Objective. This report describes a case in which the off-label use of liposomal bupivacaine (Exparel) in a peripheral nerve block resulted in marked improvement of a patient’s vasoocclusive symptoms. The vasodilating and analgesic properties of liposomal bupivacaine in patients with ischemic symptoms are unknown, but our clinical experience suggests a role in the management of patients suffering from vasoocclusive disease. Case Report. A 45-year-old African American female was admitted to the hospital with severe digital ischemic pain. She was not a candidate for any vascular surgical or procedural interventions. Two continuous supraclavicular nerve blocks were placed with modest clinical improvement. These effects were also short-lived, with the benefits resolving after the discontinuation of the peripheral nerve blocks. She continued to report severe pain and was on multiple anticoagulant medications, so a decision was made to perform an axillary nerve block using liposomal bupivacaine (Exparel) given the compressibility of the site as well as the superficial nature of the target structures. Conclusions. This case report describes the successful off-label usage of liposomal bupivacaine (Exparel) in a patient with digital ischemia. Liposomal bupivacaine (Exparel) is currently FDA approved only for wound infiltration use at this time. 1. Introduction Chemical sympathectomy from peripheral nerve blockade is well known and especially beneficial in vascular surgery . Limited data are available regarding chemical sympathectomy in patients with digital ischemic pain and vasculopathy. Patients with these conditions, especially those with ischemic pain secondary to autoimmune disorders, benefit from chemical and surgical sympathectomy [2, 3]. The benefits of surgical sympathectomy often persist for years after the surgical procedure . Exparel is a liposomal bupivacaine formulation that is currently FDA approved only for wound infiltration use. While this novel anesthetic is most commonly used during bunion and hemorrhoid surgery, it is also used in a number of other colorectal and orthopedic procedures and is gaining popularity in other surgical specialties [4, 5]. Its vasodilatory properties are unknown at this time. 2. Case Report Written informed consent was obtained from the patient after a lengthy discussion of the known and potential risks and benefits of the block procedure, and all questions were answered. Witnessed verbal consent was obtained from the patient prior to the preparation of this case report. Additionally, the Ochsner Clinic
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