Adult Dosing

Epidural anesthesia

• 10-20 mL of 0.25% for partial to moderate block; 10-20 mL of 0.5% for moderate to complete block or 10-20 mL of 0.75% for complete block
• Administer in increments of 3-5 mL allowing sufficient time to detect toxic symptoms or signs of accidental IV/IT administration
• Max: Use a test dose of 2-3 mL of 0.5% with epinephrine prior to epidural blocks

Caudal block

• 15-30 mL of 0.25% for moderate block; 15-30 mL of 0.5% for moderate to complete block
• A test dose of 2–3 mL of 0.5% with epinephrine solution is recommended prior to caudal blocks

Peripheral nerve block

• 5 mL of 0.25% or 0.5% solution (max dose= 400 mg) produces moderate to complete block

Sympathetic nerve block

• 20-50 mL of 0.25% solution

Local infiltration

• 0.25% solution infiltrated locally
• MAX: 175 mg

Retrobulbar block

• 2-4 mL of 0.75% for complete block

Dental block

• 1.8-3.6 of 0.5%
• Notes:
• Dosing of local anesthesia varies with anesthetic procedure, area to be anesthetized, vascularity of tissues, depth of anesthesia and degree of muscle relaxation required
• During epidural anesthesia, 0.5% and 0.75% solution should be given in incremental doses of 3-5 mL with sufficient time to detect toxic manifestations of unintentional intravascular or intrathecal administration
• Test dose of bupivacaine with epinephrine is recommended for use as a test dose prior to caudal and lumbar epidural blocks
• Use lowest effective dose and smallest concentration, use lower doses in elderly and/or debilitated patients
• Doses may be repeated q3 hrs. Max: 400 mg/24 hrs

Pediatric Dosing

• Safety and efficacy in pediatrics < 12 yrs have not been established

• Local anesthesia
• Regional anesthesia
• Analgesia for surgery, oral surgery procedures for diagnostic and therapeutic procedures
• Obstetric anesthesia (0.25%, 0.5% conc. only)
• Production of subarachnoid block (spinal anesthesia)

• Hypersensitivity to any of the ingredients of the product
• Hypersensitivity to amide anesthetics
• Contains bisulfites and should be avoided in patients with known intolerance
• Infection at site
• Obstetrical paracervical block
• Obstetrical anesthesia (0.75%)
• Intravenous regional anesthesia
• Intra-articular continuous infusion

• 0.75% solution is not recommended for obstetric analgesia. Cardiac arrest with difficult resuscitation or death during epidural anesthesia has occurred in obstetric patients. Cardiac arrest and convulsions can occur from systemic toxicity following accidental intravascular injury. Reserve 0.75% concentration for surgical procedures requiring high degree of muscle relaxation and prolonged effect
• Bupivacaine should be administered by clinicians trained in local anesthetic associated dose-related toxicity or acute emergency diagnosis and management. Resuscitative equipment, drugs including oxygen should be available for immediate use. Acidosis, cardiac arrest and possibly death may occur if there is any delay in management of dose-related toxicity, underventilation and/or altered sensitivity

