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Bupivacaine infusion

Updated 2 Feb 2023 | Bupivacaine


Infusions of bupivacaine.

Drugs List

  • bupivacaine 0.1% infusion
  • bupivacaine 0.125% infusion
  • Therapeutic Indications


    Local anaesthetic for lumbar epidural block to relieve pain during labour
    Treatment of post-operative pain


    Prior to initiating a continuous infusion of bupivacaine, epidural block must be established with a test and loading dose of local anaesthetic. Adrenaline can be included in the test dose to facilitate early detection of accidental intravascular injection (seen as an increase in heart rate).

    The following doses are recommended by the manufacturer for healthy adults. Dose adjustments may be required in overweight patients, the elderly, patients in poor general condition and in those with a splinted diaphragm (See Precautions and Warnings). Consult standard textbooks where necessary.

    Dosage should be titrated to meet individual requirements using the lowest effective dose.


    For all indications:
    Doses above 20mg/hour should not be necessary.
    Maximum total dose 2mg/kg in any 4 hour period and 400mg per 24 hours.
    Continuous long term use increases the risk of accumulating toxic doses, local neural injury and local infection. Use beyond 72 hours has not been adequately studied.

    Test and loading doses
    Test and loading doses should be administered with bupivacaine solution for injection. Consult the relevant product literature for details.
    A test dose of 7.5mg bupivacaine 0.25% or 10mg of bupivacaine 0.5% containing adrenaline is suggested by the manufacturer.

    Labour pain
    10mg/hour to 15mg/hour as a continuous lumbar epidural infusion.
    For bupivacaine 0.125% solution for infusion only
    The following alternative dosing schedule may be suitable:
    6.25mg/hour to 12.5mg/hour as a continuous epidural infusion up to a maximum of 400mg per day.

    Post-operative pain
    5mg/hour to 15mg/hour as a continuous thoracic, upper abdominal or lower abdominal epidural infusion.
    Take into consideration any doses administered during surgery. Dose reduction may be possible if bupivacaine is co-administered with an epidural opioid.
    For bupivacaine 0.125% solution for infusion only
    The following alternative dosing schedule may be suitable:
    Thoracic epidural block: 6.3mg/hour to 18.8mg/hour as a continuous epidural infusion up to a maximum of 400mg per day.
    Lumbar epidural block: 12.5mg/hour to 18.8mg/hour as a continuous epidural infusion up to a maximum of 400mg per day.


    For continuous epidural infusion.

    To avoid accidental intravascular administration, aspiration is required prior to administering the test dose, loading dose and initiating the infusion.

    During administration of the test dose, maintain verbal contact with the patient and monitor heart rate (via an ECG). Stop the infusion immediately if signs of toxicity or intrathecal blockade occur.

    Following initiation of the infusion, monitor the patient continuously including assessment of blood pressure, pulse rate, pain management and sedation. Segmental testing of the block is required at least every 2 hours alongside appropriate monitoring for signs of progressive spread or increasing density of the block.


    Administration site infection
    Children under 18 years
    Hypovolaemic shock
    Arteriovenous malformation in the vertebral column
    Cardiogenic shock
    Central nervous system neoplasm
    Expanding cerebral lesion
    Intracranial haemorrhage
    Spina bifida
    Subacute combined degeneration of spinal cord due to B12 deficiency
    Tuberculosis of spine

    Precautions and Warnings

    Severe obesity
    Atrioventricular block
    Circulatory failure
    Decompensated cardiac failure
    Epileptic disorder
    Hepatic impairment
    Marked cerebral atherosclerosis
    Myasthenia gravis
    Pleural disorder
    Respiratory impairment
    Severe renal impairment

    Consider dose modification in patients with respiratory depression
    Epidural use: increased risk of bleeding with concurrent thrombolytics
    Septicaemia increases risk of post-op intraspinal abscess formation
    Advise ability to drive/operate machinery may be affected by side effects
    Aspirate prior to injection to avoid intravascular administration
    Discard any unused portion
    Discontinue immediately if toxic symptoms occur, especially in epidural use
    Do not inject near site of skin infection
    Resuscitation facilities must be immediately available
    Treatment to be administered by or under supervision of specialist
    Monitor vital signs, respiration & cardiac function
    May cause anaphylactic / anaphylactoid reactions
    Discontinue if an intrathecal blockade occurs
    Discontinue if hepatic function deteriorates
    Maintain treatment at the lowest effective dose
    Reduce dose in debilitated patients
    Reduce dose in elderly

    Accidental intravascular administration or injection into highly vascular areas (particularly with large infusion volumes) may lead to high plasma concentrations of bupivacaine. This can cause central nervous system or cardiovascular toxicity including ventricular arrhythmias, ventricular fibrillation, sudden cardiovascular collapse and death.

