near infrared fluorescence imaging for up to 60 minutes after injection.Indigo carmine sodium indigotindisulfonate is a safe, biologically inactive blue dye routinely administered intravascularly during urologic and gynecologic procedures to localize the ureteral orifices and to identify severed ureters and fistulous communications.

We report a case of hypotension, cardiac arrest, and cerebral ischemia after the administration of indigo carmine in a patient under total laparoscopic hysterectomy. Indigo carmine sodium indigotindisulfonate is a blue dye commonly used urologically or in gynecological surgery to observe ureteral orifices in cystocopy since its clinical introduction in Generally, it was considered pharmacologically inert, but we report a case of hypotension, cardiac arrest, and cerebral ischemia after an intravenous indigo carmine injection during a total laparoscopic hysterectomy with accompanying literature review.

A 43 year-old female patient with American Society of Anesthesiologists ASA physical status I was diagnosed with uterine myoma and was scheduled to undergo total laparoscopic hysterectomy. The patient was cm tall and weighed 63 kg with no unusual medical history, and in the preoperative laboratory tests, her mean corpuscular hemoglobin concentration was 7.

Premedication was not used, and upon arrival in the operating room, an electrocardiogram, pulse oximeter, and non-invasive blood pressure monitor were attached. Glycopyrrolate 0. CO 2 was inserted into the abdominal cavity until the intra-abdominal pressure became 13 mmHg and the hysterectomy was done. Two hours after inducing anesthesia, 5 ml of indigo carmine was slowly IV injected to identify the ureter.

One milligram of epinephrine was IV injected; chest compressions were given, and the right radial artery was punctured and a catheter inserted to continually monitor the arterial pressure.

The pulse recovered, but the patient's state did not improve so 1 mg of epinephrine was administered 3 more times over 20 minutes.

Atropine 0. The patient's vital signs normalized so the surgery was completed; muscle relaxation was reversed with intravenous injection of glycopyrrolate 0. There were no abnormalities in the brain CT, but in the brain MRI taken on the second postoperative day, there were bilateral infarctions in the subcortical white matter in the parieto-occipital lobe Fig.

On the seventh postoperative day, mechanical ventilation was stopped. Twenty days after surgery, the patient was extubated, and on the twenty-fifth postoperative day, the patient's mental status recovered, but there was motor weakness in the left arm and visual disturbance with difficulty in the lateral gaze. Three months after surgery, the patient recovered from motor weakness and visual disturbance.

The patient is currently hospitalized for rehabilitation. Magnetic resonance imaging shows diffusion restriction of subcortical white matter in the both occipital and frontoparietal lobes.

carmin injector

Indigo carmine has been used widely and safely for IV injection, but there are rare cases of complications reported. Arterial pressure can rise from an increase in peripheral vascular resistance while bradycardia may be a reflex response from circulatory baroreceptors, and cardiac output can decrease [ 1 ]. Decreased cardiac output occurs due to increased afterload and reflex bradycardia. An increase in the mean arterial pressure and total peripheral resistance and a decrease in the cardiac output and cardiac rate with essentially no change in the stroke volume are a typical response to alpha receptor stimulation [ 2 ].

The molecular structure of indigo carmine resembles two molecules of serotonin arranged as if one is a mirror image of the other Fig.

This similarity in structure suggests a cardiovascular effect [ 1 ]. Increase in blood pressure and tachycardia that arises from such similarity with the serotonin structure has been reported, but it is very rare to cause severe hypotension and cerebral infarction as in our case.

There is a case report of severe hypotension after intravenous indigo carmine in a patient undergoing radical prostatectomy under epidural anesthesia [ 3 ]. Indigo carmine has both the effects of a stimulant and a depressant; however, in that case, the commonly observed effect as a stimulant was prevented by the epidural anesthesia thus, leaving the depressant component of the drug unmasked and causing a decline in blood pressure [ 4 ].For urgent drug information outside of normal business hours, assistance is available at: P: American Regent, Inc.

Important Administration Information Selenious Acid Injection is supplied as a pharmacy bulk package for admixing use only. It is not for direct intravenous infusion.

