Long-acting amide local anaesthetic Pregnancy: No evidence of untoward effects in human pregnancy; animal data show decreased pup survival (rats) and embryological effect (rabbits) at large doses. Do not give in early pregnancy unless benefits outweigh risks. Adrenaline may decrease uterine blood flow and contractility; foetal bradycardia may occur after paracervical block. Bupivacaine enters breast milk in quantities too small to affect the child at therapeutic doses.

Bupivacaine hydrochloride

Brand names: Marcain

Bupivacaine hydrochloride is a long-acting amide local anaesthetic used for infiltration, peripheral nerve blocks and epidural and spinal anaesthesia.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Single dose of up to 150 mg bupivacaine hydrochloride; dose varies by block type (e.g. local infiltration 0.25% up to 150 mg; lumbar epidural surgery 0.5% 50-100 mg; caudal epidural surgery 0.5% 75-150 mg; peripheral nerve block up to 150 mg)

Route: Local infiltration, epidural (lumbar/caudal), peripheral nerve and sympathetic block (this SPC: bupivacaine with adrenaline 1:200,000)

Frequency: Single dose usually sufficient; doses of up to 50 mg 2-hourly may subsequently be used

Max: Single dose up to 150 mg bupivacaine hydrochloride (experience to date); then up to 50 mg 2-hourly

Guide for the average adult; reduce doses for young, elderly or debilitated patients. Determine the maximum by the patient's size and physical status and the usual rate of systemic absorption from the injection site. Give the main dose slowly (25-50 mg/min) in incremental doses. Representative regimens from the SPC table: local infiltration 0.25% up to 60 mL (up to 150 mg); lumbar epidural surgery 0.5% 10-20 mL (50-100 mg); lumbar epidural analgesia in labour 0.5% 6-12 mL (30-60 mg) or 0.25% 6-12 mL (15-30 mg); caudal epidural surgery 0.5% 15-30 mL (75-150 mg); caudal epidural analgesia in labour 0.5% 10-20 mL (50-100 mg) or 0.25% 10-20 mL (25-50 mg); peripheral nerve block 0.5% up to 30 mL (up to 150 mg) or 0.25% up to 60 mL (up to 150 mg); sympathetic block 0.25% 20-50 mL (50-125 mg). For epidural anaesthesia give a test dose of 3-5 mL of adrenaline-containing bupivacaine (an intravascular injection is recognised by an increase in heart rate); repeat aspiration before the total dose. Solutions of bupivacaine with adrenaline must not be used in areas supplied by end arteries (digits, nose, external ear, genitalia) owing to risk of tissue necrosis.

Paediatric dose

Dose: 2 mg/kg

Route: Caudal, lumbar and thoracic epidural (acute pain management, per- and post-operative), using 2.5 mg/mL (0.25%)

Frequency: Single dose (dose range 1.5-2 mg/kg; volume 0.6-0.8 mL/kg); onset 20-30 min, duration 2-6 h

Max: Not stated as an absolute mg cap; use the lowest dose required for adequate analgesia

Children 1 to 12 years of age (bupivacaine 0.25% with adrenaline 1:200,000). SPC dose range 1.5-2 mg/kg (0.6-0.8 mL/kg of 2.5 mg/mL) for caudal/lumbar/thoracic epidural acute pain management; the value 2 mg/kg is the top of the stated range. Base dosing on ideal body weight; a gradual reduction is often necessary in children with high body weight. Safety and efficacy in children under 1 year not established (limited data); intermittent epidural bolus or continuous infusion not established. Paediatric regional procedures should be performed by qualified clinicians. Verify against a children's formulary.

Dose adjustments

Renal

Patients with severe renal dysfunction require special attention/reduced doses (listed among patients needing care to reduce the risk of dangerous side effects).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Paediatric weight-based calculator

Patient weight (kg)

Verify in a children's formulary

Contraindications

Hypersensitivity to the active substances or any excipient; known hypersensitivity to amide-group local anaesthetics
Intravenous regional anaesthesia (Bier's block)
Adrenaline-containing solutions: thyrotoxicosis or severe heart disease, particularly with tachycardia
Adrenaline-containing solutions: areas supplied by end arteries or with compromised blood supply (digits, nose, external ear, genitalia) — risk of ischaemic tissue necrosis
Epidural anaesthesia contraindications: active CNS disease (meningitis, poliomyelitis, intracranial haemorrhage, subacute combined degeneration of the cord, cerebral/spinal tumours), spinal tuberculosis, pyogenic skin infection at/near the lumbar puncture site, cardiogenic or hypovolaemic shock, coagulation disorders or ongoing anticoagulant therapy

Side effects

Hypotension (very common)
Nausea (very common)
Paraesthesia, dizziness (common); bradycardia (common); hypertension (common); vomiting (common); urinary retention (common)
Signs/symptoms of CNS toxicity — convulsions, circumoral paraesthesia, tongue numbness, visual disturbance, loss of consciousness, tremor, tinnitus, muscle twitching (uncommon)
Cardiac arrest, cardiac arrhythmias, respiratory depression, allergic/anaphylactic reactions (rare)

Interactions

Class III anti-arrhythmics (e.g. amiodarone) — cardiac effects may be additive; close surveillance and ECG monitoring
Other local anaesthetics — toxic effects are additive
Adrenaline component: ergot-type oxytocic drugs, MAOIs/tricyclic antidepressants, and non-selective beta-blockers may cause severe hypertension (per associated labelling)

Clinical monograph

How it works

It reversibly blocks voltage-gated sodium channels in nerve membranes, preventing the initiation and conduction of nerve impulses and thereby producing local anaesthesia.

Prescribing in practice

Bupivacaine is markedly cardiotoxic and accidental intravascular injection can cause refractory ventricular arrhythmias and cardiac arrest; aspirate before injection and never give the plain solution intravenously.
It is contraindicated for intravenous regional anaesthesia (Bier's block) because of the risk of fatal systemic toxicity.
Lipid emulsion rescue therapy should be available wherever doses capable of producing systemic toxicity are used.

Monitoring

Monitor cardiovascular and central nervous system status during and after administration for early signs of local-anaesthetic systemic toxicity.

Counselling the patient

The anaesthetised area will be numb and possibly weak for several hours; protect it from injury.
Report ringing in the ears, a metallic taste, tingling around the mouth, dizziness or palpitations immediately.

Evidence & guidelines

Its cardiotoxicity and the role of intravenous lipid emulsion in local-anaesthetic systemic toxicity are well established and reflected in UK resuscitation guidance.

Reference: AAGBI LAST guideline; OAA guidance; SmPC; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Ropivacaine hydrochloride · Long-acting amide local anaesthetic

Pathways