Safe Dose of Bupivacaine 0.25% for Local Wound Infiltration in a 14-Year-Old, 42kg Patient
For this 42kg adolescent, the maximum safe dose of bupivacaine 0.25% for local wound infiltration is 42 mL (105 mg total), calculated as 1 mL/kg based on the 2024 European Society for Paediatric Anaesthesiology guidelines. 1
Dose Calculation
- Maximum volume: 1 mL/kg × 42 kg = 42 mL of 0.25% bupivacaine 1
- Maximum dose in mg: 2.5 mg/kg × 42 kg = 105 mg total 1
- Since 0.25% bupivacaine contains 2.5 mg/mL, 42 mL delivers exactly 105 mg 1
Evidence-Based Rationale
The 2024 ESPA guidelines specifically address long-acting local anesthetics for wound infiltration in pediatric patients, establishing bupivacaine 0.25% at a maximum dose of 1 mL/kg (equivalent to 2.5 mg/kg) as the standard for this indication. 1 This represents the most current, high-quality guideline evidence directly applicable to your clinical scenario.
This dosing applies specifically to:
Safety Profile in Pediatric Wound Infiltration
- No cases of local anesthetic systemic toxicity (LAST) were identified in a 2019 retrospective cohort of 924 pediatric surgical patients receiving wound infiltration with bupivacaine, demonstrating excellent safety when dosed appropriately 2
- The 2.5 mg/kg maximum provides a substantial safety margin below toxic thresholds 1, 3
- Continuous subfascial bupivacaine infusion studies in children showed no wound complications or bupivacaine toxicity when proper dosing was maintained 4
Critical Safety Considerations
Always verify the following before administration:
- Confirm patient weight to ensure dose remains ≤2.5 mg/kg 1, 5
- Use preservative-free formulations only for any neuraxial or deep tissue injection 5
- Avoid intravascular injection through careful aspiration technique 2
- Monitor for early signs of LAST: perioral numbness, metallic taste, tinnitus, confusion, seizures, or cardiovascular collapse 2
Clinical Efficacy
- Wound infiltration with bupivacaine provides effective postoperative analgesia with pain scores typically <15% of maximum on visual analog scales 6
- Children receiving bupivacaine wound infusions required significantly fewer morphine doses (1.3 ± 1.3 doses) compared to placebo (3.1 ± 2.5 doses) on postoperative day one 7
- Pain control is reliable when combined with scheduled acetaminophen and rescue opioids as part of multimodal analgesia 4, 7
Common Pitfalls to Avoid
- Do not exceed 1 mL/kg of 0.25% solution even if the wound is large—consider alternative regional techniques or multimodal analgesia instead 1, 3
- Do not confuse concentrations: 0.25% = 2.5 mg/mL, so volume and mg calculations must align 1
- Do not use epinephrine-containing formulations without adjusting for the higher maximum dose (3 mg/kg with epinephrine) 3