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Bupivacaine is a local anesthetic commonly used to numb specific areas of the body during medical procedures. While effective, its use carries certain risks that patients should be aware of.

Cardiac Risks: There have been reports of cardiac arrest and death during the use of bupivacaine for intravenous regional anesthesia (Bier Block). Information on safe dosages and techniques of administration of bupivacaine hydrochloride in this procedure is lacking. Therefore, bupivacaine hydrochloride is contraindicated for use with this technique.

Toxicity from Incorrect Administration: Unintended intravascular or intrathecal injection of bupivacaine hydrochloride may be associated with systemic toxicities, including central nervous system or cardiorespiratory depression and coma, progressing ultimately to respiratory arrest. Unintentional intrathecal injection during the intended performance of caudal or lumbar epidural block or nerve blocks near the vertebral column has resulted in underventilation or apnea ("Total or High Spinal"). A high spinal has been characterized by paralysis of the legs, loss of consciousness, respiratory paralysis, and bradycardia.

Chondrolysis Risk: Intra-articular infusions of local anesthetics including bupivacaine hydrochloride following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. The majority of reported cases of chondrolysis have involved the shoulder joint; cases of gleno-humeral chondrolysis have been described in pediatric and adult patients following intra-articular infusions of local anesthetics for periods of 48 to 72 hours. There is insufficient information to determine whether shorter infusion periods are associated with chondrolysis. The time of onset of symptoms, such as joint pain, stiffness and loss of motion can be variable, but may begin as early as the 2nd month after surgery. Currently, there is no effective treatment for chondrolysis; patients who experienced chondrolysis have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement.

Methemoglobinemia: Cases of methemoglobinemia have been reported in association with local anesthetic use. Although all patients are at risk for methemoglobinemia, patients with glucose 6 phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended. Signs of methemoglobinemia may occur immediately or may be delayed some hours after exposure, and are characterized by a cyanotic skin discoloration and/or abnormal coloration of the blood. Methemoglobin levels may continue to rise; therefore, immediate treatment is required to avert more serious central nervous system and cardiovascular adverse effects, including seizures, coma, arrhythmias, and death. Discontinue bupivacaine hydrochloride and any other oxidizing agents. Depending on the severity of the signs and symptoms, patients may respond to supportive care, i.e., oxygen therapy, hydration. A more severe clinical presentation may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.

Use in Patients with Liver Impairment: Because amide local anesthetics such as bupivacaine are metabolized by the liver, consider reduced dosing and increased monitoring for bupivacaine systemic toxicity in patients with moderate to severe hepatic impairment who are treated with bupivacaine hydrochloride, especially with repeat doses.

Use in Patients with Cardiovascular Impairment: Bupivacaine hydrochloride should be given in reduced doses in patients with impaired cardiovascular function (e.g., hypotension, heartblock) because they may be less able to compensate for functional changes associated with the prolongation of AV conduction produced by bupivacaine hydrochloride. Monitor patients closely for blood pressure, heart rate, and ECG changes.

Use in Head and Neck Area: Small doses of local anesthetics (e.g., bupivacaine hydrochloride) injected into the head and neck area, including retrobulbar and stellate ganglion blocks, may produce adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses. The injection procedures require the utmost care. Confusion, convulsions, respiratory depression, and/or respiratory arrest, and cardiovascular stimulation or depression have been reported. These reactions may be due to intra-arterial injection of the local anesthetic with retrograde flow to the cerebral circulation. They may also be due to puncture of the dural sheath of the optic nerve during retrobulbar block with diffusion of any local anesthetic along the subdural space to the midbrain. Monitor circulation and respiration and constantly observe patients receiving bupivacaine hydrochloride blocks. Resuscitative equipment and drugs, and personnel for treating adverse reactions should be immediately available. Dosage recommendations should not be exceeded.

Use in Ophthalmic Surgery: Clinicians who perform retrobulbar blocks should be aware that there have been reports of respiratory arrest following local anesthetic injection. Prior to retrobulbar block (e.g., with bupivacaine hydrochloride), as with all other regional procedures, resuscitative equipment and drugs, and personnel to manage respiratory arrest or depression, convulsions, and cardiac stimulation or depression should be immediately available. As with other anesthetic procedures, patients should be constantly monitored following ophthalmic blocks for signs of these adverse reactions, which may occur following relatively low total doses. A concentration of 0.75% bupivacaine is indicated for retrobulbar block; however, this concentration is not indicated for any other peripheral nerve block, including the facial nerve, and not indicated for local infiltration, including the conjunctiva.

Use in Dental Applications: Because of the long duration of anesthesia, when bupivacaine hydrochloride and epinephrine injection [0.5% (5 mg/mL) of bupivacaine] is used for dental injections, warn patients about the possibility of inadvertent trauma to tongue, lips, and buccal mucosa and advise them not to chew solid foods until sensation returns.

Allergic Reactions: Bupivacaine hydrochloride and epinephrine injection contains sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. Bupivacaine hydrochloride injection without epinephrine does not contain sodium metabisulfite.

