bupivacaine: clinical use

Prescribing considerations

• Administer only where personnel and resuscitation facilities can promptly manage local-anaesthetic systemic toxicity.
• Account for total exposure from all local anaesthetics and the prolonged-release profile.
• Use additional caution in older people and in renal, hepatic, cardiac or pulmonary impairment.
• Consider falls and delayed mobilisation where temporary motor or sensory loss would hinder recovery.

Contraindications and cautions

• Hypersensitivity to bupivacaine, formulation excipients or amide local anaesthetics
• Intravascular administration
• Intra-articular administration
• Obstetric paracervical block anaesthesia

Monitoring

• Monitor cardiovascular and respiratory observations and consciousness after administration.
• Watch for early neurological or cardiac features of systemic toxicity, which may occasionally be delayed.
• Monitor for methaemoglobinaemia in susceptible patients or when oxidising medicines are used.
• Assess motor and sensory recovery and falls risk before mobilisation or discharge.

Clinical pharmacology

Bupivacaine blocks nerve-impulse generation and conduction. The multivesicular liposomes release it gradually; absorbed bupivacaine is highly protein-bound and metabolised mainly in the liver.

Formulation and product differences

• Liposomal bupivacaine is prolonged-release and is not bioequivalent to immediate-release bupivacaine.
• It must not be substituted for or converted directly from another bupivacaine formulation.
• It is for infiltration or perineural administration, not intravascular, intra-articular, epidural or intrathecal use.
• The dispersion requires gentle resuspension and compatible preparation techniques that preserve the liposomal particles.