Bupivacaine

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 of anaesthesia 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. Surgical anaesthesia generally requires higher concentrations and doses; a lower concentration is indicated when a less intense block is required, and the volume used will affect the extent of spread. When prolonged blocks are used, by continuous infusion or repeated bolus, the risks of reaching a toxic plasma concentration must be considered. If toxic symptoms occur, stop the injection immediately. ADULT TABLE (conc; volume; dose; onset; duration) — SURGICAL ANAESTHESIA: lumbar epidural for surgery 5 mg/ml, 15–30 ml, 75–150 mg, 15–30 min, 2–3 h; caesarean section (lumbar epidural) 5 mg/ml, 15–30 ml, 75–150 mg, 15–30 min, 2–3 h; thoracic epidural for surgery 2.5 mg/ml, 5–15 ml, 12.5–37.5 mg, 10–15 min, 1.5–2 h, or 5 mg/ml, 5–10 ml, 25–50 mg, 10–15 min, 2–3 h; caudal epidural block 2.5 mg/ml, 20–30 ml, 50–75 mg, 20–30 min, 1–2 h, or 5 mg/ml, 20–30 ml, 100–150 mg, 15–30 min, 2–3 h; major nerve block (e.g. brachial plexus, femoral, sciatic) 5 mg/ml, 10–35 ml, 50–175 mg, 15–30 min, 4–8 h (dose must be adjusted according to site of administration and patient status); field block (minor nerve blocks and infiltration) 2.5 mg/ml, < 60 ml, < 150 mg, 1–3 min, 3–4 h, or 5 mg/ml, ≤ 30 ml, ≤ 150 mg, 1–10 min, 3–8 h. Epidural doses include the test dose. ACUTE PAIN MANAGEMENT: lumbar epidural intermittent injections (e.g. post-operative pain relief) 2.5 mg/ml, 6–15 ml, 15–37.5 mg, minimum interval 30 minutes, onset 2–5 min, duration 1–2 h, total ≤ 500 mg/24 h; lumbar epidural continuous infusion 2.5 mg/ml at 5–7.5 ml/h = 12.5–18.8 mg/h; thoracic epidural continuous infusion 2.5 mg/ml at 4–7.5 ml/h = 10–18.8 mg/h; these infusion solutions are often used epidurally in combination with a suitable opioid, total ≤ 500 mg/24 h. Intra-articular block (e.g. single injection following knee arthroscopy) 2.5 mg/ml, ≤ 40 ml, ≤ 100 mg, onset 5–10 min, duration 2–4 h after wash out; field block under acute pain management 2.5 mg/ml, ≤ 60 ml, ≤ 150 mg, 1–3 min, 3–4 h. INTRA-ARTICULAR SAFETY: post-marketing reports of chondrolysis with 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): reports of cardiac arrest or death during use of bupivacaine for epidural anaesthesia or peripheral nerve blockade, with resuscitation sometimes difficult or impossible; procedures must 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 beforehand. 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). 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 of anaesthesia 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; the lowest dose required for adequate analgesia should be used. 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.