Renal Dose Adjustment

• Renal impairment: Use with caution; dose adjustments not defined

Hepatic Dose Adjustment

• Hepatic impairment: Use with caution; dose adjustments not defined

• Do not use solutions containing antimicrobial preservatives in epidural or caudal anesthesia
• Prohibit intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures
• Chondrolysis has occurred in patients receiving intraarticular infusions of local anesthetics; occurrence of joint pain, stiffness and loss of motion may begin as early as the 2nd month after surgery
• Provide additional diagnostic and therapeutic procedures, arthroplasty or shoulder replacement for patients experiencing chondrolysis
• Avoid concomitant use with ergot or other related oxytocic drugs when used in combination with epinephrine or other vasopressors
• Avoid mixing with any other local anesthetic as serious dose related cardiac arrhythmias may occur
• Avoid use in pediatrics >12 yrs of age
• Avoid mixing or concomitant use with any other local anesthetic
• Administer IV fluids during major regional nerve blocks
• Cardiac arrest and fatal death have occurred on use of drug for intravenous regional anesthesia, avoid administration by IV regional anesthesia as safety of dosages and technique is not established
• Life-threatening or less severe asthmatic episodes, anaphylactic reactions may occur in asthmatic patients administered epinephrine solutions containing sodium metabisulfite
• Use lowest effective dose to avoid high plasma levels and serious adverse effects
• Use incremental doses when possible, administer concentrated solutions (0.5-0.75%) in incremental doses of 3 to 5 mL, avoid rapid injection of large doses
• Use sufficient time between incremental doses to detect toxic manifestations of unintentional intravascular or intrathecal injection
• Perform syringe aspirations before and during each supplemental injection
• Monitor the effects after administering test dose and then administer full dose
• Administer test dose before original and all reinforcing doses while using continuous catheter technique
• Monitor for increase in heart rate after administering test dose
• Proper dosage, correct technique, adequate precautions, and readiness for emergencies governs the safety and efficacy of local anesthetics, provide resuscitative equipment, oxygen, and other resuscitative drugs for immediate use
• Administer test dose containing epinephrine (10 mcg to 15 mcg ) to serve as a warning of unintended intravascular injection if clinical conditions permit, increase in heart rate or systolic blood pressure, circumoral pallor, palpitations, and nervousness in the unsedated patient have occurred as a transient response to epinephrine
• Monitor heart rate following the test dose
• Transient rise in systolic blood pressure have occurred in patients on beta-blockers
• Test dose can contain 10-15 mg of bupivacaine or an equivalent amount of another local anesthetic to detect an unintended intrathecal administration
• systemic toxic reaction, high spinal or epinephrine-induced cardiovascular effects have occurred on administering test dose
• Administer local anesthetic solutions containing a vasoconstrictor carefully and in restricted quantities in areas of the body supplied by end arteries or having compromised blood supply such as digits, nose, external ear, or penis
• Administer reduced doses in geriatrics, debilitated, acutely ill patients and children
• Monitor cardiovascular and respiratory vital signs, state of consciousness, signs of CNS toxicity after each dose
• Exaggerated vasoconstrictor response, ischemic injury or necrosis have occurred in patients with hypertensive vascular disease
• Fatal dose-related cardiac arrhythmias have occurred on administering preparations containing a vasoconstrictor such as epinephrine in patients during or following the administration of potent inhalation anesthetics
• Malignant hyperthermia may occur, unexplained signs of tachycardia, tachypnea, labile blood pressure, and metabolic acidosis may precede temperature elevation
• Monitor the circulation and respiration constantly of the patients receiving small doses of local anesthetics into the head and neck area (etrobulbar, dental, and stellate ganglion blocks) as it produces adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses, resuscitative equipment and personnel for treating adverse reactions should be readily available
• Do not exceed the recommended dosage while injecting local anesthetics into the head and neck area
• For retrobulbar block a concentration of 0.75% bupivacaine is indicated, however this concentration is not indicated for any other peripheral nerve block, including the facial nerve or for local infiltration
• Respiratory arrest have occurred following the retrobulbar blocks, resuscitative equipment, drugs, and personnel to manage respiratory arrest or depression, convulsions, and cardiac stimulation or depression should be immediately available
• Bupivacaine 0.5% with epinephrine used for dental injections gives long duration of anesthesia, patients should be cautioned for the possibility of trauma to tongue, lips, and buccal mucosa and advised not to chew solid foods
• Monitor BUN and creatinine in elderly patients
• Confusion, convulsions, respiratory depression, and/or respiratory arrest, and cardiovascular stimulation or depression have occurred on intra-arterial injection of the local anesthetic
• Monitor circulatory and respiratory functions in patients having retrobulbar block
• Avoid use of 0.75% bupivacaine for local infiltration including the conjunctiva and peripheral nerve block including the facial nerve

Cautions: Use cautiously in

• Renal impairment
• Hepatic impairment
• Impaired cardiovascular function
• Hypertensive vascular disease
• Hypotension
• Heart block
• Hypovolemia
• Patients receiving monoamine oxidase (MAO) inhibitors or antidepressants
• Debilitated
• Acutely ill patients
• Geriatrics

Pregnancy Category:C

Breastfeeding: Bupivacaine is excreted in breastmilk in small amounts. However, since it is not absorbed orally, amounts received by the infants are small and would not cause any adverse effects in breastfed infants. May interfere with breastfeeding if administered with anesthetics and analgesics. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 30 November 2010). Manufacturer advises caution.