    Cardiac arrest has been reported which in some cases did not respond appropriately to resuscitative methods. Adequate resuscitation equipment must be available including established intravenous access in all patients.

    Bupivacaine may cause hypotension and bradycardia which can lead to more pronounced physiological effects. The risk of hypotension is greater in patients with hypovolaemia (e.g. due to haemorrhage or dehydration) or aortocaval obstruction (e.g. in patients with massive ascites, large abdominal tumours or during late pregnancy). Avoid bupivacaine in patients with untreated hypovolaemia or significantly impaired venous return. Cases of hypotension or bradycardia should be appropriately managed (e.g. with a vasopressor) and can be minimised by preloading with a crystalloid or colloid infusion.

    Consider dose reduction in patients with a splinted diaphragm where this interferes with their breathing. These patients are at an increased risk of hypoxia due to respiratory inadequacy or aortocaval compression and may include pregnant patients or those with hydramnios, large ovarian or uterine tumours, ascites or omental obesity. Lateral tilt, oxygen and mechanical ventilation may be required.

    Pregnancy and Lactation


    Bupivacaine infusion is considered safe for use during labour. Caution is advised during other stages of pregnancy.

    Bupivacaine is licensed for use as a continuous epidural infusion during labour. Available evidence indicates no untoward effects during human pregnancy although CNS and cardiovascular side effects may be intensified by progesterone. Use during late pregnancy carries an increased risk of hypotension and/or hypoxia due to aortocaval compression.

    Animal studies using high doses have shown decreased survival and embryological effects. As such, use during early pregnancy is not recommended by the manufacturer.

    Administration via paracervical block is associated with a higher incidence of foetal adverse effects including bradycardia. This is not a licensed route of administration for bupivacaine infusion.


    Bupivacaine is considered safe for use during breastfeeding.

    Bupivacaine is present in human breast milk however quantities are very small and bupivacaine is not orally absorbed. Studies have shown no adverse effects in exposed infants.

    Some studies have indicated that use during labour may delay the onset of lactation however evidence is conflicting and likely confounded by other medicines used during this period.

    Side Effects

    Abscess formation (injection site)
    Activation of latent Horner's syndrome
    Allergic reaction
    Anaphylactic reaction
    Anaphylactic shock
    Cardiac arrest
    Cardiac arrhythmias
    Cardiovascular effects
    CNS effects
    Hepatic impairment
    Increase in alkaline phosphatase
    Increases in hepatic enzymes (reversible)
    Localised areas of anaesthesia
    Loss of sphincter control
    Muscle twitch
    Muscle weakness
    Myocardial depression
    Nerve damage
    Neurological damage
    Respiratory depression
    Serum bilirubin increased
    Systemic toxicity (if accidental intravascular injection)
    Tongue numbness
    Urinary retention
    Ventricular arrhythmias
    Ventricular fibrillation
    Visual disturbances


    It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

    The following number will direct the caller to the relevant local centre (0844) 892 0111

    Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( ) or if this is unavailable at the backup site ( ).

    Further Information

    Last Full Review Date: March 2019

    Reference Sources

    Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

    Summary of Product Characteristics: Bupivacaine Hydrochloride 0.1%w/v Solution for Infusion. Advanz Pharma. Revised August 2012.

    Summary of Product Characteristics: Bupivacaine Hydrochloride 0.125%w/v Solution for Infusion. Advanz Pharma. Revised August 2012.

    NICE Evidence Services Available at: Last accessed: 05 March 2019

    US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
    Available at:
    Bupivacaine. Last revised: 03 December 2018
    Last accessed: 05 March 2019

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