What are the guidelines for using bupivacaine as a local anesthetic in podiatric procedures?

From the Guidelines

Bupivacaine is a recommended local anesthetic for podiatric procedures, with a maximum safe dose of 3.0 mg/kg with epinephrine and 1.3 mg/kg without epinephrine, as indicated in the most recent guidelines 1.

Key Considerations for Bupivacaine Use

• The maximum recommended dose of bupivacaine should not be exceeded to minimize the risk of systemic toxicity, which can manifest as perioral numbness, metallic taste, seizures, or cardiac arrhythmias 1.
• Bupivacaine should be used cautiously in patients with liver disease, heart block, or those taking certain medications like beta-blockers, as these conditions may affect the metabolism and excretion of the anesthetic 1.
• Aspiration is essential before administration to prevent intravascular injection, and the solution should be warmed to body temperature to reduce injection pain 1.
• Buffered solutions with sodium bicarbonate can be used to reduce injection pain and enhance safety 1.

Guidelines for Administration

• Digital blocks typically require 2-3 mL per digit, while ankle blocks may need 5-7 mL per nerve, with concentrations of 0.25% to 0.5% bupivacaine 1.
• The anesthetic onset occurs within 5-10 minutes and provides 4-8 hours of pain relief, making it ideal for postoperative comfort 1.
• Epinephrine (1:200,000) can be added to prolong the effect and reduce bleeding, but should be avoided in digits and in patients with cardiovascular disease 1.

Special Considerations

• Neonates and former preterm infants require specific management due to immaturity of hepatic and renal function, which may alter the ability to metabolize and excrete sedating medications, resulting in prolonged sedation and the need for extended postsedation monitoring 1.
• The use of bupivacaine in pediatric patients under 4 years of age is not recommended, and doses should be decreased by 30% in infants younger than 6 months 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Podiatric Guidelines for Bupivacaine

• The use of bupivacaine as a local anesthetic in podiatric procedures is supported by various studies, including one published in 2025 2, which evaluated the efficacy and safety of different local anesthesia techniques in podiatry.
• Another study from 1996 3 compared the onset and duration of local anesthesia using a 50/50 mixture of lidocaine and bupivacaine, plain lidocaine, and plain bupivacaine, and found that bupivacaine had a prolonged duration of anesthesia compared to the other two solutions.
• While there are studies on the safety of bupivacaine in other medical fields, such as urologic inguinal and scrotal surgery in children 4, and total hip and total knee arthroplasty 5, the specific guidelines for podiatric procedures are not extensively outlined in these studies.

Safety and Efficacy of Bupivacaine

• A study on liposomal bupivacaine 6 found it to be an effective tool for postoperative pain relief with opioid sparing effects and an acceptable adverse effect profile, although its use in podiatry is not specifically mentioned.
• The safety and efficacy of bupivacaine in podiatric procedures can be inferred from its use in other medical fields, but more studies are needed to establish specific guidelines for its use in podiatry.
• The available evidence suggests that bupivacaine can be a useful local anesthetic in podiatric procedures, but its use should be guided by the principles of safe and effective anesthesia practice, including careful patient selection, appropriate dosing, and monitoring for potential adverse effects 2, 3.