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The Use of Liposomal Bupivacaine in the Treatment of Vaso-occlusive Symptoms in the Hand
Scott F.M. Duncan, MD, MPH, MBA1; Jose Soberon, MD2
1Department of Orthopedic Surgery, Ochsner Health System, New Orleans, LA; 2Department of Anesthesia, Ochsner Health System, New Orleans, LA

Purpose: To evaluate the use of a long acting liposomal bupivacaine in the salvage treatment and rescue of vascularly compromised upper extremity limbs that had failed other conventional treatment.

Methods: We have IRB approval to utilize 1.3% liposomal bupivacaine (Exparel) in an FDA off-label fashion for upper extremity treatment of limbs showing vascular compromise. The protocol allows us to use it when there is a limb threatening vascular emergency that has failed conventional treatment. An ultrasound-guided axillary block was performed with 3ml injected incrementally around the musculocutaneous, radial, median, and ulnar nerves. A total of 12mL of Exparel was used, corresponding to a total dose of 159.6mg. The patients are monitored in the block area 30 minutes after the procedure and placed on continuous telemetry monitoring for the remainder of their hospital stay.

Results: We have an ongoing case series of 7 patients that have had Exparel used to rescue hands showing evidence of vascular compromise. Photoplethysmography (PPG) studies were performed during hospital admissions, and the results illustrated increased flow in the effected digits on the PPG studies, even one week after the liposomal bupivacaine block. Several of these patients have had their extremities saved with this intervention, while others have required less to be amputated because of the improved vascular viability of the limb secondary to the block. Patients self reported improvement in their symptoms, even after the block had technically worn off.

Discussion: We describe the off label use of Exparel to induce sympathetically mediated blockade, resulting in marked improvement both objectively and subjectively of vaso-occlusive symptoms. We believe that the benefits of this treatment potentially outweigh the risks in these patients where conventional treatment has failed, or where no other options exist.

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