Bupivacaine Hydrochloride

Pronunciation

Class: Local Anesthetics
CAS Number: 14252-80-3
Brands: Marcaine, Marcaine Spinal, Marcaine Hydrochloride with Epinephrine, Sensorcaine, Sensorcaine-MPF, Sensorcaine-MPF Spinal, Sensorcaine with Epinephrine, Sensorcaine-MPF with Epinephrine

Warning(s)

  • Use of the 0.75% solution of bupivacaine hydrochloride not recommended for obstetrical epidural anesthesia.211 212 Cardiac arrest with difficult resuscitation or death reported in patients receiving bupivacaine hydrochloride (generally the 0.75% concentration) for obstetrical epidural anesthesia.211 212

  • Reserve 0.75% solution for surgical procedures that require a high degree of muscle relaxation and prolonged anesthetic effect.211

Introduction

Long-acting local anesthetic (amide type).211 212 a

Uses for Bupivacaine Hydrochloride

Local or Regional Anesthesia

Local or regional anesthesia or analgesia in surgical procedures (including oral surgery), diagnostic and therapeutic procedures, and obstetrical procedures.211 212

Slideshow: 2014 Update: First Time Brand-to-Generic Switches

Bupivacaine Hydrochloride Dosage and Administration

General

  • Determine dosage based on type and extent of surgical procedure, area to be anesthetized, vascularity of tissues, number of neuronal segments to be blocked, depth and duration of anesthesia, degree of muscular relaxation, individual tolerance, and physical condition of the patient.211 212 Use smallest dose required to produce the desired effect.211 212

  • During major regional nerve blocks, administer IV fluids via an indwelling catheter to ensure a functioning IV pathway.211 212

Administration

Injection

For solution and drug compatibility information, see Compatibility under Stability.

Administer by local infiltration, peripheral nerve block, retrobulbar block, sympathetic block, lumbar epidural block, caudal block, or subarachnoid (spinal) block.211 212 IV regional anesthesia (Bier block) not recommended due to risk of cardiac arrest and death.211 Has been administered by continuous intra-articular infusion (e.g., for control of postoperative pain); however, such use associated with chondrolysis.200 201 202 203 204 205 206 207 208 209 211 212 213 214 (See Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics under Cautions.)

Consult specialized references for specific techniques and procedures for administering local anesthetics.211 212

Avoid rapid injection of large volumes; when feasible, administer in fractional (incremental) doses.211 Aspirate prior to injections to avoid intravascular administration and to either confirm entry into the subarachnoid space (for spinal anesthesia) or avoid inadvertent subarachnoid injection.211 212 215

For caudal or epidural block, use single-dose ampuls or vials only.211 Do not use multiple-dose vials containing antimicrobial preservatives (e.g., methylparaben), since safety of intrathecal administration using these preparations not established.211

For chemical disinfection of container surface, moisten cotton or gauze with isopropyl (rubbing) alcohol (91%) or ethyl alcohol (70%) and wipe ampul or vial stopper thoroughly just prior to use.211

Dosage

Available as bupivacaine hydrochloride, as fixed combination containing bupivacaine hydrochloride and epinephrine bitartrate, and as bupivacaine hydrochloride in dextrose injection.211 212 Dosage expressed in terms of bupivacaine hydrochloride.212

Pediatric Patients

Local or Regional Anesthesia
Local Infiltration, Peripheral/Sympathetic Nerve Block, Lumbar Epidural/Caudal Block

Children ≥12 years of age: Use lower dosages than those suggested for healthy adults (see Adults under Dosage and Administration).211

Adults

Local or Regional Anesthesia
Local Infiltration

Administer bupivacaine hydrochloride 0.25% solution (with or without epinephrine) at dosages up to maximum dosage (see Prescribing Limits under Dosage and Administration).211

Lumbar Epidural Block

Prior to lumbar epidural anesthesia, administer test dose to detect accidental intravascular injection.211 Test dose should contain 10–15 mcg epinephrine (when clinical conditions permit) and 10–15 mg (2–3 mL) of 0.5% bupivacaine hydrochloride (or equivalent dose of a short-acting amide type local anesthetic such as 30–40 mg of lidocaine hydrochloride).211 Following injection of test dose, monitor for increase in heart rate.211

0.75% solution is for single-dose use; not for intermittent epidural technique.211 Reserve for surgical procedures requiring a high degree of muscle relaxation and prolonged anesthetic effect.211

0.75% solution is not for obstetrical anesthesia; in obstetrics, use 0.25 or 0.5% solutions only.211 (See Boxed Warning and see Risks Associated with Obstetrical Use of Bupivacaine Hydrochloride 0.75% Injection under Cautions.)

