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Long-acting amide LA + vasoconstrictor Pregnancy: §4.6, verbatim: 'There is no evidence of untoward effects in human pregnancy. In large doses there is evidence of decreased pup survival in rats and an embryological effect in rabbits if bupivacaine is administered in pregnancy. Bupivacaine should not therefore be given in early pregnancy unless the benefits are considered to outweigh the risks. The addition of adrenaline may potentially decrease uterine blood flow and contractility, especially after inadvertent injection into maternal blood vessels. Foetal bradycardia may occur following paracervical nerve block. Labour may be prolonged leading to the need for caesarean section.' §4.4 lists 'Patients in late stages of pregnancy' among those requiring special attention. Breast-feeding: 'Bupivacaine enters the mother's milk, but in such small quantities that there is no risk of affecting the child at therapeutic dose levels.' Fertility: no data available. US label 8.1 (cross-check): the product is CONTRAINDICATED for obstetrical paracervical block anaesthesia — 'Its use in this technique has resulted in fetal bradycardia and death'; there are no available human data to inform a drug-associated risk; 'Local anesthetics rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity.'

Bupivacaine with adrenaline

Brand names: Marcain with Adrenaline

A combination injection of the long-acting amide local anaesthetic bupivacaine with adrenaline as a vasoconstrictor, used for infiltration and nerve-block anaesthesia to prolong the block and reduce bleeding.

Adult dose

Dose: SCOPE — ADULT LOCAL INFILTRATION AND PERIPHERAL NERVE BLOCK with Bupivacaine & Adrenaline (Epinephrine) Injection BP 0.25% w/v, 1 in 200,000. Local infiltration: up to 60 ml of the 0.25% solution, up to 150 mg bupivacaine hydrochloride. Peripheral nerve block: up to 60 ml of the 0.25% solution, up to 150 mg, giving slight to moderate motor block. The same §4.2 table gives, for this 0.25% strength, three further blocks: sympathetic block 20 to 50 ml (50 to 125 mg); caudal epidural analgesia in labour 10 to 20 ml (25 to 50 mg), moderate motor block; lumbar epidural analgesia in labour 6 to 12 ml (15 to 30 mg), minimal motor block. §4.2: 'The lowest dosage required to achieve effective anaesthesia should be given', the dose varying with the area to be anaesthetised, tissue vascularity, the number of neuronal segments to be blocked, individual tolerance and technique; 'For young, elderly or debilitated patients, these doses should be reduced.'
Route: Injection — percutaneous local infiltration and peripheral nerve block (this page's primary routes). §4.1 also licenses central neural block (caudal or epidural), and the §4.2 table covers sympathetic block. ⚠ §4.2 'Method of administration' for this presentation states only: 'Epidural injection.' NOT for intravenous regional anaesthesia (Bier's block), and not for injection into areas of the body supplied by end arteries or otherwise having a compromised blood supply (digits, nose, external ear, genitalia) because the adrenaline content risks ischaemic tissue necrosis.
Frequency: For most indications a single dose is sufficient — §4.2: 'For most indications, the duration of anaesthesia with bupivacaine solutions is such that a single dose is sufficient.' If repeat dosing is required: 'Doses of up to 50mg 2-hourly may subsequently be used.' The main dose is injected slowly, 25 to 50 mg/min, in incremental doses under constant contact with the patient, stopping immediately if mild toxic symptoms develop. With continuous (intermittent) techniques, repeat doses increase the degree of motor block.
Max: Maximum single dose 150 mg bupivacaine hydrochloride — §4.2, verbatim: 'Experience to-date indicates a single dose of up to 150mg bupivacaine hydrochloride.' Both the local-infiltration and the peripheral-nerve rows of the §4.2 table are capped at 150 mg for each dose, and subsequent doses are limited to 'up to 50mg 2-hourly'. §4.2 adds: 'The maximum dosage must be determined by evaluating the size and physical status of the patient and considering the usual rate of systemic absorption from a particular injection site.'
§4.1, verbatim: 'Bupivacaine 0.25% and 0.5% solutions are used for the production of local anaesthesia by percutaneous infiltration, peripheral nerve block(s) and central neural block (caudal or epidural), that is, for specialist use in areas where prolonged anaesthesia is indicated. Bupivacaine is particularly useful for pain relief e.g. during labour, as its sensory nerve block is more marked than its motor block.' §4.1 scopes the licence by age: 'Surgical anaesthesia in adults and children above 12 years of age. Acute pain management in adults, infants and children above 1 year of age.' TEST DOSE AND ASPIRATION (§4.2): 'Great care must be taken in order to prevent an accidental intravascular injection, always including careful aspirations. For epidural anaesthesia, a test dose of 3 - 5ml of bupivacaine containing adrenaline should be administered, since an intravascular injection of adrenaline will be quickly recognised by an increase in heart rate. Verbal contact and frequent measurements of the heart rate, preferably by electrographic (ECG) monitoring, should be maintained throughout a period of 5 minutes following the test dose. Aspiration should be repeated prior to the administration of the total dose.' STRENGTH SCOPE: the 0.50% rows of the §4.2 table (lumbar epidural surgical 10–20 ml / 50–100 mg; lumbar epidural analgesia in labour 6–12 ml / 30–60 mg; caudal epidural surgical 15–30 ml / 75–150 mg; caudal epidural analgesia in labour 10–20 ml / 50–100 mg; peripheral nerves up to 30 ml / up to 150 mg) belong to a 0.5% presentation, NOT to the 0.25% product sourced here, and are recorded only for completeness of the quoted table. §4.4 warns of the risk of systemic effects of adrenaline with large volumes of adrenaline-containing solutions, and that the elderly and patients in poor general condition should be given reduced doses commensurate with their physical status. The US label is a cross-check only; its posology section is truncated at the source-fetch limit and no dose was taken from it.