Use in Patients with Hypertension: Sympathetic blockade due to spinal anesthesia may result in peripheral vasodilation and hypotension, the extent of which depends on the number of dermatomes blocked. Patients over 65 years, particularly those with hypertension, may be at increased risk for experiencing the hypotensive effects of bupivacaine spinal. Monitor blood pressure frequently, especially in the early phases of anesthesia. Hypotension may be controlled by administration of vasoconstrictor agents in titrated dosages depending on the severity of hypotension and response to treatment. Monitor the onset of adequate spinal anesthesia because it is not always possible to control the level of anesthesia after subarachnoid injection of bupivacaine spinal.

Use in Patients with Severe Disturbances of Cardiac Rhythm, Shock, or Heart Block: Consider alternate anesthetic techniques in patients with severe disturbances of cardiac rhythm, shock, or heart block.

Use in Patients with Impaired Cardiovascular Function: Bupivacaine spinal should be given in reduced doses in patients with impaired cardiovascular function (e.g., hypotension, heartblock, valvular abnormalities) because they may be less able to compensate for functional changes associated with the sympathetic blockade observed after subarachnoid administration of bupivacaine spinal and the prolongation of AV conduction produced by the drug. Monitor patients closely for blood pressure, heart rate, and ECG changes.

Use of Spinal Anesthetics During Uterine Contractions: Spinal anesthetics including bupivacaine spinal should not be injected during uterine contractions because cerebrospinal fluid current may carry the drug further cephalad than desired, resulting in a high motor block.

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Bupivacaine is a local anesthetic commonly used to numb specific areas of the body during surgical procedures, childbirth, or dental work. While effective in pain management, it can cause various side effects, ranging from mild to severe. Understanding these potential reactions is essential for patients and healthcare providers. Common Side Effects:

• Local Reactions: Patients may experience pain, redness, or swelling at the injection site.
• Neurological Symptoms: Dizziness, drowsiness, blurred vision, and ringing in the ears are possible.
• Gastrointestinal Issues: Nausea and vomiting can occur following administration.
• Muscle Weakness: Temporary weakness or numbness in the affected area is common. Serious Side Effects:
• Cardiovascular Effects: Bupivacaine can lead to low blood pressure, slow or irregular heartbeats, and in rare cases, cardiac arrest.
• Central Nervous System Reactions: Symptoms such as restlessness, anxiety, tremors, seizures, or even loss of consciousness may occur.
• Allergic Reactions: Although uncommon, some individuals may experience itching, hives, swelling of the face or throat, difficulty breathing, or rapid heartbeat.
• Methemoglobinemia: A rare condition where the blood carries less oxygen, leading to symptoms like pale or blue-colored skin, headache, rapid heart rate, shortness of breath, and fatigue. Precautions:
• Medical History: Inform your healthcare provider about any existing heart, liver, or kidney conditions, as well as any known allergies to local anesthetics.
• Monitoring: During and after administration, medical staff will monitor vital signs to detect and manage any adverse reactions promptly.
• Post-Procedure Care: Avoid activities requiring full alertness, such as driving, until the effects of bupivacaine have completely worn off. If you experience any severe or concerning symptoms after receiving bupivacaine, seek immediate medical attention.

When using bupivacaine, it's important to be aware of potential interactions with other medications, as these can affect its safety and effectiveness. Here are some key considerations:

Other Local Anesthetics: Combining bupivacaine with other local anesthetics can increase the risk of toxic effects. If such combinations are necessary, patients should be closely monitored for signs of nervous system and heart-related side effects.

Monoamine Oxidase Inhibitors (MAOIs) and Tricyclic Antidepressants: Using bupivacaine with Epinephrine in patients taking MAOIs or tricyclic antidepressants may lead to severe and prolonged high blood pressure. It's generally advised to avoid this combination. If it's unavoidable, careful monitoring of the patient's blood pressure and heart function is essential.

Ergot-Type Oxytocic Drugs: Combining bupivacaine with epinephrine and ergot-type drugs, which are sometimes used to control bleeding after childbirth, can cause dangerously high blood pressure or even strokes. This combination should be avoided.

Nonselective Beta-Blockers: Patients taking nonselective beta-blockers who receive bupivacaine with epinephrine may experience severe high blood pressure and slow heart rate. Concurrent use is generally discouraged, but if necessary, the patient's heart rate and blood pressure should be closely monitored.

Drugs Associated with Methemoglobinemia: Bupivacaine can increase the risk of methemoglobinemia, a condition where the blood can't carry oxygen effectively, especially when used with certain other drugs. These include:

• Nitrates/Nitrites: Such as Nitroglycerin and nitrous oxide.

• Other Local Anesthetics: Including Lidocaine and prilocaine.

• Antibiotics: Like Dapsone and sulfonamides.

• Antimalarials: Such as chloroquine and Primaquine.

• Anticonvulsants: Including Phenytoin and sodium valproate.

• Other Drugs: Such as Acetaminophen and Metoclopramide.

Patients receiving bupivacaine alongside these medications should be monitored for signs of methemoglobinemia, such as skin discoloration, fatigue, and shortness of breath.

Potent Inhalation Anesthetics: Using bupivacaine with epinephrine during or after administration of strong inhaled anesthetics can lead to serious heart rhythm problems. Careful monitoring is required in such cases.

Phenothiazines and Butyrophenones: These medications may reduce or reverse the blood pressure-raising effects of epinephrine. Concurrent use with bupivacaine and epinephrine should generally be avoided, but if necessary, close patient monitoring is essential.

Always inform your healthcare provider about all medications you're taking to ensure safe and effective use of bupivacaine.