75–150 mg (10–20 mL) of bupivacaine hydrochloride 0.75% solution (with or without epinephrine) produces complete motor blockade.211 Administer in incremental doses of 3–5 mL.211 Allow sufficient time between doses to detect toxic manifestations of unintentional intravascular or intrathecal injection.211

50–100 mg (10–20 mL) of bupivacaine hydrochloride 0.5% solution (with or without epinephrine) produces moderate to complete motor blockade.211 Administer in incremental doses of 3–5 mL.211 Allow sufficient time between doses to detect toxic manifestations of unintentional intravascular or intrathecal injection.211

25–50 mg (10–20 mL) of bupivacaine hydrochloride 0.25% solution (with or without epinephrine) produces partial motor blockade.211

Caudal Block

75–150 mg (15–30 mL) of bupivacaine hydrochloride 0.5% solution (with or without epinephrine) produces moderate to complete motor blockade.211

37.5–75 mg (15–30 mL) of bupivacaine hydrochloride 0.25% solution (with or without epinephrine) produces moderate motor blockade.211

Peripheral Nerve Block

25 mg (5 mL) to maximum dosage (see Prescribing Limits under Dosage and Administration) of bupivacaine hydrochloride 0.25% solution (with or without epinephrine) produces moderate to complete motor blockade.211

12.5 mg (5 mL) to maximum dosage (see Prescribing Limits under Dosage and Administration) of bupivacaine hydrochloride 0.5% solution (with or without epinephrine) produces moderate to complete motor blockade.211

Retrobulbar Block

15–30 mg (2–4 mL) of bupivacaine hydrochloride 0.75% solution (with or without epinephrine) produces complete motor blockade.211

Sympathetic Block

50–125 mg (20–50 mL) of bupivacaine hydrochloride 0.25% solution.211

Anesthesia in Maxillary and Mandibular Area (for oral surgery)

9 mg (1.8 mL) up to 90 mg (18 mL) of bupivacaine hydrochloride 0.5% solution per dental sitting.215 a

Subarachnoid (Spinal) Block for Vaginal Delivery

6 mg (0.8 mL) of bupivacaine hydrochloride 0.75% in dextrose 8.25% injection produces complete motor and sensory block.212

Subarachnoid (Spinal) Block for Cesarean Section

7.5–10.5 mg (1–1.4 mL) of bupivacaine hydrochloride 0.75% in dextrose 8.25% injection produces complete motor and sensory block.212

Subarachnoid (Spinal) Block for Lower Extremity and Perineal Procedures (e.g., TURP, vaginal hysterectomy)

7.5 mg (1 mL) of bupivacaine hydrochloride 0.75% in dextrose 8.25% injection produces complete motor and sensory block.212

Subarachnoid (Spinal) Block for Lower Abdominal Procedures (e.g., abdominal hysterectomy, tubal ligation, appendectomy)

12 mg (1.6 mL) of bupivacaine hydrochloride 0.75% in dextrose 8.25% injection produces complete motor and sensory block.212

Prescribing Limits

Adults

Local or Regional Anesthesia
Local Infiltration, Peripheral/Sympathetic Nerve Block, Lumbar Epidural/Caudal Block

Most experience to date has involved single doses up to 175 mg (without epinephrine) or 225 mg (with epinephrine 1:200,000).211

Maximum 400 mg in any 24-hour period.211

Special Populations

Hepatic Impairment

Reduce dosage in patients with hepatic impairment.211 212

Geriatric Patients

Reduce dosage in geriatric patients.211 212 215

Other Populations

Reduce dosage in patients with cardiac disease, debilitated patients, and acutely ill patients.211 212 215 Also reduce dosage in patients with increased intra-abdominal pressure (including obstetrical patients) undergoing spinal anesthesia.212

Cautions for Bupivacaine Hydrochloride

Contraindications

  • Bupivacaine hydrochloride used for obstetrical paracervical block (this technique has resulted in fetal bradycardia and death).211

  • Contraindications to spinal anesthesia: severe hemorrhage, severe hypotension or shock, arrhythmias (e.g., complete heart block) that severely restrict cardiac output, local infection at site of lumbar puncture, and septicemia.212

  • Known hypersensitivity to bupivacaine, other local anesthetics of the amide type, sodium metabisulfite, or any ingredients in the formulation.

