Bupivacaine — Bupivacaine is an amide anesthetic that is more potent and has a longer

duration of action than lidocaine mepivacaine, or procaine [2,10]. The increases in potency

and duration of action are related to prolonged binding of sodium channels. Thus, if
systemically absorbed, bupivacaine has a higher risk of major toxicity (eg, seizures,
intractable cardiac arrhythmias) than lidocaine and most other local anesthetics [3].
Bupivacaine is contraindicated for local infiltration in pregnant women [2,10], and should be
infiltrated with caution in acutely ill, debilitated, or elderly patients.

Bupivacaine is a good choice for longer procedures, for patients who have contraindications
to epinephrine injection, for situations where there will be a delay between infiltration of local
anesthetic and the procedure, or for instances in which prolonged post-procedure pain
control is preferred.

●Preparation – Bupivacaine is commercially available in concentrations of 0.25 percent

(2.5 mg/mL) and 0.5 percent (5 mg/mL). The lower concentration should be used in
awake patients because local infiltration with 0.5 percent bupivacaine is painful.
Unlike lidocaine, buffering with sodium bicarbonatedoes not reduce the pain of injection
and may lead to precipitation of the active drug [2]. (See 'Methods to decrease injection
pain'below.)

●Dose – The dose of bupivacaine should notexceed the following [12]:

•Bupivacaine WITHOUT epinephrine – 2 mg/kg (0.8 mL/kg of bupivacaine 0.25

percent, maximum total dose: 175 mg [70 mL of bupivacaine 0.25 percent])

•Bupivacaine WITH epinephrine – 3 mg/kg (1.2 mL/kg of bupivacaine 0.25 percent,

maximum total dose: 225 mg [90 mL of bupivacaine 0.25 percent with
epinephrine])

●Onset of action and duration of anesthesia – The onset of action of bupivacaine is

5 to 10 minutes and the duration of effect is up to six hours (table 2) [12]. The addition
of epinephrine does not increase the duration of anesthetic effect but may decrease
systemic absorption, and use may be desirable for hemostatic purposes [2,3].