Bupivacaine Dosage

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Usual Adult Dose for:

Usual Pediatric Dose for:

Additional dosage information:

Usual Adult Dose for Local Anesthesia

Bupivacaine: Most experience to date is with single doses up to 175 mg; more or less drug may be used to individualize dose

Doses may be repeated up to once every 3 hours.
Maximum dose: 400 mg per 24 hours

Local infiltration:
0.25% concentration: Inject up to the maximum dose

Epidural block:
0.75% concentration: Inject 75 to 150 mg (10 to 20 mL) once for complete motor block; not for obstetrical anesthesia
0.5% concentration: Inject 50 to 100 mg (10 to 20 mL) for moderate to complete motor block; repeat doses increase the degree of motor block
0.25% concentration: Inject 25 to 50 mg (10 to 20 mL) for partial to moderate motor block; repeat doses increase the degree of motor block

Epidural anesthesia: 0.5% and 0.75% solutions should be administered in 3 to 5 mL increments with sufficient time between doses to detect toxicity or accidental intravascular or intrathecal injection

Epidural anesthesia in obstetrics: Only 0.5% and 0.25% concentrations should be used; 0.5% solution should be administered in 3 to 5 mL increments not exceeding 50 to 100 mg at any dosing interval; repeat doses should follow a test dose containing epinephrine if not contraindicated; preservative-free product should be used

Caudal block:
0.5% concentration: Inject 75 to 150 mg (15 to 30 mL) for moderate to complete motor block; repeat doses increase the degree of motor block
0.25% concentration: Inject 37.5 to 75 mg (15 to 30 mL) for moderate motor block; repeat doses increase the degree of motor block

Peripheral nerve block:
0.5% concentration: Inject 25 mg up to the maximum dose (5 mL up to the maximum dose) for moderate to complete motor block; repeat doses increase the degree of motor block
0.25% concentration: Inject 12.5 mg up to the maximum dose (5 mL up to the maximum dose) for moderate to complete motor block; repeat doses increase the degree of motor block

Retrobulbar block:
0.75% concentration: Inject 15 to 30 mg (2 to 4 mL) for complete motor block; repeat doses increase the degree of motor block

Sympathetic block:
0.25% concentration: Inject 50 to 125 mg (20 to 50 mL)

Bupivacaine in dextrose injection:
Spinal anesthesia: Inject 7.5 mg (1 mL) for lower extremity and perineal procedures (including transurethral resection of the prostate and vaginal hysterectomy); 12 mg (1.6 mL) has been used for lower abdominal procedures (such as abdominal hysterectomy, tubal ligation, and appendectomy); doses as low as 6 mg have been used for vaginal delivery

These dosages are recommended as a guide for use in an average adult.

Usual Adult Dose for Cesarean Section

Bupivacaine in dextrose injection:
Spinal anesthesia: 7.5 to 10.5 mg (1 to 1.4 mL) has been used

Usual Pediatric Dose for Local Anesthesia

Bupivacaine:

Epidural block:
1.25 mg/kg/dose (preservative free)

Caudal block:
1 to 3.7 mg/kg (preservative free)

Peripheral nerve block: 5 mL dose of 0.25% or 0.5% (12.5 to 25 mg); maximum dose: 400 mg/day.

Sympathetic nerve block: 20 to 50 mL of 0.25% (no epinephrine) solution.

Continuous epidural (caudal or lumbar) infusion (preservative free):
:

Loading dose: 2 to 2.5 mg/kg (0.8 to 1 mL/kg of 0.25% bupivacaine).

Infusion dose: Infants 4 months or younger: 0.2 to 0.25 mg/kg/h; Infants older than 4 months and children: 0.4 to 0.5 mg/kg/h.

Bupivacaine in dextrose injection: Not recommended in pediatric patients less than 18 years of age.

Renal Dose Adjustments

Data not available

Liver Dose Adjustments

Dosages of bupivacaine should be reduced for patients with liver disease.

Dose Adjustments

Dosages of bupivacaine should be reduced for elderly and/or debilitated patients and patients with cardiac disease.

Precautions

Bupivacaine is contraindicated in obstetrical paracervical block anesthesia. Bupivacaine in dextrose injection is contraindicated in patients with severe hemorrhage, severe hypotension or shock, arrhythmias (such as complete heart block) which severely restrict cardiac output, local infection at the site of proposed lumbar puncture, and septicemia.

