Bupivacaine Dosing Guidelines in Pediatric Patients
The maximum safe dose of bupivacaine 0.25% in pediatric patients is 2.5 mg/kg without epinephrine and 3.0 mg/kg with epinephrine, with doses requiring reduction by 30% in infants younger than 6 months. 1, 2, 3
General Dosing Principles
- Calculate maximum allowable dose before administration to prevent toxicity
- Use the smallest effective dose and concentration
- For infants <6 months: reduce amide local anesthetic doses by 30%
- Use ideal body weight for dose calculations, especially in patients with BMI >30 kg/m²
Route-Specific Dosing Recommendations
Neuraxial Administration
- Caudal block: Bupivacaine 0.25% at 1.0 ml/kg (2.5 mg/kg) 1, 2
- Lumbar epidural block: Bupivacaine 0.25% at 0.5 ml/kg (max 15ml) initially 1
- Thoracic epidural block: Bupivacaine 0.25% at 0.2-0.3 ml/kg (max 10ml) initially 1
- Spinal anesthesia: Bupivacaine 1 mg/kg for newborns/infants, 0.5 mg/kg for children >1 year 4
Peripheral Nerve Blocks
- Peripheral nerve blocks (axillary, infraclavicular, etc.): Bupivacaine 0.25% at 0.5-1.5 mg/kg 4
- Paravertebral block: Bupivacaine 0.25% at 0.2-0.5 ml/kg 1
- Femoral nerve/fascia iliaca block: Bupivacaine 0.25% at 0.2-0.5 ml/kg 1, 2
- Intercostal block: Bupivacaine 0.25% at 0.1 ml/kg per intercostal space 1, 2
- TAP/rectus sheath block: Bupivacaine 0.25% at 0.2-0.5 ml/kg per side 1
Safety Considerations
Risk Factors for Toxicity
- Vascular areas (increased absorption)
- Young age (especially <6 months)
- Hepatic or cardiac dysfunction
- Accidental intravascular injection
Monitoring Requirements
- Monitor vital signs at least every 5 minutes initially when using high doses
- Once the child begins to awaken, monitoring intervals may be increased to 10-15 minutes 1
- Have resuscitation equipment and 20% lipid emulsion available when using higher doses 2
Signs of Toxicity
- Early: Circumoral numbness, facial tingling, slurred speech, metallic taste
- Progressive: Seizures, CNS depression, cardiac arrhythmias
- Treatment: Support ventilation, control seizures with benzodiazepines, administer 20% lipid emulsion (1.5 ml/kg over 1 minute) for amide local anesthetic toxicity 2, 5
Important Caveats
- Bupivacaine is more cardiotoxic than most other local anesthetics 6
- Bupivacaine-induced dysrhythmias may be refractory to treatment 6
- Aspiration for blood before injection is essential but does not guarantee against intravascular injection 3
- Lower concentrations (0.125%-0.25%) are preferred for pediatric use to minimize toxicity risk while maintaining efficacy 7
- The FDA does not recommend bupivacaine for pediatric patients younger than 12 years due to limited data, though it is commonly used in clinical practice with appropriate precautions 3
- Avoid intra-articular infusions due to risk of chondrolysis 3
By following these guidelines and maintaining vigilant monitoring, bupivacaine can be used safely and effectively for regional anesthesia in pediatric patients, providing excellent pain control with minimal systemic effects.