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Bupivacaine Max Dose — FRCA Primary MCQ

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HardPharmacology - AnalgesicsBupivacaine Max DoseFRCA Primary

An older patient receives repeated bupivacaine top-ups during a prolonged peripheral nerve catheter procedure. The final top-up is within the nominal single-dose limit, yet tinnitus and ventricular ectopy occur. Which explanation is most defensible?

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Correct answer: E — Progressive accumulation across repeated bupivacaine doses

The best answer is “Progressive accumulation across repeated bupivacaine doses”. The UK SmPC warns that repeated bupivacaine doses can produce significant stepwise increases in blood concentration because of slow accumulation. A nominal single-dose limit is therefore not a guarantee of safety. Age, physiological reserve, protein binding, vascularity and inadvertent intravascular delivery all modify risk; bupivacaine is an amide and is not rapidly cleared by plasma cholinesterase.

Reference: Bupivacaine hydrochloride 0.5% solution for injection, UK SmPC: https://www.medicines.org.uk/emc/product/6618/smpc; Royal College of Anaesthetists, Primary FRCA syllabus v2.2: https://www.rcoa.ac.uk/sites/default/files/documents/2026-01/Primary-FRCA-Syllabus.pdf