bupivacaine

Absorption: Systemic absorption follows epidural administration, but amount absorbed depends on dose.

Distribution: If systemic absorption occurs, this agent is widely distributed and crosses the placenta.

Metabolism/Excretion: Small amounts that may reach systemic circulation are mostly metabolized by the liver; 6% excreted unchanged in the urine.

Half-Life: 1.5–5 hr (after epidural use).

Time/Action Profile ⬆ ⬇

(analgesia)

ROUTE	ONSET	PEAK	DURATION
Epidural	10–30 min	Unknown	2–8 hr‡

‡Duration of anesthetic block.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity; cross-sensitivity with other amide local anesthetics may occur (ropivacaine, lidocaine, mepivacaine, prilocaine);
Contains bisulfites and should be avoided in patients with known intolerance;
OB: Obstetrical paracervical block anesthesia.

Use Cautiously in:

Glucose-6-phosphate dehydrogenase deficiency; history of methemoglobinemia, cardiac, or pulmonary disease; or concurrent exposure to oxidizing agents (or metabolites of these agents) (↑ risk of methemoglobinemia);
Concurrent use of other local anesthetics;
Hepatic impairment;
Concurrent use of anticoagulants (including low-dose heparin and low-molecular-weight heparins/heparinoids) ↑ the risk of spinal/epidural hematomas;
Hypotension or heart block;
Pedi: Infants <6 mo (↑ risk of methemoglobinemia); children <12 yr (safety not established).

Adv. Reactions/Side Effects ⬆ ⬇

CV: arrhythmias, bradycardia, CARDIOVASCULAR COLLAPSE, hypotension

Derm: pruritus

EENT: blurred vision, tinnitus

F and E: metabolic acidosis

GI: nausea, vomiting

GU: urinary retention

Hemat: methemoglobinemia

Neuro: anxiety, circumoral tingling/numbness, dizziness, dysgeusia, headache, irritability, SEIZURES, tremor

Misc: fever, allergic reactions

Interactions ⬆ ⬇

Drug-drug:

Additive toxicity may occur with concurrent use of other amide local anesthetics, including lidocaine, mepivacaine, and prilocaine.
Concurrent use of acetaminophen, benzocaine, chloroquine, cyclophosphamide, dapsone, flutamide, hydroxyurea, ifosfamide, metoclopramide, nitrofurantoin, nitroglycerin, nitroprusside, nitrous oxide, phenobarbital, phenytoin, prilocaine, primaquine, procaine, quinine, rasburicase, ropivacaine, sulfonamides, tetracaine, and valproate may ↑ risk of methemoglobinemia; monitor closely.
Use of solution containing epinephrine with MAO inhibitors may cause hypertension.

Route/Dosage ⬆ ⬇

Solutions containing preservatives should not be used for caudal or epidural blocks.
Epidural (Adults and Children >12 yr): 10–20 mL of 0.25% (partial to moderate block), 0.5% (moderate to complete block), or 0.75% (complete block) solution. Administer in increments of 3–5 mL allowing sufficient time to detect toxic signs/symptoms of inadvertent IV or IT administration. A test dose of 2–3 mL of 0.5% with epinephrine solution is recommended prior to epidural blocks.
Caudal block(Adults and Children >12 yr): 15–30 mL of 0.25% or 0.5% solution. A test dose of 2–3 mL of 0.5% with epinephrine solution is recommended prior to caudal blocks.
Peripheral nerve block(Adults and Children >12 yr): 5 mL of 0.25% or 0.5% solution (maximum dose = 400 mg).
Sympathetic nerve block(Adults and Children >12 yr): 20–50 mL of 0.25% solution.
Dental block(Adults and Children >12 yr): 1.8–3.6 mL per site of 0.5% with epinephrine solution.
Local infiltration(Adults and Children >12 yr): 0.25% solution infiltrated locally (maximum dose = 175 mg).

Availability ⬆ ⬇

(Generic available)

Solution for injection (with and without preservatives): 0.25%; 0.5%; 0.75%
In combination with:
epinephrine 1:200,000; meloxicam (Zynrelef Kit). See Combination Drugs.

Assessment ⬆ ⬇

Monitor for sensation during procedure and return of sensation after procedure.
Monitor BP, HR, and respiratory rate continuously while patient is receiving this medication.
Monitor for ECG changes in those with impaired cardiovascular function (hypotension, heart block) who may be less able to compensate for functional changes associated with bupivacaine associated atrioventricular conduction prolongation.
Monitor for signs and symptoms of methemoglobinemia (cyanotic skin discoloration, abnormal coloration of blood). Methemoglobin levels may continue to rise, requiring immediate treatment with oxygen therapy, hydration, methylene blue, exchange transfusion, hyperbaric oxygen, and removal of implant, depending on symptom severity.
Systemic Toxicity: Assess for systemic toxicity (circumoral tingling and numbness, ringing in ears, metallic taste, dizziness, blurred vision, tremors, slow speech, irritability, twitching, seizures, cardiac arrhythmias). Notify health care professional if symptoms occur.
Epidural: Monitor BP, HR, and respiratory rate continuously while patient is receiving this medication. Mild hypotension is common because of the effect of local anesthetic block of nerve fibers on the sympathetic nervous system, causing vasodilation. Significant hypotension and bradycardia may occur, especially when rising from a prone position or following large dose ↑ or boluses. Treatment of unresolved hypotension may include hydration, ↓ the epidural infusion rate, and/or removal of local anesthetic from analgesic solution.
Unwanted Motor and Sensory Deficit: The goal of adding low-dose local anesthetics to epidural opioids for pain management is to provide analgesia, not to produce anesthesia. Patients should be able to ambulate if their condition allows, and epidural analgesic should not hamper this important recovery activity. However, many factors, including location of the epidural catheter, local anesthetic dose, and variability in patient response, can result in patients experiencing unwanted motor and sensory deficits. Pain is the 1st sensation lost, followed by temperature, touch, proprioception, and skeletal muscle tone.
- Assess for sensory deficit every shift. Ask patient to point to numb and tingling skin areas (numbness and tingling at the incision site is common and usually normal). Notify health care professional of unwanted motor and sensory deficits.
- Unwanted motor and sensory deficits often can be corrected with simple treatment. For example, a change in position may relieve temporary sensory loss in an extremity. Minor extremity muscle weakness is often treated by ↓ the epidural infusion rate and keeping the patient in bed until the weakness resolves. Sometimes removing the local anesthetic from the analgesic solution is necessary, such as when signs of local anesthetic toxicity are detected or when simple treatment of motor and sensory deficits has been unsuccessful.

Implementation ⬆ ⬇

Bupivacaine is ready to use and does not require dilution or mixing. Do not dilute or mix with local anesthetics or other drugs or diluents.
Do not confuse bupivacaine with ropivacaine.

Patient/Family Teaching ⬆ ⬇

Explain the purpose and side effects of bupivacaine to patient.
Instruct patient to notify health care professional if signs or symptoms of systemic toxicity occur.
Advise patient to request assistance during ambulation until orthostatic hypotension and motor deficits are ruled out.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
Rep: Advise women of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Bupivacaine use has resulted in fetal bradycardia and death; its use is not recommended for use in obstetrical anesthesia. If used after risk/benefit analysis, monitor the fetal HR continuously during labor and delivery.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