Long-Acting Local Anaesthetic (Amide) Pregnancy: SPC §4.6: levobupivacaine solutions are CONTRAINDICATED for use in paracervical block in obstetrics (based on experience with bupivacaine, foetal bradycardia may occur following paracervical block). There are no clinical data on first-trimester-exposed pregnancies; animal studies do not indicate teratogenic effects but have shown embryo-foetal toxicity at systemic exposure levels in the same range as those obtained in clinical use, and the potential risk for humans is unknown — levobupivacaine should therefore not be given during early pregnancy unless clearly necessary. Clinical experience with bupivacaine for obstetrical surgery at term or for delivery is extensive and has not shown foetotoxic effects. Lactation: it is unknown whether levobupivacaine or its metabolites are excreted in human breast milk, but as for bupivacaine it is likely to be poorly transmitted — breastfeeding is possible after local anaesthesia.

Levobupivacaine

Brand names: Chirocaine

Levobupivacaine is a long-acting amide local anaesthetic, the single S-enantiomer of bupivacaine, used surgically for regional and local anaesthesia and post-operative analgesia including epidural, peripheral nerve block and wound infiltration.

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: Post-operative pain management by continuous epidural infusion: levobupivacaine 1.25 mg/ml at 10-15 ml/hour, i.e. 12.5-18.75 mg/hour

Route: Epidural use ONLY (the fetched label is the 1.25 mg/ml solution for infusion). It must not be used for intravenous administration.

Frequency: Continuous infusion. Careful aspiration before infusion is recommended to prevent intravascular injection; if toxic symptoms occur the injection should be stopped immediately.

Max: The maximum recommended dose during a 24 hour period is 400 mg. For post-operative pain management the dose should not exceed 18.75 mg/hour, and the accumulated dose for a 24 hour period should not exceed 400 mg. For labour analgesia by epidural infusion the dose should not exceed 12.5 mg/hour. The maximum dosage must be determined by evaluating the size and physical status of the patient.

OTHER REGIMEN IN THE SAME §4.2 TABLE: lumbar epidural for analgesia in labour — levobupivacaine 1.25 mg/ml at 4-10 ml/hour (5-12.5 mg/hour). DURATION: there is limited safety experience with levobupivacaine therapy for periods exceeding 24 hours; to minimise the risk of severe neurological complications, the patient and the duration of administration should be closely monitored. There have been post-marketing reports of cauda equina syndrome and events indicative of neurotoxicity temporally associated with the use of levobupivacaine for at least 24 hours for epidural analgesia. SPECIAL POPULATIONS: debilitated, elderly or acutely ill patients should be given reduced doses of levobupivacaine commensurate with their physical status; in the management of post-surgery pain, the dose given during surgery must be taken into account; there are no relevant data in patients with hepatic impairment. PAEDIATRIC: 'The safety and efficacy of levobupivacaine in children for pain management has not been established' — no paediatric dose is stated, so paedDose is null; verify any under-18 use against a children's formulary. IMPORTANT SOURCE LIMITATION: the fetched SPC is for the 1.25 mg/ml EPIDURAL INFUSION presentation only. It does NOT contain surgical-anaesthesia block doses for the more concentrated levobupivacaine solutions (e.g. 2.5, 5.0 or 7.5 mg/ml) — re-source the relevant SPC if surgical anaesthesia dosing is required. §4.4 does note that during epidural administration, concentrated solutions (0.5-0.75%) 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, and that when a large dose is to be injected (e.g. in epidural block) a test dose of 3-5 ml lidocaine with adrenaline is recommended. Levobupivacaine should be administered only by, or under the supervision of, a clinician having the necessary training and experience. All patients must have intravenous access established, with appropriate fluids, vasopressors, anaesthetics with anticonvulsant properties, myorelaxants, atropine, resuscitation equipment and expertise available. No §4.5 interactions section was present in the fetched bundle, and no US label was retrieved, so no interactions list is given — re-source §4.5 before relying on this draft for interaction checking.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Known hypersensitivity to levobupivacaine, to local anaesthetics of the amide type, or to any of the excipients
General contraindications related to regional anaesthesia, regardless of the local anaesthetic used, should be taken into account
Intravenous regional anaesthesia (Bier's block)
Severe hypotension such as cardiogenic or hypovolaemic shock
Paracervical block in obstetrics

Side effects

Hypotension (very common)
Anaemia (very common)
Nausea (very common) and vomiting (common)
Dizziness and headache (common); convulsion, loss of consciousness, somnolence, syncope, paraesthesia, paraplegia and paralysis (frequency not known — paralysis and loss of sphincter control may be signs of cauda equina syndrome)
Back pain (common), pyrexia (common), procedural pain (common); foetal distress syndrome (common, in obstetric use)
Cardiac: atrioventricular block, cardiac arrest, ventricular tachyarrhythmia, tachycardia, bradycardia (frequency not known); allergic reactions including anaphylactic shock (not known)

Clinical monograph

How it works

It reversibly blocks voltage-gated sodium channels in nerve membranes, preventing impulse initiation and conduction to produce local anaesthesia and sensory block.

Prescribing in practice

Guard against systemic local-anaesthetic toxicity by aspirating before and during injection, using incremental dosing and adhering to maximum dose limits — have resuscitation facilities and lipid emulsion available, as inadvertent intravascular injection can cause seizures and cardiac arrest.
Levobupivacaine has a better cardiac safety profile than racemic bupivacaine but is still cardiotoxic in overdose; it must never be given by intravenous bolus and is not for intravenous regional anaesthesia (Bier's block).
Reduce dose in frail, elderly or hepatically impaired patients and avoid injection into infected or inflamed tissue.

Monitoring

Monitor cardiovascular and respiratory status and conscious level during and after administration, watching for early signs of systemic toxicity such as perioral tingling, tinnitus or agitation.

Counselling the patient

Explain the area will feel numb and possibly heavy or weak for some hours and to protect the numb part from injury.
Tell staff immediately about ringing in the ears, a metallic taste, dizziness or numbness around the mouth.

Evidence & guidelines

Levobupivacaine is a well-established regional anaesthetic with a favourable cardiotoxicity profile relative to bupivacaine; UK practice and the SPC mandate strict toxicity precautions and dose limits.

Reference: Chirocaine SPC; AAGBI LAST Guidelines 2023; 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.

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