The 0.75% concentration of bupivacaine is not recommended for obstetrical anesthesia. There have been reports of cardiac arrest with difficult resuscitation or death during epidural anesthesia in obstetrical patients, in most cases following the use of the 0.75% concentration of bupivacaine. Cardiac arrest has occurred following convulsions resulting from systemic toxicity, presumably after accidental intravascular injection. The 0.75% concentration should be saved for use when a high level of muscle relaxation and prolonged effect are required during surgery.

Bupivacaine should not be used for intravenous regional anesthesia (Bier Block).

Bupivacaine should only be used by clinicians well versed in the potential toxicities that may occur with local anesthetics and the management of those toxicities. Adequate oxygen, resuscitative equipment and personnel resources should be immediately available prior to the administration of any local anesthetic.

Spinal anesthetics should not be injected during uterine contractions because the drug may be carried further than desired via spinal fluid current.

The general condition of the patient should be optimized and an intravenous line inserted prior to receiving major blocks. All necessary precautions should be taken to prevent intravascular injection.

The lowest dosage of local anesthetic that results in effective anesthesia should be used to avoid high plasma levels and serious adverse effects. The rapid injection of a large volume of local anesthetic solution should be avoided. Bupivacaine should be dosed in increments when possible.

Repeated doses of local anesthetics may cause significant increases in plasma levels due to slow accumulation or slow metabolic degradation. Tolerance to elevated blood levels varies with the status of the patient. Debilitated, elderly, and acutely ill patients should be given reduced doses appropriate for their age and physical status. Local anesthetics should be used with caution in patients with hypotension or heart block. Spinal anesthetics should be used with caution in patients with severe disturbances of cardiac rhythm, shock or heart block.

Careful and constant monitoring of cardiovascular and respiratory vital signs and the patient's state of consciousness is recommended after each local anesthetic injection. Restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, twitching, depression, or drowsiness may be early warning signs of central nervous system toxicity.

Bupivacaine should be used cautiously in patients with liver disease and cardiovascular abnormalities. Patients with liver disease may not be able to adequately metabolize bupivacaine for excretion increasing the risk for toxic plasma concentrations. Additionally, patients with cardiovascular disease may not be able to compensate for the functional changes associated with the prolongation of atrioventricular conduction induced by amide-type local anesthetics.

Caution is recommended when bupivacaine is used for local anesthesia in the head and neck area. Dosage recommendations should not be exceeded.

Local anesthetics containing antimicrobial preservatives should not be used for epidural or caudal anesthesia. The safety of intrathecal injection of such preservatives has not been established.

Aspiration for blood or cerebrospinal fluid is recommended prior to injecting any local anesthetic, both the original dose and all subsequent doses, to avoid intravascular or subarachnoid injection. However, a negative aspiration does not ensure against an intravascular or subarachnoid injection.

Mixing or the prior or intercurrent use of other local anesthetics with bupivacaine is not recommended due to insufficient data on the clinical use of such mixtures.

Safety and effectiveness of bupivacaine have not been established in pediatric patients less than 12 years of age. Safety and effectiveness of bupivacaine with dextrose have not been established in pediatric patients less than 18 years of age.

Dialysis

Data not available

Other Comments

The dose of any local anesthetic administered varies with the anesthetic procedure, the area to be anesthetized, the vascularity of the tissues, the number of neuronal segments to be blocked, the depth of anesthesia and degree of muscle relaxation needed, the duration of anesthesia desired, individual tolerance, and the physical condition of the patient. The lowest dosage and concentration that results in desired anesthesia should be used.

Bupivacaine produces complete sensory block at recommended doses, but the effect on motor function differs among the 3 concentrations.

0.25% concentration: Produces partial motor block when used for caudal, epidural, or peripheral nerve block. Should be used for surgeries in which muscle relaxation is not essential, or when muscle relaxation is provided through other means. Onset of action may be slower than with the 0.5% or 0.75% solutions.

0.5% concentration: Provides motor blockade for caudal, epidural, or nerve block, but muscle relaxation may be insufficient for surgeries in which complete muscle relaxation is needed.

0.75% concentration: Produces complete motor block. It is most useful for epidural block in abdominal surgeries requiring total muscle relaxation and for retrobulbar anesthesia. Not for obstetrical anesthesia.

The anesthetic duration of bupivacaine is such that a single dose is adequate for most indications.

Bupivacaine in dextrose injection for spinal anesthesia produces complete sensory and motor block at recommended doses.

For bupivacaine administration, standard textbooks should be consulted for specific techniques and procedures.

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