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Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.

ACL Repair

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.

Background
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CASE INFORMATION
 
Physician Name(s)
Sean McMillan, DO (Orthopedics)
Bernard C. Ciongoli, DO (Anesthesiology)
Affiliation
Mount Holly Hospital, Mt Holly, NJ
Surgical Case Performed
Anterior cruciate ligament tear with lateral meniscus tear
Inpatient or Outpatient Procedure
Outpatient
PATIENT CHARACTERISTICS
 
Gender
Male
Age
18 years
Patient History and Characteristics
85 kg, 18-year-old male injured playing high school football. Plans on playing collegiate football. He incurred a valgus injury to the knee while making a football tackle. The anesthetic plan included general anesthesia as well as an adductor canal block for postoperative pain using an admixture of EXPAREL and bupivacaine HCl as well as an iPACK infiltration.
PROCEDURAL DETAILS
 
Incision Type
8 cm anterior incision for the graft harvest and standard arthroscopic portals.
Preoperative Medications Used
  • Acetaminophen 975 mg x 1
  • Celecoxib 400 mg PO x 1
  • Adductor canal block with 133 mg (10 mL) EXPAREL
    admixed with 0.5% bupivacaine HCl 50 mg (10 mL)
  • iPACK nerve infiltration with 133 mg (10 mL) EXPAREL
    admixed with 0.5% bupivacaine HCl 50 mg (10 mL)
Intraoperative Medications Used
  • 15 mg IV ketorolac at conclusion of the case
Postoperative Medications Used
  • 15 mg IV ketorolac in postanesthesia care unit
Preoperative Medications Used
  • Ibuprofen 400 mg x 30 pills, 1-2 every 8 hours for pain
  • Acetaminophen 500 mg x 30 pills, 1-2 every 8 hours for pain
  • Oxycodone/acetaminophen 5 mg/325 mg x 10 pills, PO for breakthrough pain, 1 every 6 hours as needed
PO=by mouth.

The recommended dose of EXPAREL for 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 (20 mL). The recommended dose of EXPAREL for patients aged 6 to <17 years is 4 mg/kg, up to a maximum of 266 mg (20 mL). The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block and sciatic nerve block in the popliteal fossa is 133 mg (10 mL). The recommended dose of EXPAREL in adults for an adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) 0.5% bupivacaine HCL, for a total volume of 20 mL.

EXPAREL ADMINISTRATION DETAILS
 
Dose of EXPAREL Used
266 mg (20 mL) divided equally between adductor canal block and iPACK infiltration
Did You Expand the Volume?
No
Did You Admix With Bupivacaine?
Yes, with 20 mL of 0.5% bupivacaine HCl (100 mg) divided equally between adductor canal block and iPACK infiltration
Total Volume Used
20ml
Needle Used
100-mm 21-gauge block needle

STEP 1

A linear ultrasound transducer was placed in a transverse orientation over the anteromedial thigh at the midpoint between the inguinal crease and the patella. The femoral artery was observed centered beneath the sartorius muscle. The saphenous nerve was visualized anterolateral to the femoral artery; the nerve to vastus medialis was not visualized.

STEP 2

After skin preparation and using sterile technique, a 21G 100-mm block needle was advanced in-plane from the lateral aspect aiming for the femoral artery in a trajectory that traveled just deep to the sartorius muscle.

STEP 3

The needle was then directed to the saphenous nerve, passing through the vastoadductor membrane, and 20 mL of local anesthetic mixture was then administered at this location.

ADDITIONAL NOTES

  • A supplemental infiltration of the interspace between the popliteal artery and capsule of the knee (iPACK block) was performed under ultrasound guidance to anesthetize the popliteal plexus for control of posterior knee pain. The local anesthetic used was 133 mg (10 mL) of EXPAREL admixed with 0.5% bupivacaine HCl 50 mg (10 mL)
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Important Notice

Indication

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.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

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.

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