Warnings/Precautions

Warnings

Risks Associated with Obstetrical Use of Bupivacaine Hydrochloride 0.75% Injection

Risk of seizures, cardiac arrest, difficult resuscitation, or death following obstetrical epidural block (possibly due to systemic toxicity secondary to unintentional intravascular injection).211

Not recommended for obstetrical anesthesia.211 Reserve for surgical procedures requiring a high degree of muscle relaxation and prolonged anesthetic effect.211

Experience of Supervising Clinician

Should be used only by clinicians who are sufficiently knowledgeable in the diagnosis and management of dose-related toxicity and other acute emergencies that might arise.211 212 215 Oxygen, resuscitative equipment, drugs, and personnel required for treatment of adverse reactions must be immediately available.211 212 215 Delay in proper management of dose-related toxicity may result in acidosis, cardiac arrest, and, possibly, death.211 212 215

Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics

Chondrolysis (necrosis and destruction of articular cartilage) reported in patients receiving continuous intra-articular infusions of local anesthetics, administered for 48–72 hours via elastomeric infusion devices, for treatment of postoperative pain.200 201 202 203 204 205 206 207 208 209 211 212 213 214 Primarily observed in the shoulder joint following arthroscopic or other shoulder surgery.200 211 212 213 214 May result in long-term disability; often requires intervention (e.g., debridement, arthroplasty).200 202 203 204 205 206 209 211 212 213 214 Not known whether the drug, infusion device, and/or other factors contributed to the development of chondrolysis.200 201 Neither local anesthetics nor elastomeric infusion devices are approved for use for continuous intra-articular infusion therapy.200 201 211 212 213 214

Accidental Intravascular Injection

Accidental intravascular injection may result in confusion, seizures, CNS excitement and/or depression, myocardial depression, coma, and/or respiratory arrest.211 212 (See CNS Effects and also see Cardiovascular Effects, under Cautions.)

Aspirate prior to administration to guard against intravascular injection.211 212

Injection During Uterine Contractions

Do not inject spinal anesthetics during uterine contractions, since spinal fluid current may carry drug further cephalad than desired.212

Epinephrine Administration

Some bupivacaine hydrochloride preparations contain epinephrine, which may cause ischemic injury or necrosis.211 212 Consider usual precautions associated with epinephrine administration.211 212 (See Cardiovascular Effects under Cautions.)

Sensitivity Reactions

Hypersensitivity Reactions and Cross Hypersensitivity

Allergic reactions are rare.

Possible urticaria, pruritus, erythema, angioedema (including laryngeal edema), tachycardia, sneezing, nausea, vomiting, dizziness, syncope, excessive sweating, elevated temperature, and anaphylactoid reactions (including severe hypotension).211 212

Cross hypersensitivity between amide-type local anesthetics reported.211 212

Sulfite Sensitivity

Some epinephrine-containing bupivacaine preparations contain sodium metabisulfite, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.211

General Precautions

CNS Effects

Toxic plasma concentrations of local anesthetics (resulting from systemic absorption) associated with adverse CNS effects (e.g., restlessness, anxiety, dizziness, tinnitus, blurred vision, tremors, drowsiness, seizures).211 212

Carefully monitor level of consciousness after each local anesthetic injection.211 212

Cardiovascular Effects

Toxic plasma concentrations of local anesthetics (resulting from systemic absorption) associated with adverse cardiovascular effects (e.g., decreased cardiac output, heart block, hypotension, bradycardia, ventricular arrhythmias, cardiac arrest).211 212 Carefully monitor cardiovascular and respiratory vital signs after each local anesthetic injection.211 212

Use with caution in patients with impaired cardiovascular function, hypotension, or heart block.211 212

Possible peripheral vasodilation and hypotension following spinal anesthesia; monitor BP carefully, particularly in early phases of anesthesia.212 Use spinal anesthesia with caution in patients with severe disturbances of cardiac rhythm, shock, or heart block.212

