What is the recommended dose and volume of bupivacaine for an 80-year-old patient, 170 cm tall, with no comorbidities, undergoing inguinal hernia surgery?

Bupivacaine Dosing for Inguinal Hernia Surgery in an 80-Year-Old Patient

For an 80-year-old patient (170 cm) with no comorbidities undergoing inguinal hernia surgery, the recommended maximum dose of 0.25% bupivacaine is 1 ml/kg (2.5 mg/kg), which equates to approximately 50-70 ml total volume depending on weight. 1, 2

Dosing Considerations for Elderly Patients

• Elderly patients (80 years old) require careful dosing of local anesthetics due to potential increased sensitivity and reduced physiological reserve 1
• The maximum safe dose of bupivacaine with epinephrine is 3.0 mg/kg, and without epinephrine is 2.0 mg/kg 1
• For peripheral nerve blocks in this population, 0.25% bupivacaine at 0.2-0.5 ml/kg is appropriate 1

Specific Recommendations for Inguinal Hernia Repair

• For wound infiltration or peripheral nerve block (ilioinguinal/iliohypogastric):

  • Use 0.25% bupivacaine at a volume of 0.2-0.5 ml/kg (maximum 1 ml/kg) 1
  • This provides approximately 4-10 hours of postoperative analgesia 1

• For spinal anesthesia (if chosen as technique):

  • Lower doses of intrathecal bupivacaine (<10 mg) are recommended to reduce hypotension risk 1
  • For unilateral spinal anesthesia, 8 mg of hyperbaric bupivacaine 0.5% is effective 3
  • Consider adding fentanyl (15-25 μg) to enhance analgesia while minimizing local anesthetic dose 1

Regional Anesthesia Options

• Ilioinguinal/iliohypogastric nerve block:

  • 0.25% bupivacaine, 10-15 ml total volume 1
  • Provides targeted analgesia for the surgical site with minimal systemic effects 4

• Transversus abdominis plane (TAP) block:

  • 0.25% bupivacaine, 0.2-0.5 ml/kg per side 1
  • Effective for postoperative pain management in inguinal hernia repair 5

Safety Considerations

• Monitor for signs of local anesthetic toxicity, including perioral numbness, tinnitus, seizures, or cardiovascular depression 1
• Have lipid emulsion 20% readily available for treatment of local anesthetic systemic toxicity 1
• Reduce doses by approximately 20-30% in elderly patients due to decreased clearance and increased sensitivity 1
• Avoid vasopressin, calcium channel blockers, and β-blockers if local anesthetic toxicity occurs 1

Practical Application

• For this 80-year-old patient (170 cm), assuming average weight of 70 kg:

  • Maximum safe volume of 0.25% bupivacaine would be 70 ml (175 mg) 1, 2
  • Recommended practical volume for wound infiltration: 20-35 ml (50-87.5 mg) 4, 6
  • If using spinal anesthesia: 8-10 mg (1.6-2 ml of 0.5% solution) 1, 3

• The technique with best risk-benefit profile for this elderly patient would be local infiltration or peripheral nerve block using 0.25% bupivacaine at a total volume of 20-30 ml, which provides effective analgesia while minimizing cardiovascular risks 1, 4, 6