Why is bupivacaine (local anesthetic) not recommended for use as a local anesthetic in children?

From the Guidelines

Bupivacaine is not recommended for routine use as a local anesthetic in young children due to its increased risk of cardiac toxicity compared to other local anesthetics. The most recent guidelines from 2019 1 emphasize the importance of careful consideration when using local anesthetic agents in pediatric patients, highlighting that all local anesthetic agents are cardiac depressants and may cause central nervous system excitation or depression.

Key Considerations for Bupivacaine Use in Children

• The maximum recommended dose for children is 2-2.5 mg/kg without epinephrine and 3 mg/kg with epinephrine, as indicated in the guidelines 1.
• Bupivacaine has a narrower therapeutic window than other local anesthetics like lidocaine or ropivacaine, meaning the difference between effective and toxic doses is smaller.
• The drug's high protein binding and lipid solubility contribute to its prolonged duration of action but also increase its potential for systemic toxicity.
• If local anesthesia is needed for children, alternatives like lidocaine, mepivacaine, or ropivacaine are generally safer options with wider therapeutic margins.

Safety Measures for Bupivacaine Administration

• Careful calculation of weight-based dosing is essential to avoid overdose.
• Aspiration before injection to avoid intravascular administration is crucial.
• Close monitoring for signs of toxicity, such as cardiac arrhythmias or central nervous system depression, is necessary.

Given the potential risks associated with bupivacaine, particularly in pediatric patients, it is prudent to select alternative local anesthetics when possible, based on the most recent and highest quality evidence available 1.

From the FDA Drug Label

Until further experience is gained, Bupivacaine Hydrochloride is not recommended for pediatric patients younger than 12 years. Until further experience is gained in pediatric patients younger than 12 years, administration of Bupivacaine Hydrochloride in this age group is not recommended. Until further experience is gained, Bupivacaine in dentistry is not recommended for pediatric patients younger than 12 years.

Bupivacaine is not recommended for use as a local anesthetic in children younger than 12 years due to insufficient clinical experience in this age group 2 2. Key considerations include:

• Lack of clinical data on the safe use of bupivacaine in pediatric patients
• Potential risks associated with the use of local anesthetics in children
• Need for further research and experience to establish safe and effective dosing guidelines for pediatric patients.

From the Research

Reasons for Not Using Bupivacaine in Children

• Bupivacaine is not recommended for use as a local anesthetic in children due to its potential for cardio- and neurotoxicity 3, 4.
• The introduction of newer local anesthetics such as ropivacaine and levobupivacaine, which are thought to be less toxic than bupivacaine, has challenged the position of bupivacaine as a gold standard for prolonged duration of analgesia in pediatrics 3.
• Studies have shown that bupivacaine can cause cardiac arrests in regional anesthesia, and its use in children may increase the risk of such complications 5.
• Although there is limited data on the use of bupivacaine in children, available studies suggest that alternative local anesthetics such as ropivacaine may have a greater margin of safety in this age group 4.

Safety Profile of Bupivacaine in Children

• A retrospective matched cohort analysis found no cases of local anesthetic systemic toxicity syndrome in pediatric surgical patients receiving wound infiltration with either plain or liposomal bupivacaine 6.
• However, the study noted that the safety profile of bupivacaine in children has not been well described, and further research is needed to determine its safety and efficacy in this age group 6.
• Another study found that bupivacaine-induced cardiac arrest can be treated with lipid emulsion, telemetry, and local anesthetic toxicity resuscitation training, but more research is needed to improve survival rates 5.
• A systematic review of case reports found that both bupivacaine and ropivacaine can cause cardiac arrests in regional anesthesia, highlighting the need for careful consideration of the risks and benefits of using these local anesthetics in children 5.

Alternative Local Anesthetics for Children

• Ropivacaine and levobupivacaine are considered to be safer alternatives to bupivacaine for use in children due to their lower potential for cardio- and neurotoxicity 3, 4.
• These alternative local anesthetics may provide a greater margin of safety for children undergoing surgical procedures, although further research is needed to determine their safety and efficacy in this age group 4.