Some bupivacaine hydrochloride preparations contain epinephrine; risk of exaggerated vasoconstrictor response in patients with hypertensive vascular disease.211 Use with caution and in carefully restricted quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply (e.g., digits, nose, external ear, penis).211

Familial Malignant Hyperthermia

Many drugs used during the conduct of anesthesia may trigger familial malignant hyperthermia; not known whether amide-type local anesthetics trigger this reaction.211 212 However, standard protocol for management should be available.211 212 Early unexplained signs of tachycardia, tachypnea, labile BP, and metabolic acidosis may precede temperature elevation.211 212 If familial malignant hyperthermia is confirmed, discontinue triggering agent and initiate appropriate therapy (e.g., oxygen, dantrolene) and other supportive measures.211 212

Preexisting Conditions Precluding Use of Spinal Anesthesia

Conditions that may preclude the use of spinal anesthesia (depending upon the clinician’s evaluation of the situation and ability to manage potential complications) include preexisting CNS disease (e.g., disease associated with pernicious anemia, poliomyelitis, syphilis, tumor); hematological disorders predisposing to coagulopathies; current anticoagulant therapy; chronic backache; preoperative headache; hypotension or hypertension; technical problems (persistent paresthesias, persistent bloody tap); arthritis or spinal deformity; extremes of age; and psychosis or other causes of poor patient cooperation.212

Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Specific Populations

Pregnancy

Category C.211 212

Labor and Delivery

Maternal hypotension reported.211 212 To prevent decreases in BP, elevate patient’s legs and position patient on her left side.211 212 Monitor fetal heart rate continuously; electronic fetal monitoring highly advisable.211 212

Epidural anesthesia may prolong second stage of labor (by removing parturient’s reflex urge to bear down or by interfering with motor function); may increase need for forceps assistance.211 212

Possible diminished muscle strength and tone on neonate’s first or second day of life.211 212

Lactation

Distributed into milk.211 Discontinue nursing or the drug.211

Pediatric Use

Bupivacaine hydrochloride injection with or without epinephrine not recommended in children <12 years of age.211 IV infusion associated with high plasma concentrations and seizures; high plasma concentrations associated with adverse cardiovascular effects.211

Bupivacaine hydrochloride in dextrose injection not recommended in children <18 years of age.212

Geriatric Use

Increased risk of hypotension, particularly in patients with hypertension.211 Dosage adjustments recommended.211 212

Possible increased risk of toxicity in geriatric patients with renal impairment; monitor renal function.211

Hepatic Impairment

Possible increased risk of toxicity, particularly in patients with severe hepatic impairment.211 212 Use with caution.211 212 Dosage adjustments recommended.211 212

Renal Impairment

Possible increased risk of toxicity.211

Common Adverse Effects

Adverse CNS and cardiovascular effects, respiratory paralysis, underventilation.211 212 (See CNS Effects and also see Cardiovascular Effects, under Cautions.)

Interactions for Bupivacaine Hydrochloride

Consider usual drug interactions associated with epinephrine administration.211 212

Specific Drugs

Drug

Interaction

Comments

Anesthetics, general

Possible serious cardiac arrhythmias due to epinephrine component211 212

 

Antidepressants, tricyclics

Possible severe, prolonged hypertension due to epinephrine component211 212

Avoid concomitant use;211 212 if must be used concomitantly, careful monitoring is required211 212

Butyrophenones

Possible reduction or reversal of pressor effect of epinephrine211 212

 

Ergot alkaloid oxytocics (ergonovine, methylergonovine)

Possible severe, persistent hypertension or cerebrovascular accidents due to epinephrine component211 212

Avoid concomitant use212

MAO inhibitors

Possible severe, prolonged hypertension due to epinephrine component211 212

Avoid concomitant use;211 212 if must be used concomitantly, careful monitoring is required211 212

Phenothiazines

Possible reduction or reversal of pressor effect of epinephrine211 212

Avoid concomitant use;211 212 if must be used concomitantly, careful monitoring is required211 212

Bupivacaine Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Systemic absorption dependent upon total dose and concentration administered, route of administration, vascularity of administration site, and presence or absence of epinephrine in formulation.211 212

Peak blood concentrations achieved approximately 30–45 minutes following injection for caudal, epidural, or peripheral nerve block.211

