From the FDA Drug Label
The duration of anesthesia with Bupivacaine Hydrochloride is such that for most indications, a single dose is sufficient Maximum dosage limit must be individualized in each case after evaluating the size and physical status of the patient, as well as the usual rate of systemic absorption from a particular injection site Most experience to date is with single doses of Bupivacaine Hydrochloride up to 225 mg with epinephrine 1:200,000 and 175 mg without epinephrine; more or less drug may be used depending on individualization of each case.
The maximum dose of bupivacaine for an incision and a tap block is not explicitly stated in the label, but the maximum dosage limit must be individualized in each case.
- The recommended dose for infiltration and block injection is 1.8 mL (9 mg) per injection site.
- The total dose for all injection sites should not exceed 90 mg for a healthy adult patient.
- The maximum dose with epinephrine is up to 225 mg and without epinephrine is up to 175 mg. 1
From the Research
You can administer the maximum dose of Exparel (liposomal bupivacaine) in an incision and use plain bupivacaine for a TAP block in the same patient, with careful consideration of the total bupivacaine dose to avoid exceeding the maximum safe limit. The maximum recommended dose of Exparel is 266 mg (20 mL of 1.3% solution) for surgical site infiltration, as supported by a study published in 2020 2. For the TAP block, you can use plain bupivacaine at a dose of up to 2-3 mg/kg (not exceeding 175 mg total for 0.25% or 225 mg for 0.5% concentration).
When combining these medications, it's essential to calculate the total bupivacaine dose from both formulations to avoid exceeding the maximum safe limit. The two formulations have different pharmacokinetic profiles - Exparel provides slow release of bupivacaine over 72-96 hours, while plain bupivacaine has a faster onset and shorter duration (4-8 hours). This combination approach can provide both immediate and prolonged analgesia. However, be mindful of potential systemic toxicity, especially in smaller patients or those with liver dysfunction, as both medications contain bupivacaine as the active ingredient. A recent study published in 2024 found that the incidence of local anesthetic systemic toxicity (LAST) was higher in patients undergoing total hip arthroplasty compared to those undergoing total knee arthroplasty 3.
Some key points to consider when using Exparel and plain bupivacaine together include:
- Calculating the total bupivacaine dose to avoid exceeding the maximum safe limit
- Monitoring patients for signs of systemic toxicity, especially those with liver dysfunction or smaller patients
- Being aware of the different pharmacokinetic profiles of Exparel and plain bupivacaine
- Considering the use of alternative anesthetic agents, such as lidocaine, which may have a faster onset and shorter duration of action 4
- Following the recommended dosing guidelines for Exparel and plain bupivacaine, as supported by studies such as the one published in 2020 2 and 2016 5.