What are the recommended epidural doses of lidocaine, bupivacaine, and ropivacaine for single‑shot and continuous infusion in adults (including elderly or patients with cardiovascular, hepatic, or renal disease) and in pediatric patients?

Epidural Anesthetic Agent Dosing

Bupivacaine Epidural Dosing

For adult lumbar epidural anesthesia, use an initial dose of 0.5 ml/kg of 0.25% bupivacaine (maximum 15 ml), and for thoracic epidural use 0.2-0.3 ml/kg (maximum 10 ml), with the maximum safe dose being 2.5 mg/kg for plain solutions. 1, 2

Adult Single-Shot Dosing

• Lumbar epidural: 0.5 ml/kg of 0.25% bupivacaine (maximum 15 ml initially) 1, 2
• Thoracic epidural: 0.2-0.3 ml/kg of 0.25% bupivacaine (maximum 10 ml initially) 1, 2
• Maximum safe dose: 2.5 mg/kg for plain bupivacaine, up to 3 mg/kg (or 225 mg total) when combined with epinephrine 1:200,000 2

Adult Continuous Infusion

• Continuous epidural infusion: 0.1-0.3 ml/kg/h of 0.25% bupivacaine 2
• For postoperative analgesia, bupivacaine 0.2% is effective when combined with opioids 3

Pediatric Dosing

• Maximum dose: 1 ml/kg of 0.25% bupivacaine (2.5 mg/kg) 1, 2
• Caudal block: 1.0 ml/kg of 0.25% bupivacaine 1, 2
• Continuous infusion: 0.1-0.3 ml/kg/h of 0.25% bupivacaine 2

Special Populations

• Elderly, debilitated, or patients with cardiac/hepatic disease: Reduce the dose of bupivacaine, though specific reduction percentages are not provided in guidelines 1
• Obese patients: Calculate dose based on ideal body weight, not actual weight 1
• Patients <40 kg: Calculate dose carefully based on weight 1

Ropivacaine Epidural Dosing

Ropivacaine 0.2% can be used as an alternative to bupivacaine with a maximum dose of 3 mg/kg (1.5 ml/kg), offering reduced cardiotoxicity and less motor blockade. 2, 3

Adult Dosing

• Maximum dose: 3 mg/kg (1.5 ml/kg of 0.2% solution) 2
• Epidural analgesia: 0.2% ropivacaine is effective for labor analgesia and postoperative pain, especially when combined with opioids 3
• Surgical anesthesia: Higher concentrations (0.75% or 1.0%) may be needed to match the sensory and motor blockade of bupivacaine 0.5-0.75% for lower limb or genitourinary surgery 3

Continuous Infusion

• EC50 for elderly patients: Approximately 0.4% ropivacaine for lower limb surgery, which can be reduced when combined with opioids like oxycodone 4

Advantages Over Bupivacaine

• Reduced CNS and cardiotoxic potential compared to bupivacaine 3, 5
• Lower propensity for motor block at equivalent analgesic doses 3
• Shorter duration of motor blockade than bupivacaine 3

Lidocaine Epidural Dosing

Lidocaine is less commonly used for epidural anesthesia due to shorter duration, but can be administered intravenously (1.5 mg/kg bolus followed by 2 mg/kg/h infusion) when epidural is contraindicated. 6

Intravenous Alternative

• IV bolus: 1.5 mg/kg at induction 6
• IV infusion: 2 mg/kg/h during surgery for anti-inflammatory and opioid-sparing effects 6
• This is recommended when epidural is not feasible or contraindicated 6

Pediatric Emergency Dosing (Non-Epidural)

• IV/IO for arrhythmias: 1 mg/kg (maximum 100 mg), repeat every 5-10 min to maximum 3 mg/kg 6
• IV infusion: 20-50 mcg/kg/min 6

Critical Safety Considerations

Dose Calculation Pitfalls

• Always calculate weight-based dosing to avoid exceeding maximum safe doses 2
• Use ideal body weight for obese patients, not actual weight 1
• In elderly patients, consider dose reduction even though specific percentages are not defined 1

Cardiovascular and Hepatic Disease

• Reduce doses in patients with significant cardiac or hepatic disease 1
• Ropivacaine may be preferred over bupivacaine in these populations due to lower cardiotoxicity 3, 5

Monitoring Requirements

• High concentrations of local anesthetics can cause myocardial depression, hypotension, and seizures 6
• Bupivacaine has greater cardiotoxic potential than ropivacaine or lidocaine 5
• Have lipid emulsion available for local anesthetic systemic toxicity (LAST) treatment

Adjuvant Considerations

• Adding opioids (fentanyl, sufentanil, oxycodone) allows for lower concentrations of local anesthetics 3, 4
• Epinephrine 1:200,000 can increase maximum safe dose and prolong duration 2
• In elderly patients receiving epidural opioids, use reduced doses (e.g., 2 mg morphine rather than 4 mg) to avoid respiratory depression 7