Paediatric dose

Dose: 1.5 mg/kg
Route: Caudal, lumbar or thoracic epidural administration — ⚠ NOT the infiltration / peripheral-block route this page leads with. §4.1: 'From the reviewed literature only evidence for the use of bupivacaine 1.25 - 2.5 mg/ml + 2.5 - 5 microgram/ml adrenaline for caudal epidural block in children > 1 year of age could be derived. Regarding other anaesthetic techniques, the investigated paediatric population were mostly very small and a variety of different applications were studied, so that no reliable recommendations can be derived from the literature.'
Frequency: Single dose for acute pain management (per- and post-operative) in children 1 to 12 years; onset 20 to 30 minutes, duration of effect 2 to 6 hours. §4.2: 'Safety and efficacy of intermittent epidural bolus injection or continuous infusion have not been established. Only limited data is available.'
Max: Maximum single dose 150 mg bupivacaine hydrochloride — §4.2: 'Experience to-date indicates a single dose of up to 150mg bupivacaine hydrochloride.' The SPC states no separate paediatric ceiling and directs that in children of high body weight a gradual reduction of the dosage is often necessary, based on the ideal body weight.
Concentration: 2.5 mg/ml
Age bands
  • 1–12m: Acute pain management (per- and post-operative), caudal / lumbar / thoracic epidural: 1.5–2 mg/kg (0.6–0.8 ml/kg of the 2.5 mg/ml solution); onset 20–30 min, duration 2–6 hours
SCOPE — CHILDREN 1 TO 12 YEARS, ACUTE PAIN MANAGEMENT (per- and post-operative) BY CAUDAL, LUMBAR OR THORACIC EPIDURAL ADMINISTRATION. The §4.2 paediatric table gives concentration 2.5 mg/ml, volume 0.6–0.8 ml/kg, dose 1.5–2 mg/kg, onset 20–30 min, duration 2–6 hours. dosePerKg is set to 1.5, the LOWER bound of the label's own 1.5–2 mg/kg range, so the weight calculator returns the conservative end of the licensed range; the full labelled range is 1.5 to 2 mg/kg, equivalent to 0.6 to 0.8 ml/kg of the 2.5 mg/ml solution. §4.2: 'Paediatric regional anaesthetic procedures should be performed by qualified clinicians who are familiar with this population and the technique… The lowest dose required for adequate analgesia should be used. The duration may be prolonged with the adrenaline-containing solutions. N.B. Risk of systemic effects of adrenaline with large volumes of adrenaline containing solutions should be considered.' Aspiration must be repeated before and during administration of the main dose, which is injected slowly in incremental doses — particularly by the lumbar and thoracic epidural routes — with the patient's vital functions constantly and closely observed; thoracic epidural blocks are given by incremental dosage until the desired level of anaesthesia is achieved. 'The safety and efficacy of Bupivacaine and Adrenaline (Epinephrine) Injection 0.25% w/v, 1 in 200,000 in children < 1 year of age have not been established. Only limited data are available.' §4.3 states: 'No specific contraindications were identified for paediatric patients.' Verify paediatric use against a children's formulary.

