Bupivacaine

Amide Anaesthetic·Analgesia - Topicals & Local

Surgical anaesthesia, epidural analgesia (labor/post-op), prolonged peripheral nerve blocks

INJECTABLEMarcain, Marcain with AdrenalineAmpoules/Vials (0S4TGA

Max Dose

2 mg/kg

Half-life

3 h

Cardiotoxic

CRITICAL

Intralipid

ANTIDOTE

Rapid Summary

Overview

Highly potent, long-acting amide local anaesthetic. The cornerstone of epidurals, spinals, and major regional nerve blocks.

Maximum Dose

Max 2 mg/kg (without adrenaline). Absolute maximum single dose ~150 mg.

Clinical Focus

Bupivacaine is intensely cardiotoxic. Accidental IV injection causes refractory ventricular fibrillation (VF) that resists standard CPR/defibrillation.

Bottom Line

Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest.

Formulation & Access

Brand Names

Marcain, Marcain with Adrenaline

Parenteral

Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics.

Prescribing & PBS

Hospital/OT supply. Restricted.

Indications & Use

Primary

TGA

Surgical anaesthesia, epidural analgesia (labor/post-op), prolonged peripheral nerve blocks.

Clinical Place

Provides hours of pain relief compared to the minutes/hour provided by Lidocaine. Essential for major surgery.

Quick reference

Class & Role

Amide Anaesthetic — Highly potent, long-acting amide local anaesthetic.

Route / Formulation

Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics. (Marcain, Marcain with Adrenaline)

Usual Dose & Max

SC / Perineural 0.25% or 0.5% solution. Dose strictly calculated by weight. Aspiration prior to injection is mandatory to rule out intravascular placement. Max 2 mg/kg (without adrenaline). Absolute maximum single dose ~150 mg.

Key Indication Doses

Local Infiltration / Nerve Block: SC / Perineural 0.25% or 0.5% solution. Dose strictly calculated by weight. Aspiration prior to injection is mandatory to rule out intravascular placement. Epidural Infusion: Epidural 0.1% or 0.125% (often combined with fentanyl) run continuously.

Best Uses

Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest.

Avoid / Cautions

Intravenous Regional Anaesthesia (Bier Block) — fatal if the tourniquet fails. Pre-existing severe heart block. Pregnancy Category A. The 0.75% formulation is strictly banned in epidurals for labor due to historical maternal cardiac arrests.

Key Risks

Cardiovascular: Local Anaesthetic Systemic Toxicity (LAST). Bupivacaine tightly binds cardiac fast sodium channels, causing widening of the QRS, bradycardia, complete heart block, and refractory VF/Asystole. Neurological: LAST (CNS phase): Perioral numbness, metallic taste, tinnitus, leading to sudden violent seizures and coma. Tissue: Chondrotoxicity (can destroy cartilage if injected directly into a joint space continuously).

Key Interactions

Additive toxicity with other local anaesthetics. You must calculate the TOTAL cumulative dose if the patient has had a Lidocaine block and a Bupivacaine epidural.

Monitoring

Aspiration before injecting every 3-5 mL is critical to ensure you are not in a blood vessel. Resuscitation equipment and Intralipid 20% MUST be immediately available in the room. Continuous ECG monitoring during large volume nerve blocks.

Clinical Pearl

If accidental IV injection occurs and the patient arrests, standard ALS (Adrenaline) often fails because the Bupivacaine is locked onto the cardiac receptors. You MUST administer Intralipid 20% IV. The lipid emulsion acts as a 'lipid sink', physically drawing the highly lipophilic Bupivacaine out of the heart tissue and saving the patient's life.

Access

Marcain, Marcain with Adrenaline

Brand: Marcain, Marcain with Adrenaline

Bupivacaine

Amide Anaesthetic·Analgesia - Topicals & Local

Surgical anaesthesia, epidural analgesia (labor/post-op), prolonged peripheral nerve blocks

INJECTABLEMarcain, Marcain with AdrenalineAmpoules/Vials (0S4TGA

Max Dose

2 mg/kg

Half-life

3 h

Cardiotoxic

CRITICAL

Intralipid

ANTIDOTE

Rapid Summary

Overview

Highly potent, long-acting amide local anaesthetic. The cornerstone of epidurals, spinals, and major regional nerve blocks.

Maximum Dose

Max 2 mg/kg (without adrenaline). Absolute maximum single dose ~150 mg.

Clinical Focus

Bupivacaine is intensely cardiotoxic. Accidental IV injection causes refractory ventricular fibrillation (VF) that resists standard CPR/defibrillation.

Bottom Line

Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest.

Formulation & Access

Brand Names

Marcain, Marcain with Adrenaline

Parenteral

Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics.

Prescribing & PBS

Hospital/OT supply. Restricted.

Indications & Use

Primary

TGA

Surgical anaesthesia, epidural analgesia (labor/post-op), prolonged peripheral nerve blocks.

Clinical Place

Provides hours of pain relief compared to the minutes/hour provided by Lidocaine. Essential for major surgery.

Quick reference

Class & Role

Amide Anaesthetic — Highly potent, long-acting amide local anaesthetic.

Route / Formulation

Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics. (Marcain, Marcain with Adrenaline)

Usual Dose & Max

Key Indication Doses

Best Uses

Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest.

Avoid / Cautions

Key Risks

Key Interactions

Additive toxicity with other local anaesthetics. You must calculate the TOTAL cumulative dose if the patient has had a Lidocaine block and a Bupivacaine epidural.

Monitoring

Clinical Pearl

Access

Marcain, Marcain with Adrenaline

Brand: Marcain, Marcain with Adrenaline