Local Anesthetic

Bupivacaine

Long-acting amide LA · Marcaine, Sensorcaine

Mechanism: Blocks voltage-gated Na+ channels with high cardiac affinity.

Onset

5–10 min (infiltration); 5–8 min (epidural)

Duration

4–8 h

Metabolism

Hepatic.

Dosing

Adult

Max: 2 mg/kg plain (175 mg); 3 mg/kg with epi (225 mg). Spinal: 7.5–15 mg.

Indications

Regional blocks
Epidural/spinal
Post-op wound infiltration

Contraindications

IV regional (Bier block) — high cardiotoxicity

Side Effects

Profound cardiotoxicity (refractory VF) — treat with lipid emulsion
LAST

Clinical Pearls

1More cardiotoxic than equipotent lidocaine — the 'CC/CNS ratio' is lower.

2Levobupivacaine and ropivacaine are less cardiotoxic alternatives.

References & Further Reading

1
Textbook
Flood P, Rathmell JP, Shafer S. Stoelting's Pharmacology and Physiology in Anesthetic Practice. 5th ed. Philadelphia: Wolters Kluwer; 2015.
2
GuidelineOpen source
Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version. Reg Anesth Pain Med. 2021;46(1):81-82.
3
Journal
Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med. 2010;35(2):188-193.
4
Textbook
Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.
5
Textbook
Adriano A, Morris R, eds. 2021 CA-1 Tutorial Textbook (15th Ed.). Stanford University Medical Center, Department of Anesthesiology.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.