Dose adjustments

Renal

No numeric adjustment is given. §4.4 lists 'Patients with advanced liver disease or severe renal dysfunction' among those who 'require special attention in order to reduce the risk of dangerous side effects', alongside the general instruction that 'The elderly and patients in poor general condition should be given reduced doses commensurate with their physical status.' US label 8.5 (cross-check): 'This product is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.'

Hepatic

No numeric adjustment is given. §4.4 lists 'Patients with advanced liver disease or severe renal dysfunction' among those requiring special attention and reduced doses commensurate with physical status. §4.8 also notes: 'Hepatic dysfunction, with reversible increases of SGOT, SGPT, alkaline phosphates and bilirubin, has been observed following repeated injections or long-term infusions of bupivacaine' — the sentence that follows is cut off at the source-fetch limit.

Dose independently re-sourced from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — clinician-reviewed. Always confirm against the product SmPC and your local formulary before prescribing.

Paediatric weight-based calculator

SCOPE — CHILDREN 1 TO 12 YEARS, ACUTE PAIN MANAGEMENT (per- and post-operative) BY CAUDAL, LUMBAR OR THORACIC EPIDURAL ADMINISTRATION. The §4.2 paediatric table gives concentration 2.5 mg/ml, volume 0.6–0.8 ml/kg, dose 1.5–2 mg/kg, onset 20–30 min, duration 2–6 hours. dosePerKg is set to 1.5, the LOWER bound of the label's own 1.5–2 mg/kg range, so the weight calculator returns the conservative end of the licensed range; the full labelled range is 1.5 to 2 mg/kg, equivalent to 0.6 to 0.8 ml/kg of the 2.5 mg/ml solution. §4.2: 'Paediatric regional anaesthetic procedures should be performed by qualified clinicians who are familiar with this population and the technique… The lowest dose required for adequate analgesia should be used. The duration may be prolonged with the adrenaline-containing solutions. N.B. Risk of systemic effects of adrenaline with large volumes of adrenaline containing solutions should be considered.' Aspiration must be repeated before and during administration of the main dose, which is injected slowly in incremental doses — particularly by the lumbar and thoracic epidural routes — with the patient's vital functions constantly and closely observed; thoracic epidural blocks are given by incremental dosage until the desired level of anaesthesia is achieved. 'The safety and efficacy of Bupivacaine and Adrenaline (Epinephrine) Injection 0.25% w/v, 1 in 200,000 in children < 1 year of age have not been established. Only limited data are available.' §4.3 states: 'No specific contraindications were identified for paediatric patients.' Verify paediatric use against a children's formulary.

Verify in a children's formulary

Contraindications

  • Hypersensitivity to the active substances or to any of the excipients, and known hypersensitivity to local anaesthetic agents of the amide group (§4.3; US label 4)
  • Intravenous regional anaesthesia (Bier's block) — §4.3; US label 4 adds that there have been reports of cardiac arrest and death during use of bupivacaine for intravenous regional anaesthesia
  • Solutions containing adrenaline: thyrotoxicosis, or severe heart disease particularly when tachycardia is present (§4.3)
  • Solutions containing adrenaline: anaesthesia in areas of the body supplied by end arteries or otherwise having a compromised blood supply, such as digits, nose, external ear or genitalia, owing to the risk of tissue necrosis; injection in areas of end arteries (e.g. penile block, Oberst block) may cause ischaemic tissue necrosis (§4.3)
  • Obstetrical paracervical block anaesthesia — US label 4: 'Its use in this technique has resulted in fetal bradycardia and death.'
  • Epidural anaesthesia (§4.3): active disease of the central nervous system such as meningitis, poliomyelitis, intracranial haemorrhage, subacute combined degeneration of the cord due to pernicious anaemia, and cerebral or spinal tumours
  • Epidural anaesthesia (§4.3): tuberculosis of the spine; pyogenic infection of the skin at or adjacent to the site of lumbar puncture
  • Epidural anaesthesia (§4.3): cardiogenic or hypovolaemic shock; coagulation disorders or ongoing anticoagulant therapy
  • Epidural anaesthesia (§4.3): an expanding cerebral lesion, tumour, cyst or abscess which may, if the intracranial pressure is suddenly altered, cause obstruction to the cerebrospinal fluid or blood circulation (the pressure cone)
  • Not a contraindication but a US restriction (label 2.1): not for intrathecal use; avoid solutions containing antimicrobial preservatives (multiple-dose vials) for epidural or caudal anaesthesia
  • §4.3 note: 'No specific contraindications were identified for paediatric patients.'

