Bupivacaine (Orthopaedic Nerve Blocks)

GENERAL: the dosage varies and depends on the area to be anaesthetised, the vascularity of the tissues, the number of neuronal segments to be blocked, individual tolerance and the technique used — the lowest dosage needed to provide effective anaesthesia should be administered, and the maximum dosage must be determined by evaluating the size and physical status of the patient and the usual rate of systemic absorption from the particular injection site. Doses should be reduced for young, elderly or debilitated patients. When prolonged blocks are used, either by continuous infusion or by repeated bolus administration, the risks of reaching a toxic plasma concentration must be considered. FIELD BLOCK (minor nerve blocks and infiltration), same SPC table: 2.5 mg/ml, < 60 ml, < 150 mg, onset 1–3 min, duration 3–4 h; or 5 mg/ml, ≤ 30 ml, ≤ 150 mg, onset 1–10 min, duration 3–8 h. INTRA-ARTICULAR SAFETY: there have been post-marketing reports of chondrolysis in patients receiving post-operative intra-articular continuous infusion of local anaesthetics — bupivacaine is NOT approved for continuous intra-articular infusion. BLOCK-SPECIFIC RISK: interscalene and supraclavicular brachial plexus blocks may be associated with a higher frequency of serious adverse reactions, regardless of the local anaesthetic used. SAFETY (§4.4): there have been reports of cardiac arrest or death during use of bupivacaine for epidural anaesthesia or peripheral nerve blockade, with resuscitation sometimes difficult or impossible; regional/local anaesthetic procedures should always be performed in a properly equipped and staffed area with resuscitation equipment and drugs immediately available, and patients receiving major blocks should be in optimal condition with an i.v. line inserted before the blocking procedure. Major peripheral nerve blocks may require a large volume of local anaesthetic in areas of high vascularity close to large vessels, increasing the risk of intravascular injection and/or high plasma concentrations. Special attention is needed in older people and patients in poor general condition, patients with partial or complete heart block, patients with advanced liver disease or severe renal dysfunction, patients in late pregnancy, and patients on class III antiarrhythmics (e.g. amiodarone). SCOPE: the same SPC table also covers epidural/caudal/caesarean-section anaesthesia and epidural acute-pain infusions, which are not the indication for this orthopaedic nerve-block page and have not been carried over. SOURCE LIMITS: §4.5 was not retrieved in this bundle; §4.4 and §4.8 were truncated at the source-fetch limit, so warnings and adverse reactions are partial. SOURCE: eMC SPC, Bupivacaine 2.5mg/ml Solution for Injection, https://www.medicines.org.uk/emc/product/11611/smpc

Children 1–12 years only (eMC §4.2). dosePerKg is left null because the SPC states ranges, not a single value. Caudal, lumbar or thoracic epidural administration: bupivacaine 2.5 mg/ml, 0.6–0.8 ml/kg = 1.5–2 mg/kg, onset 20–30 min, duration 2–6 h (thoracic epidural blocks must be given by incremental dosage until the desired level is achieved). Field block and peripheral nerve blocks (e.g. ilioinguinal–iliohypogastric): SPC table lists 2.5 and 5.0 mg/ml with '0.5–2.0' appearing in both the volume ml/kg and dose mg/kg columns of the flattened source text — verify the column mapping against the SPC table before use. Specific figures stated in the SPC prose: ilioinguinal–iliohypogastric blocks in children aged 1 year or older, bupivacaine 2.5 mg/ml at 0.1–0.5 ml/kg equivalent to 0.25–1.25 mg/kg; children aged 5 years or older have received bupivacaine 5 mg/ml at 1.25–2 mg/kg; penile blocks, bupivacaine 5 mg/ml at total doses of 0.2–0.5 ml/kg equivalent to 1–2.5 mg/kg; peritonsillar infiltration in children above 2 years, bupivacaine 2.5 mg/ml at 7.5–12.5 mg per tonsil. Paediatric regional anaesthetic procedures should be performed by qualified clinicians familiar with this population and the technique; in children with a high body weight a gradual reduction of the dosage is often necessary and should be based on ideal body weight. Safety and efficacy in children under 1 year of age have not been established (only limited data available). US labelling retrieved for cross-check (Dyural 40 Kit) states administration in patients younger than 12 years is not recommended and that continuous infusions in paediatric patients have been reported to result in high systemic levels and seizures. Verify all paediatric dosing against a children's formulary and local specialist protocols.