Bupivacaine Hcl-Epinephrine (bupivacaine HCl/epinephrine)

Dosage of bupivacaine varies with the anesthetic procedure, degree of anesthesia required, surgical site, and individual patient response. The usual dosages should generally be reduced in geriatric, debilitated, or acutely ill patients and in patients with cardiac and/or hepatic disease. The lowest effective dose should be used.

Dosage of epinephrine salts is expressed in terms of epinephrine. Dosage of racepinephrine hydrochloride is expressed in terms of racepinephrine; racepinephrine is about one-half as active as epinephrine.

Conventional bupivacaine hydrochloride preparations may be administered by local infiltration or by lumbar epidural (including caudal), peripheral, retrobulbar, sympathetic, or dental block. For spinal anesthesia, 0.75% bupivacaine hydrochloride in 8.25% dextrose is administered by subarachnoid injection. BUPivacaine liposomal injection (Exparel(R)) is administered by local infiltration or interscalene brachial plexus nerve block; the liposomal formulation should not be administered by epidural or intrathecal routes, and should not be used for other regional nerve blocks.

Local anesthetics, including bupivacaine, have been administered by continuous intra-articular infusion+ (e.g., for control of postoperative pain); however, such use has been associated with chondrolysis. (See Cautions: Musculoskeletal Effects in the Local Anesthetics, Parenteral, General Statement 72:00.) BUPivacaine should not be administered using the Bier block technique (IV regional anesthesia) due to the risk of cardiac arrest and death.

BUPivacaine solutions containing preservatives should not be used for epidural or caudal block. Partially used solutions that do not contain preservatives should be discarded.

The liposomal formulation is not bioequivalent to and should not be used interchangeably with other bupivacaine formulations.

USP has changed its labeling standard for single-entity drug products to no longer allow the use of ratios to express drug concentrations. This labeling change was prompted by numerous reports of serious medication errors caused by confusion with different ratio expressions. Effective May 1, 2016, all single-entity preparations of epinephrine injection, USP should be labeled only in terms of strength per mL (i.e., mg/mL). While concentrations of some epinephrine preparations were historically expressed in ratios (e.g., 1:1000 or 1:10,000), such designation is no longer acceptable because of the risk of dosing errors.

Epinephrine usually is administered by IM, subcutaneous, or IV injection, or by continuous IV infusion. Epinephrine also has been administered by intraosseous (IO) injection+ in the setting of advanced cardiovascular life support (ACLS), generally when IV access is not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration. If vascular access (IV or IO) cannot be established during cardiac arrest, epinephrine may be administered endotracheally; however, this method of administration results in lower plasma concentrations compared with the same dose given intravascularly. Epinephrine also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration is not recommended in current ACLS guidelines.

The appropriate concentration and route of administration of epinephrine should be selected carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV. Because of the risks associated with IV use, epinephrine generally should be administered by the IV route only in extreme situations (such as in the treatment of septic or anaphylactic shock, cardiac arrest, or when the patient is unresponsive to multiple IM injections). Dilute solutions of epinephrine (e.g., 0.1 mg/mL) should always be used when administering the drug IV. Commercially available epinephrine solutions for IM or subcutaneous injection are tenfold more concentrated (1 mg/mL) and should not be administered IV without dilution.

Solutions of epinephrine should be inspected visually for particulate matter and discoloration prior to administration. Epinephrine injection must not be used if it is discolored or cloudy or contains any particulate matter.

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There is no enhanced messaging for this drug.

There are no contraindication interactions for this drug.

There are no severe interactions for this drug.

There are no moderate interactions for this drug.

There is no enhanced messaging for this drug.

There are no contraindication contraindications for this drug.

There are no severe contraindications for this drug.

There are no moderate contraindications for this drug.

There is no enhanced messaging for this drug.

There are no severe adverse reactions for this drug.

There are no less severe adverse reactions for this drug.

BUPivacaine shares the toxic potentials of the local anesthetics, and the usual precautions of local anesthetic therapy should be observed. (See Cautions in the Local Anesthetics, Parenteral, General Statement 72:00.)

Adverse effects of bupivacaine generally are limited when administered locally at the recommended dosages and routes. However, excessive plasma concentrations can lead to systemic toxicity manifesting principally as CNS and cardiovascular effects.

The 0.75% solution of bupivacaine hydrochloride is not recommended for obstetric anesthesia since use of this concentration for epidural anesthesia in obstetric patients has been associated with cardiac arrest with difficult resuscitation or death. Cardiac arrest has occurred after seizures resulting from systemic toxicity, apparently following inadvertent intravascular injection.

Some commercially available formulations of bupivacaine hydrochloride contain sodium metabisulfite, a sulfite that may cause allergic-type reactions, including anaphylaxis and life-threatening or less severe asthmatic episodes, in certain susceptible individuals. The overall prevalence of sulfite sensitivity in the general population is unknown but probably low; such sensitivity appears to occur more frequently in asthmatic than in nonasthmatic individuals.

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Epinephrine usually inhibits spontaneous or oxytocin-induced contractions of the pregnant human uterus and may delay the second stage of labor. In dosages sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage. If used during pregnancy, epinephrine may cause anoxia to the fetus and/or spontaneous abortion. When administered in advanced cardiovascular life support (ACLS) during cardiac resuscitation, epinephrine may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus. Some manufacturers state that epinephrine should be avoided during the second stage of labor; parenteral administration of the drug to maintain blood pressure during spinal anesthesia for delivery can cause acceleration of fetal heart rate and should not be used in obstetric patients when maternal systolic/diastolic blood pressure exceeds 130/80 mm Hg. Epinephrine should be administered cautiously by oral inhalation to pregnant patients. Epinephrine should be used during pregnancy only if the potential benefits justify the possible risks to the fetus. There is some evidence to support that epidural administration of some local anesthetics (e.g., lidocaine) with epinephrine during labor is safe.

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