Side effects

  • Very common (§4.8): hypotension; nausea
  • Common (§4.8): paraesthesia, dizziness; bradycardia; hypertension; vomiting; urinary retention
  • Uncommon (§4.8): signs and symptoms of CNS toxicity — convulsions, circumoral paraesthesia, numbness of the tongue, hyperacusis, visual disturbances, loss of consciousness, tremor, light headedness, tinnitus, dysarthria, muscle twitching
  • Rare (§4.8): allergic reactions, anaphylactic reaction/shock; neuropathy, peripheral nerve injury, arachnoiditis, paresis and paraplegia; diplopia; cardiac arrest, cardiac arrhythmias; respiratory depression
  • Accidental intravascular injection may lead to systemic toxicity resulting in cerebral haemorrhage due to the sudden rise in blood pressure, convulsions leading to cardiac arrest, or ventricular arrhythmia, ventricular fibrillation, sudden cardiovascular collapse and death (§4.4)
  • Neurological damage is a rare but well recognised consequence of regional and particularly epidural and spinal anaesthesia, and may cause localised paraesthesia or anaesthesia, motor weakness, loss of sphincter control and paraplegia — occasionally permanent (§4.8)
  • Following epidural injection, high sympathetic blockade may occasionally result in ocular and other symptoms similar to Horner's syndrome, encountered more commonly in pregnant women (§4.8)
  • Hepatic dysfunction with reversible increases of SGOT, SGPT, alkaline phosphatase and bilirubin after repeated injections or long-term infusions (§4.8)
  • Methemoglobinemia has been reported in association with local anaesthetic use (US label 5.3)
  • The adrenaline-containing product contains sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people (US label 5.8)
  • Chondrolysis has been reported post-marketing after intra-articular infusions of local anaesthetics, an unapproved use (US label 5.5)

Monitoring

  • After an epidural test dose of 3–5 ml (§4.2): 'Verbal contact and frequent measurements of the heart rate, preferably by electrographic (ECG) monitoring, should be maintained throughout a period of 5 minutes following the test dose.'
  • Constant verbal contact with the patient while the main dose is injected slowly at 25–50 mg/min in incremental doses; stop the injection immediately if mild toxic symptoms develop (§4.2)
  • Repeat aspiration before and during administration of the main dose to avoid intravascular injection (§4.2; US label 2.1 — 'a negative aspiration for blood or cerebrospinal fluid does not ensure against an intravascular or intrathecal injection')
  • Cardiovascular and respiratory vital signs (adequacy of oxygenation and ventilation) and the patient's level of consciousness after each local anaesthetic injection (US label 2.1, 5.2)
  • Close surveillance and ECG monitoring in patients treated with class III anti-arrhythmic drugs (e.g. amiodarone), since cardiac effects may be additive (§4.4)
  • Vital functions constantly and closely observed during paediatric epidural administration, with incremental dosing for thoracic blocks (§4.2)
  • Renal function in elderly patients, who are more likely to have decreased renal function; elderly patients may require lower doses (US label 8.5)
  • Watch for signs of hepatic dysfunction during treatment (§4.8) and for methaemoglobinaemia (US label 5.3)
  • Resuscitation readiness: equipment and drugs for monitoring and emergency resuscitation must be immediately available, and patients receiving major blocks should have an intravenous line inserted before the block (§4.4; US label 2.1)

Clinical monograph

How it works

Bupivacaine blocks neuronal voltage-gated sodium channels to abolish nerve conduction, while adrenaline produces local vasoconstriction that slows systemic absorption, prolongs the anaesthetic effect and reduces local bleeding.

Prescribing in practice

  • Avoid intravascular injection: bupivacaine is highly cardiotoxic and the adrenaline component adds risk of severe hypertension and arrhythmia, so aspirate carefully before injecting.
  • Do not use adrenaline-containing solutions for ring blocks of digits, the penis or other areas supplied by end-arteries, where vasoconstriction risks ischaemic tissue damage.
  • Use with caution alongside tricyclic antidepressants, non-selective beta-blockers and in cardiovascular disease or hyperthyroidism, where the pressor response may be exaggerated.

Monitoring

Monitor cardiovascular status and watch for signs of local-anaesthetic systemic toxicity during and after injection.

Counselling the patient

  • The treated area will be numb for several hours; avoid injury until full sensation returns.
  • Report palpitations, tremor, dizziness, tinnitus or circumoral tingling promptly.

Evidence & guidelines

The principle that adrenaline-containing local anaesthetics must be avoided in end-artery sites is long-established surgical and anaesthetic practice.

Reference: AAGBI LAST guideline; 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).

Related

Curated clinical cross-links plus same-class fallbacks.

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