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Pulmonary Embolism due to Pulmonary Vascular Precipitates: If signs of pulmonary distress occur, stop the infusion and initiate a medical evaluation. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Preterm infants are particularly at risk for aluminum toxicity because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which also contain aluminum.

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Lactation: Risk Summary: Selenium is present in human milk. There is no information on the effects of selenious acid on milk production. Pediatric Use: Safety and dosing recommendations in pediatric patients are based on clinical experience. Receive Availability Emails submit. Locate Distributor.

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Indigo Carmine

Find a Distributor. We will reach out to you for details about the Adverse Reactions you are reporting. Please make sure your contact information is accurate.

Your name. Street Address. Zip Code. For additional safety information, please see Full Prescribing Information. Out of Stock. In Stock.For further information about unapproved drugs, click here. If you are a consumer or patient please visit this version. Sterile, nonpyrogenic. Sufficient Indigo Carmine is contained in each 5 mL ampule to permit accurate withdrawal and administration of the full dose.

It gives a deep blue solution when dissolved in water. Indigo Carmine is excreted largely by the kidneys, retaining its blue color during passage through the body. Elimination of the dye begins soon after injection, appearing in the urine within 10 minutes in average cases. The biological half-life is 4 to 5 minutes following intravenous injection. Larger quantities are necessary when intramuscular injection is employed.

Appearance time and elimination are delayed following intramuscular injection. Originally employed as a kidney function test, the chief application of Indigo Carmine at present is localizing ureteral orifices during cystoscopy and ureteral catheterization. Indigo Carmine is contraindicated in patients who have previously experienced an adverse reaction following its use. An occasional idiosyncratic drug reaction may occur.

A mild pressor effect may be encountered in some patients. Animal Reproduction studies have not been conducted with indigotindisulfonate sodium injection. It is also not known whether indigotindisulfonate sodium injection can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity.

Indigotindisulfonate sodium injection should be given to a pregnant woman only if clearly needed. It is not known whether this drug is excreted in human milk.

carmin injector

Because many drugs are excreted in human milk, caution should be exercised when Indigo Carmine is administered to a nursing woman. Indigo Carmine is not a controlled substance listed in any of the Drug Enforcement Administration Schedules.

Its use is not known to lead to dependence or abuse. There are no data available describing the signs, symptoms or laboratory findings accompanying overdosage.Generic Name: indigotindisulfonate sodium Dosage Form: injection, solution. For further information about unapproved drugs, click here. Medically reviewed by Drugs.

Cardiac arrest from intravenous indigo carmine during laparoscopic surgery -A case report-

Last updated on Dec 1, Sterile, nonpyrogenic. Sufficient Indigo Carmine is contained in each 5 mL ampule to permit accurate withdrawal and administration of the full dose. It gives a deep blue solution when dissolved in water. Indigo Carmine is excreted largely by the kidneys, retaining its blue color during passage through the body. Elimination of the dye begins soon after injection, appearing in the urine within 10 minutes in average cases.

The biological half-life is 4 to 5 minutes following intravenous injection. Larger quantities are necessary when intramuscular injection is employed. Appearance time and elimination are delayed following intramuscular injection. Originally employed as a kidney function test, the chief application of Indigo Carmine at present is localizing ureteral orifices during cystoscopy and ureteral catheterization. Indigo Carmine is contraindicated in patients who have previously experienced an adverse reaction following its use.

An occasional idiosyncratic drug reaction may occur. A mild pressor effect may be encountered in some patients. Animal Reproduction studies have not been conducted with indigotindisulfonate sodium injection. It is also not known whether indigotindisulfonate sodium injection can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity.

Indigotindisulfonate sodium injection should be given to a pregnant woman only if clearly needed. It is not known whether this drug is excreted in human milk.

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Because many drugs are excreted in human milk, caution should be exercised when Indigo Carmine is administered to a nursing woman. Indigo Carmine is not a controlled substance listed in any of the Drug Enforcement Administration Schedules.

Its use is not known to lead to dependence or abuse. There are no data available describing the signs, symptoms or laboratory findings accompanying overdosage.


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