What is the recommended dose of Exparel (bupivacaine liposome injectable suspension) for a single fascia iliaca block?

Exparel Dosing for Fascia Iliaca Block

Exparel (liposomal bupivacaine) is not FDA-approved for peripheral nerve blocks including fascia iliaca blocks, and current evidence does not support its use for this indication due to inconsistent analgesic effects and potential analgesic gaps. 1

Why Exparel Should Not Be Used

• Exparel has only been approved for wound infiltration, not for regional anesthesia or peripheral nerve blocks. 1

• Clinical case series demonstrate large variability in response when Exparel is used off-label for peripheral nerve blocks, with bimodal kinetics creating problematic analgesic gaps in patients. 1

• The inconsistent results make Exparel unreliable for fascia iliaca blocks where predictable, sustained analgesia is critical for patient mobilization and pain control. 1

Recommended Alternative: Standard Bupivacaine

For a single fascia iliaca block, use 0.2-0.5 ml/kg of bupivacaine 0.25% (maximum 2.5 mg/kg total dose). 2, 3

Specific Dosing Guidelines

• For ultrasound-guided fascia iliaca blocks: bupivacaine 0.25% at 0.2-0.5 ml/kg provides effective analgesia for hip fractures and lower extremity procedures. 2, 3

• For nerve stimulator-guided fascia iliaca blocks: the same dose range of 0.2-0.5 ml/kg of bupivacaine 0.25% is recommended. 2

• Clinical studies in hip fracture patients have successfully used 30-40 mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine for single-shot fascia iliaca blocks in adults. 2

• Alternative study protocols used 40 mL of 0.2% bupivacaine with adrenaline, demonstrating significant morphine-sparing effects and prolonged time to first rescue analgesia. 4, 5

Adjuvants to Prolong Duration

• Add preservative-free clonidine 1-2 mcg/kg to extend the duration of the block without using Exparel. 2, 6

• This combination provides reliable, predictable analgesia lasting 4-8 hours or longer, with proven efficacy in reducing opioid consumption. 4, 5

Safety Considerations

• Always calculate weight-based dosing to stay below the maximum safe dose of 2.5 mg/kg for bupivacaine 0.25%. 2, 3, 7

• Aspirate before injection, use incremental dosing, and monitor closely for local anesthetic systemic toxicity (LAST). 7

• Consider adding low-dose epinephrine (1:200,000) to decrease systemic absorption and prolong block duration. 2, 7

• Use ultrasound guidance when possible to visualize injectate spread and minimize risk of intravascular injection. 7

Alternative Local Anesthetics

• Ropivacaine 0.2% at 0.2-0.5 ml/kg (maximum 3 mg/kg) can be used as an alternative with potentially improved safety profile. 2, 3

• Levobupivacaine 0.25% at 0.2-0.5 ml/kg offers similar efficacy with potentially reduced cardiac toxicity compared to racemic bupivacaine. 2, 3