Bupivacaine / Epinephrine Dosage

Applies to the following strengths: 0.25%-1:200,000; 0.5%-1:200,000; 0.75%-1:200,000; 0.25%-1:200,000 preservative-free; 0.5%-1:200,000 preservative-free; 0.75%-1:200,000 preservative-free

Usual Adult Dose for Local Anesthesia

Dental Block:
0.5% concentration: Inject 9 mg (1.8 mL) per injection site; a second dose of 9 mg (1.8 mL) may be used if needed to produce adequate anesthesia after allowing for 2 to 10 minutes onset time

Comments:

A single dose per injection site will usually suffice and only occasionally is a second dose needed.
The lowest effective dose should be used and adequate time allowed between injections.
The total dose for all injection sites spread out over a single dental sitting should not ordinarily exceed 90 mg for a healthy adult patient.

Use: For infiltration and block injection in the maxillary and mandibula area when a longer duration of local anesthetic action is desired (e.g., oral surgical procedures generally associated with significant postoperative pain)

Local Infiltration:
0.25% concentration: Inject up to maximum dose of bupivacaine (up to 400 mg/day have been studied in clinical studies and this dose should not be exceeded in 24 hours)

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

Caudal Block:
0.25% concentration: Inject 37.5 to 75 mg (15 to 30 mL) for moderate motor block
0.5% concentration: Inject 75 to 150 mg (15 to 30 mL) for moderate to complete motor block

Peripheral Nerve Block:
0.25% concentration: Inject 12.5 mg up to the maximum dose of bupivacaine (5 mL up to the maximum dose) for moderate to complete motor block
0.5% concentration: Inject 25 mg up to the maximum dose of bupivacaine (5 mL up to the maximum dose) for moderate to complete motor block

Retrobulbar Block:
0.75% concentration: Inject 15 to 30 mg (2 to 4 mL) for complete motor block

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

Epidural Test Dose:
0.5% concentration: Inject 10 to 15 mg (2 to 3 mL) bupivacaine (10 to 15 mcg epinephrine)

Comments:

Doses may be repeated up to once every 3 hours.
Most experience to date is with single doses up to 225 mg with epinephrine.
Clinical studies to date have included total daily doses up to 400 mg and this dose should not be exceeded in 24 hours.
The addition of epinephrine may prolong anesthetic effect.

Usual Pediatric Dose for Local Anesthesia

12 years or older:
Dental Block:
0.5% concentration: Inject 9 mg (1.8 mL) per injection site; a second dose of 9 mg (1.8 mL) may be used if needed to produce adequate anesthesia after allowing for 2 to 10 minutes onset time

Comments:

A single dose per injection site will usually suffice and only occasionally is a second dose needed.
The lowest effective dose should be used and adequate time allowed between injections.
The total dose for all injection sites spread out over a single dental sitting should not ordinarily exceed 90 mg for a healthy adult patient.

Use: For infiltration and block injection in the maxillary and mandibula area when a longer duration of local anesthetic action is desired (e.g., oral surgical procedures generally associated with significant postoperative pain)

12 years or older:

Local Infiltration:
0.25% concentration: Inject up to maximum dose of bupivacaine (up to 400 mg/day have been studied in clinical studies and this dose should not be exceeded in 24 hours)

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

Caudal Block:
0.25% concentration: Inject 37.5 to 75 mg (15 to 30 mL) for moderate motor block
0.5% concentration: Inject 75 to 150 mg (15 to 30 mL) for moderate to complete motor block

Peripheral Nerve Block:
0.25% concentration: Inject 12.5 mg up to the maximum dose of bupivacaine (5 mL up to the maximum dose) for moderate to complete motor block
0.5% concentration: Inject 25 mg up to the maximum dose of bupivacaine (5 mL up to the maximum dose) for moderate to complete motor block

Retrobulbar Block:
0.75% concentration: Inject 15 to 30 mg (2 to 4 mL) for complete motor block

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

Epidural Test Dose:
0.5% concentration: Inject 10 to 15 mg (2 to 3 mL) bupivacaine (10 to 15 mcg epinephrine)

Comments:

Doses may be repeated up to once every 3 hours.
Most experience to date is with single doses up to 225 mg with epinephrine.
Clinical studies to date have included total daily doses up to 400 mg and this dose should not be exceeded in 24 hours.
The addition of epinephrine may prolong anesthetic effect.

Renal Dose Adjustments

Use with caution; this drug is known to be excreted via the kidney and the risk of toxic reactions may be greater in patients with impaired renal function.

Liver Dose Adjustments

Use with caution; patients with hepatic disease, especially severe, are at a greater risk of developing toxic plasma concentrations due to the inability to metabolize local anesthetics normally.

Dose Adjustments

Doses should be reduced in debilitated, elderly patients and acutely ill patients and those with cardiac and/or liver disease.

Precautions

US BOXED WARNING: OBSTETRICAL ANESTHESIA

The 0.75% concentration is not recommended for obstetrical anesthesia. There have been reports of cardiac arrest with difficult resuscitation or death during use of this drug for epidural anesthesia in obstetrical patients. In most cases, this has followed use of the 0.75% concentration. Resuscitation has been difficult or impossible despite apparently adequate preparation and appropriate management. Cardiac arrest has occurred after convulsions resulting from systemic toxicity, presumably following unintentional intravascular injection. The 0.75% concentration should be reserved for surgical procedures where a high degree of muscle relaxation and prolonged effect are necessary.

Safety and efficacy have not been established in patients younger than 12 years.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

Not recommended for use in IV regional anesthesia (Bier Block).
The lowest effective dose and concentration should be employed and adequate time allowed between injections.
Doses should be individualized based on patient needs and general health status.
A test dose is recommended prior to caudal and lumbar epidural blocks.
During epidural anesthesia, this drug should be administered in incremental doses of 3 to 5 mL with sufficient time between doses to detect toxic manifestations of unintentional intravascular or intrathecal injection.
Only the 0.5% and 0.25% concentrations should be used in obstetrics; incremental doses of 3 to 5 mL of the 0.5% solution not exceeding 50 to 100 mg at any dosing interval are recommended.
Multiple dose vials contain a preservative and should not be used for caudal or epidural anesthesia.
Rapid injection of a large volume should be avoided and incremental doses always used.
Injections should be made slowly and with frequent aspirations.
The duration of anesthesia is such that a single dose is sufficient for most indications.
Standard textbooks should be consulted for specific techniques and procedures.
The manufacturer product information should be consulted.

Storage requirements:

Protect from light.

Reconstitution/preparation techniques:

Solutions of bupivacaine that contain epinephrine should not be autoclaved.
The manufacturer product information should be consulted.

General:

The dose of any local anesthetic varies with the anesthetic procedure, area to be anesthetized, vascularity of the tissues, number of neuronal segments to be blocked, depth of anesthesia, degree of muscle relaxation required, duration of anesthesia desired, individual tolerance, and physical condition of the patient.

Monitoring:

Careful and constant monitoring of cardiovascular and respiratory vital signs (e.g., adequacy of ventilation) and patient's state of consciousness should be performed after each injection.