Onset

Onset within 2–10 minutes following local infiltration or nerve block (for dental anesthesia) with 0.5% solution.215 a

Onset within 4–17 minutes following epidural, caudal, peripheral, or sympathetic block with 0.25 or 0.5% solution.a More rapid onset following epidural block with 0.75% solution.a

Following 12-mg injection for spinal block, sensory blockade occurs within 1 minute; motor blockade occurs within 15 minutes.212

Duration

Longer duration of anesthesia compared with other commonly used local anesthetics.211 212

Duration of up to 7 minutes following local infiltration or nerve block (for dental anesthesia) with 0.5% solution.215 a

Duration of 3–7 minutes following epidural, caudal, peripheral, or sympathetic block with 0.25 or 0.5% solution.a Slightly longer duration (6–9 hours) with 0.75% solution.a

Following a 12-mg injection for spinal block, sensory blockade persists for 2 hours (with or without 0.2 mg epinephrine); motor blockade persists for 3.5 hours (without epinephrine) or 4.5 hours (with 0.2 mg epinephrine).212 Similar duration of sensory blockade but shorter duration of motor blockade compared with mg-equivalent dose of tetracaine.212

Special Populations

Increased peak plasma concentrations in geriatric patients.211 Maximal spread of analgesia and maximal motor blockade achieved more rapidly than in younger patients.211

Distribution

Extent

Local anesthetics are distributed to some extent to all body tissues, with high concentrations found in highly perfused organs (e.g., liver, lungs, heart, brain).211 212

Lower degree of placental transmission than other parenteral local anesthetics.a Distributed into milk.211

Plasma Protein Binding

95%.211 212

Elimination

Metabolism

Systemically absorbed bupivacaine is metabolized in the liver via conjugation with glucuronic acid.211 212

Elimination Route

Excreted principally in urine as inactive metabolites and small amounts (6%) of unchanged drug.211 212

Half-life

Approximately 2.7–3.5 hours (in adults) or 8.1 hours (in neonates).211 212

Special Populations

Decreased total plasma clearance in geriatric patients.211

Stability

Storage

Parenteral

Injection

20–25°C.211 212 215 If preparation contains epinephrine, protect from light.211 215

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Compatible

Sodium chloride 0.9%

Drug Compatibility

Do not mix with other local anesthetics (insufficient clinical data).211 212

Admixture CompatibilityHID

Compatible

Buprenorphine HCl

Clonidine HCl with fentanyl citrate

Fentanyl citrate

Hydromorphone HCl

Morphine sulfate

Sufentanil citrate

Ziconotide acetate

Syringe CompatibilityHID

Compatible

Clonidine HCl

Clonidine HCl with fentanyl citrate

Clonidine HCl with morphine sulfate

Hydromorphone HCl

Ketamine with fentanyl citrate

Morphine sulfate

Variable

Sodium bicarbonate

Actions

  • Local anesthetics block the generation and conduction of nerve impulses by increasing the threshold for electrical excitation, slowing the propagation of the nerve impulse, and reducing the rate of rise of the action potential.211 212

  • Bupivacaine exhibits analgesic effects that persist after return of sensation; thus need for strong analgesics is reduced.211 212

  • Some preparations formulated with epinephrine to decrease bupivacaine’s rate and extent of systemic absorption and to prolong its duration of action.211

  • Has long duration of action.211 212

Advice to Patients

  • Prior to administration, advise patients of the possibility of temporary loss of sensation and muscle function (e.g., in lower half of body following caudal, lumbar epidural, or subarachnoid block).211 212

  • Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular or liver disease).211 212

  • Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.211 212

  • Importance of informing patients of other important precautionary information.211 212 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Bupivacaine Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

0.25%*

Bupivacaine Hydrochloride Injection

Marcaine Hydrochloride

Hospira

Sensorcaine

APP Pharmaceuticals

Sensorcaine-MPF

APP Pharmaceuticals

0.5%*

Bupivacaine Hydrochloride Injection

Marcaine Hydrochloride

Hospira

Sensorcaine

APP Pharmaceuticals

Sensorcaine-MPF

APP Pharmaceuticals

0.75%*

Bupivacaine Hydrochloride Injection

Marcaine Hydrochloride

Hospira

Sensorcaine-MPF

APP Pharmaceuticals

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Bupivacaine Hydrochloride in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

