Is It Justified to Inject IV Bupivacaine Plus Epinephrine in Children to Determine Its Reliability as a Test Dose?

Abstract

To the Editor For several reasons, we question the appropriateness of injecting 0.25% bupivacaine with epinephrine (1:200,000) in children as part of a study to determine its reliability to indicate inadvertent intravascular injection.1 First, Polaner et al. injected 0.1 mL/kg 0.25% bupivacaine (maximum 3 mL) with 1:200,000 epinephrine and, based on an estimated blood volume of 2 to 2.5 L in a 30-kg child, a concentration approaching the cardiotoxic level of 3 to 4 μg/mL could be reached. Second, intravascular 0.125% bupivacaine (0.2–0.4 mL/kg) with 1:200,000 epinephrine has been shown to be more effective in demonstrating an increase in heart rate and T wave amplitude as compared with 0.125% bupivacaine alone in neonatal piglets under sevoflurane anesthesia.2 Similar hemodynamic changes were demonstrated with 0.5 μg/kg epinephrine in combination with lidocaine or bupivacaine in children receiving sevoflurane anesthesia.3,4 In other words, it is likely that the epinephrine alone rather than the local anesthetic is responsible for the hemodynamic changes observed after intravascular injection and, if applied to this study, could have spared these children anesthetized with propofol-remifentanil the IV injection of a potentially dangerous dose of bupivacaine. Third, the depth of anesthesia was not tested and it is possible that the variability of response is a function of anesthetic depth. In view of the above, we wonder if exposing children as young as 8 months to intravascular bupivacaine is justified. Anjolie Chhabra, MBBS, MD, DNB Gautham Ganesan, MBBS Department of Anesthesiology and Intensive Care All India Institute of Medical Sciences Ansari Nagar New Delhi, India [email protected]