• CNS: Excitation, depression, drowsiness, restleness, seizures, anxiety, dizziness, headache, tremors, incoherent speech, irritability, unconsciousness, convulsions, syncope, loss of sphincter control, septic meningitis; meningismus, cranial nerve palsies, lightheadedness, numbness, twitching, tingling of the mouth and lips
• NEURO: Persistent anesthesia, paresthesia, weakness, paralysis
• CV: Cardiovascular collapse, ventricular arrhythmias, ventricular fibrillation, ventricular tachycardia bradycardia, hypotension, decreased cardiac output, heart block, cardiac arrest, angioneurotic edema, myocardial depression, severe hypotension
• EENT: Blurred vision, tinnitus, constriction of the pupils, sneezing
• RESP: Respiratory arrest
• GI: Metallic taste, nausea, vomiting
• DERM: Pruritus, urticaria, erythema, excessive sweating
• GU: Urinary retention, fecal and urinary incontinence, loss of perineal sensation and sexual function, slowing of labor, increased incidence of forceps delivery
• MUSC: Backache, pain
• LOCAL: Burning at injection site
• NEURO: Paresthesia
• MISC: Anaphylactoid symptomatology, chills, allergic reactions, fever, pain

• Local anesthetic; blocks both the initiation and conduction of nerve impulses reducing the permeability of neuronal membranes to Na ions resulting in inhibition of depolarization with resultant blockade of conduction
• Rapid onset of action
• Metabolized by liver
• Excreted in urine 6% (unchanged)
• Half-life:
• Adults: 2.7 Hrs
• Neonates: 8.1 Hrs

US Trade Name(s)

• Marcaine
• Sensorcaine

US Availability

bupivacaine (generic)

• INJ: 0.25%
• INJ: 0.50%
• INJ: 0.75%

Marcaine, Sensorcaine

• INJ: 0.25% (10, 30, 50 mL vials)
• INJ: 0.50% (10, 30, 50 mL vials)
• INJ: 0.75% (10, 30 mL vials)

Canadian Trade Name(s)

• Marcaine
• Sensorcaine
• Marcaine spinal

Canadian Availability

bupivacaine (generic)

• INJ: 0.25% (10,20 mL vials)
• INJ: 0.5% (10,20 mL vials)
• INJ: 0.75% (10,20 mL vials)

Marcaine

• INJ: 0.25% (10, 20, 50 mL vials)
• INJ: 0.5% (10, 20, 50 mL vials)
• INJ: 0.75% (20 mL vials)

Marcaine spinal

• INJ: 0.75% (2mL amp)

Sensorcaine

• INJ: 0.25% (10, 20 mL vials)
• INJ: 0.5% (10, 20 mL vials)

UK Trade Name(s)

• Marcain
• Marcain heavy

UK Availability

bupivacaine (generic)

• INJ: 0.1% (100, 250 mL bags)
• INJ: 0.125% (100, 250 mL bags)
• INJ: 0.25% (10, 20 mL amp)
• INJ: 0.5% (10, 20 mL amp)
• INJ: 0.375% (10, 20, 50, 100 mL amp)
• INJ: 0.75% (10, 20 mL amp)

Hyperbaric bupivacaine (generic)

• INJ: 0.5% (5, 10, 20 mL amp)

Marcain

• INJ: 0.25% (10, 20 mL amp)
• INJ: 0.5% (10, 20 mL amp)

Marcain heavy

• INJ: 0.5% (4 mL amp)

Australian Trade Name(s)

• Marcain
• Marcain 0.5%
• Marcain spinal 0.5% heavy

Australian Availability

bupivacaine (generic)

• INJ: 0.25% (20 mL vials)
• INJ: 0.5% (20 mL vials)
• INJ: 0.5% (10 mL ampoules)

Marcain

• INJ: 0.125% (100, 200 mL Polybags)
• INJ: 0.25% (20 mL ampoules)
• INJ: 0.25% (100 mL Polybags)
• INJ: 0.5% (10, 20 mL ampoules)
• INJ: 0.375% (20 mL ampoules)

Marcain 0.5%, Marcain spinal 0.5% heavy

• INJ: 0.5% (4 mL ampoules)

Anesthesia

Local Anesthetics; Injectable