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This case study represents an individual clinician experience with and methodology for using EXPAREL.
Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.
Please see Important Safety Information below and refer to the Full Prescribing Information.
Disclosure: Dr Sigman is a paid consultant for Pacira BioSciences, Inc.
The recommended dose of EXPAREL for infiltration in adults is based on the size of the surgical site, the volume required to cover the area, and individual patient factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg. The recommended dose of EXPAREL for patients aged 6 to <17 years old is 4 mg/kg, up to a maximum of 266 mg. The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal is 133 mg. The recommended dose of EXPAREL in adults for adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) of 0.5% bupivacaine HCl, for a total volume of 20 mL.
EXPAREL can be administered unexpanded (20 mL) or expanded to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL [ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.
Bupivacaine HCl (which is approved for use in patients aged 12 and older) may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should be used with caution, including monitoring for neurological and cardiovascular effects related to local anesthetic systemic toxicity. Other than with bupivacaine, EXPAREL should not be admixed with other drugs prior to administration.
ASSESSED THE SIZE OF THE SURGICAL SITE AND DEPTH OF TISSUE, THEN PREPARED INJECTION MATERIALS ACCORDINGLY
In this procedure, Dr Sigman determined that a total volume of 80 mL would be needed to cover the surgical site. He expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 40 mL of normal saline and then admixed 20 mL of 0.25% bupivacaine HCl. Dr Sigman added bupivacaine HCl to provide short-term local analgesia that overlapped with the long-term local analgesia provided by EXPAREL.
Dr Sigman infiltrated EXPAREL® (bupivacaine liposome injectable suspension) into all tissue layers using a moving needle technique. With a moving needle technique, the injections were spread in a fan-like pattern and occurred as the needle was withdrawn to maximize the coverage area. This technique was systematically and meticulously repeated at each injection site, with overlapping diffusion of EXPAREL to ensure there were no gaps in analgesic coverage.
DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE GAUGES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE) AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION
For this procedure, Dr Sigman divided the injectate into eight 10-mL syringes with 22-gauge needles. He then infiltrated as follows:
Dr Sigman infiltrated 10 mL of expanded EXPAREL® (bupivacaine liposome injectable suspension) into the quadriceps tendon along the midline incision into the deep tissue.
FIGURE 1. Quadriceps tendon
Dr Sigman infiltrated 10 mL of expanded EXPAREL into the subcutaneous tissues along the length of the incision, injecting every 1 to 1.5 cm to achieve consistent coverage throughout the soft tissue.
FIGURE 2. Subcutaneous tissue alongincision
Dr Sigman infiltrated 10 mL of expanded EXPAREL in an arch across the lateral side of the patella, into the skin, soft tissue, and retinaculum. This created a field block of the anterior femoral cutaneous nerve where it branches into the intermediate and medial branches of the lateral femoral cutaneous nerve.
FIGURE 3. Femoral nerve field block(lateral)
Dr Sigman infiltrated 10 mL of expanded EXPAREL in an arch across the medial side of the patella, into the skin, soft tissue, and retinaculum. This created a field block of the lateral and intermediate branches of the anterior femoral cutaneous nerve.
FIGURE 4. Femoral nerve field block(medial)
Dr Sigman infiltrated 10 mL of expanded EXPAREL along the medial aspect of the knee just below the patella, establishing a field block of the infrapatellar branch of the saphenous nerve. He infiltrated expanded EXPAREL every 1 cm.
FIGURE 5. Saphenous nerve fieldblock
He then infiltrated 5 mL of expanded EXPAREL into the subcutaneous tissue along each of the planned incisions for the 2 arthroscopy portals. Infiltration at these points also provided analgesia of the fat pad.
FIGURE 6. Arthroscopy portal incisionsites
Dr Sigman infiltrated 10 mL of expanded EXPAREL around the planned site for the tibial tunnel, being sure to infiltrate into the periosteum and the subcutaneous tissues.
FIGURE 7. Femoral nerve field block(lateral)
Following removal of the femoral exit pin, Dr Sigman infiltrated 10 mL of expanded EXPAREL into the periosteum and subcutaneous tissues in that area. He infiltrated prior to placement of the instrumentation to avoid potentially cutting the eventual suture.
FIGURE 8. Femoral exit pin incision
ASP, average sales price; CMS, Centers for Medicare and Medicaid Services.
EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.
Please refer to full Prescribing Information.
EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration
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