From the FDA Drug Label
The duration of anesthesia with Bupivacaine Hydrochloride is such that for most indications, a single dose is sufficient Maximum dosage limit must be individualized in each case after evaluating the size and physical status of the patient, as well as the usual rate of systemic absorption from a particular injection site Most experience to date is with single doses of Bupivacaine Hydrochloride up to 225 mg with epinephrine 1:200,000 and 175 mg without epinephrine; more or less drug may be used depending on individualization of each case. 0. 25% ─ when used for caudal, epidural, or peripheral nerve block, produces incomplete motor block.
The 0.25% Marcaine dose with epinephrine is recommended for operations in which muscle relaxation is not important, or when another means of providing muscle relaxation is used concurrently. The maximum dosage limit must be individualized, but most experience is with single doses up to 225 mg with epinephrine 1:200,000 1.
From the Research
The maximum safe dose of 0.25% marcaine (bupivacaine) with epinephrine is 3 mg/kg or up to 225 mg total for an average adult, as supported by the most recent study 2. This equates to approximately 90 mL of the 0.25% solution with epinephrine for a 75 kg adult. The addition of epinephrine (typically 1:200,000 concentration) to marcaine increases the maximum safe dose and prolongs the anesthetic effect by causing local vasoconstriction, which slows systemic absorption and keeps the anesthetic at the site of action longer, as noted in 3. Marcaine with epinephrine typically provides 4-8 hours of anesthesia, longer than plain marcaine. When administering, always aspirate before injection to avoid intravascular administration, and be aware that epinephrine is contraindicated in certain areas (digits, penis, nose, ears) due to risk of ischemia. Also, use caution in patients with cardiovascular disease, as epinephrine can cause tachycardia and hypertension, as mentioned in 4. Onset of action is typically within 5-10 minutes, and the drug should be stored at room temperature and protected from light. Some key points to consider when using 0.25% marcaine with epinephrine include:
- The importance of proper dosing to avoid toxicity, as discussed in 5
- The potential benefits of combining marcaine with other local anesthetics, such as lidocaine, as noted in 5
- The need for careful patient selection and monitoring, particularly in patients with certain medical conditions, as mentioned in 6
- The potential for variations in analgesic duration and quality depending on the specific local anesthetic and concentration used, as demonstrated in 2