Can Exparel Be Used for Supraclavicular Block?
Exparel (liposomal bupivacaine) is currently FDA-approved only for local tissue infiltration and interscalene nerve blocks—it is NOT approved for supraclavicular blocks and should not be used for this indication. 1
FDA-Approved Indications for Exparel
- Exparel is approved exclusively for tissue infiltration during surgery and for interscalene nerve block analgesia following shoulder surgery 1
- The FDA has not extended approval to other peripheral nerve blocks, including supraclavicular approaches 1
- A pilot study specifically examining liposomal bupivacaine in supraclavicular blocks concluded that "liposomal bupivacaine is currently only approved for local anesthetic infiltration use" 2
Evidence from Off-Label Use Attempts
- One prospective randomized pilot study attempted to use Exparel for supraclavicular blocks in upper extremity surgery, but found no significant differences in postoperative quality of life scores compared to standard techniques 2
- The study noted that in some cases, the short-acting component of the block resolved in the recovery room, leading to higher pain scores and increased analgesic requirements before discharge 2
- The authors concluded that "larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery" 2
Alternative Approaches for Supraclavicular Blocks
For upper limb surgery requiring supraclavicular block, use standard bupivacaine formulations with evidence-based adjuvants:
- Standard 0.5% bupivacaine (either racemic or S(-)-bupivacaine) provides effective sensory block lasting approximately 15 hours (892-1039 minutes) for supraclavicular approaches 3
- Adding clonidine 30 mcg to 0.5% bupivacaine extends analgesia duration from 194 minutes to 415 minutes without clinically significant adverse effects beyond sedation 4
- Adding dexamethasone 8 mg to 0.5% bupivacaine provides more rapid onset and longer duration than epinephrine or midazolam adjuvants 5
Consider Alternative Block Approaches
If prolonged analgesia is the goal, consider infraclavicular block instead of supraclavicular block:
- Infraclavicular blocks avoid respiratory compromise by sparing the phrenic nerve, unlike supraclavicular blocks which carry significant risk of hemidiaphragmatic paralysis 6, 7
- The American Society of Anesthesiologists recommends choosing infraclavicular blocks over supraclavicular blocks when minimizing respiratory interference is a priority 6
- Infraclavicular blocks provide superior postoperative analgesia with opioid-sparing effects and a number needed to treat of 2.5 6
Critical Safety Considerations
- Using Exparel off-label for supraclavicular blocks exposes patients to potential risks without established efficacy data 2
- All brachial plexus blocks must be performed with ultrasound guidance to reduce local anesthetic systemic toxicity risk 7
- Supraclavicular blocks are high bleeding risk procedures where compression cannot be applied if bleeding occurs 7