0.75% in 8.25% Dextrose*

Bupivacaine Spinal

Marcaine Spinal

Hospira

Sensorcaine-MPF Spinal

APP Pharmaceuticals

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Bupivacaine Hydrochloride Combinations

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

0.25% with Epinephrine Bitartrate 1:200,000 (of epinephrine)*

Bupivacaine Hydrochloride and Epinephrine

Marcaine Hydrochloride with Epinephrine

Hospira

Sensorcaine with Epinephrine

APP Pharmaceuticals

Sensorcaine-MPF with Epinephrine

APP Pharmaceuticals

0.5% with Epinephrine Bitartrate 1:200,000 (of epinephrine)*

Bupivacaine Hydrochloride and Epinephrine

Marcaine Hydrochloride with Epinephrine

Hospira

Sensorcaine with Epinephrine

APP Pharmaceuticals

Sensorcaine-MPF with Epinephrine

APP Pharmaceuticals

0.75% with Epinephrine Bitartrate 1:200,000 (of epinephrine)

Sensorcaine-MPF with Epinephrine

APP Pharmaceuticals

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions June 18, 2013. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

200. Food and Drug Administration. Information for healthcare professionals: Chondrolysis reported with continuously infused local anesthetics (marketed as bupivacaine, chloroprocaine, lidocaine, mepivacaine, procaine, and ropivacaine). Rockville, MD; Updated 2010 Feb 16. From FDA website ().

201. Todd JF. Chondrolysis linked to intra-articular infusions. Medical Devices Alerts and Notices. Silver Spring, MD: Food and Drug Administration; 2010 June. From FDA website ().

202. Hansen BP, Beck CL, Beck EP et al. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007; 35:1628-34. [PubMed 17609526]

203. Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009 Sep-Oct; 18:742-7.

204. Anakwenze OA, Hosalkar H, Huffman GR. Case Reports: Two Cases of Glenohumeral Chondrolysis after Intraarticular Pain Pumps. Clin Orthop Relat Res. 2010; :.

205. Anderson SL, Buchko JZ, Taillon MR et al. Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases. Arthroscopy. 2010; 26:451-61. [PubMed 20362823]

206. Rapley JH, Beavis RC, Barber FA. Glenohumeral chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion. Arthroscopy. 2009; 25:1367-73. [PubMed 19962061]

207. Scheffel PT, Clinton J, Lynch JR et al. Glenohumeral chondrolysis: A systematic review of 100 cases from the English language literature. J Shoulder Elbow Surg. 2010; :. [PubMed 20421168]

208. Ballieul RJ, Jacobs TF, Herregods S et al. The peri-operative use of intra-articular local anesthetics: a review. Acta Anaesthesiol Belg. 2009; 60:101-8. [PubMed 19594092]

209. Busfield BT, Romero DM. Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis. Arthroscopy. 2009; 25:647-52. [PubMed 19501296]

211. APP Pharmaceuticals. Sensorcaine (bupivacaine hydrochloride injection, USP), Sensorcaine-MPF (bupivacaine hydrochloride injection, USP), Sensorcaine with epinephrine (bupivacaine hydrochloride and epinephrine injection, USP), and Sensorcaine-MPF with epinephrine (bupivacaine hydrochloride and epinephrine injection, USP) prescribing information. Schaumburg, IL; 2010 Feb.

212. APP Pharmaceuticals. Sensorcaine-MPF spinal injection (bupivacaine hydrochloride in dextrose injection, USP) prescribing information. Schaumburg, IL; 2010 Feb.

213. Hospira. Marcaine (bupivacaine hydrochloride injection, USP), Marcaine with epinephrine (bupivacaine hydrochloride and epinephrine injection, USP) prescribing information. Lake Forest, IL; 2009 Nov.

214. Hospira. Marcaine Spinal (bupivacaine hydrochloride in dextrose injection, USP) prescribing information. Lake Forest, IL; 2009 Nov.

215. Hospira. Bupivacaine hydrochloride and epinephrine injection prescribing information. Lake Forest, IL; 2006 Nov.

a. AHFS drug information 2011. McEvoy GK, ed. Bupivacaine Hydrochloride. Bethesda, MD: American Society of Health-System Pharmacists; 2011; e-pub ahead of print.

HID. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013:163-7.

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