NAME OF DRUG
bupivacaine HCl

CLASSIFICATION

Local anesthetic

ALTERNATE NAMES

MARCAINE

 INDICATIONS

• peripheral nerve block, infiltration, sympathetic blockade, caudal, epidural, pudendal block
• analgesia via the epidural route
• spinal anaesthesia - route

 RECONSTITUTION AND STABILITY

• partially used bottles which do not contain preservatives should be discarded
• solutions that are cloudy, discoloured or contain crystals should be discarded
• solutions that do not contain epinephrine may be autoclaved repeatedly
• protect solutions containing epinephrine from exposure to direct sunlight

 COMPATIBILITY

• compatible with NS
• compatible with fentanyl and morphine
• incompatible with other drugs

 ROUTES OF ADMINISTRATION

• local injection - for regional and block anesthesia

• post-operative infusion of continuous regional analgesia (PICRA) - continuous infusion

• rate dependent on patient response (See Policy for Administration of PICRA)

• epidural - intermittent injection

• continuous infusion; rate dependent on patient response (see Policy for Administration of Epidural Injections)

 VH & HSC ADMINISTRATION POLICY

C - Must be administered by the physician by all routes.

Nurses in critical and selected non-critical care areas can administer bupivacaine by continuous epidural infusion provided the epidural catheter has been established and according to policies and procedures stated in this manual.

DOSAGE

Local injection: 

• individualized, varying with the anesthetic procedure, the degree of anesthesia required and the patient's response.
• Maximum single dose - 175 mg without epinephrine; 225 mg with epinephrine
• dose may be repeated at intervals of not less than 3 hours
• Maximum daily dose - 400 mg

PICRA

• 20mL of 0.25% solution injected directly into the nerve sheath, followed by a continuous infusion of 0.2% concentration to infuse at 120-240 mg/24 hours (maximum 400 mg/day)
• continue for 72 hours or longer as necessary

Epidural (preservative free) 

• 5-20 mL of a 0.125% to 0.25% solution with or without epinephrine; may be followed by continuous infusion of 5-10 mL/hr of a 0.0625% to 0.25% solution with or without epinephrine
• dosage adjusted based on patient response

Dosage adjustments should be considered in patients with severe liver disease.

• repeated or high doses or inadvertent intravascular injection may cause serious CNS effects such as excitation, tremors, convulsions, or drowsiness, coma and respiratory arrest, and cardiovascular effects such as myocardial depression, hypotension, and ventricular arrhythmias
• epidural administration may result in hypotension, paresthesias and urinary retention
• rarely, tissue necrosis and sloughing may occur at injection site

 IMPORTANT IMPLICATIONS

• solutions containing epinephrine should not be used in the presence of peripheral vascular disease or in areas with limited blood supply i.e. digits, ears, nose, penis

• resuscitative equipment and drugs for treatment of adverse effects should be readily available

• when solutions containing epinephrine are used the usual cautions for epinephrine apply

• contraindicated if known allergy to local anesthetics of the amide type

• Epidural monitoring parameters:  heart rate, blood pressure

• PICRA monitoring parameters: pain level, sedation scale, motor function, blood pressure, respiratory rate, pulse, temperature

Rev. Sept 1999

August 04, 2005