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

Ankle Fracture

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 Munz is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
John W. Munz, MD
Affiliation
Orthopedic Trauma Surgeon, University of Texas Health and McGovern Medical School Memorial Hermann Hospital, Houston, TX
Surgical Case Performed
Open reduction and internal fixation of right trimalleolar ankle fracture
Inpatient or Outpatient Procedure
Outpatient
PATIENT CHARACTERISTICS
 
Gender
Female
Age
36 years
Patient History and Characteristics
Patient presented 9 days prior with a trimalleolar fracture of the right ankle with compromised medial soft tissue due to a fall down the stairs and is returning for surgery. The patient had a history of nausea with opioid medications and requested to avoid taking any opioid medications.
PROCEDURAL DETAILS
 
Incision Size
Posterolateral: 15 cm (prone position)
Medial: 7 cm (supine position)
Preoperative Analgesics Used
PO acetaminophen 500 mg
Intraoperative Analgesics Used
Fentanyl upon induction of general anesthesia
Dose of EXPAREL and Total Volume Used
20ml
PO=by mouth.

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 Munz determined a total volume of 35 mL would be needed to cover the surgical site. He admixed 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 15 mL of 0.25% bupivacaine HCI. Bupivacaine HCI was added to provide short-term local analgesia in the postanesthesia care unit that overlapped with the long-term local analgesia provided by EXPAREL.

DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE SIZES APPROPRIATE FOR INFILTRATION (23-GAUGE) AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION

For this procedure, Dr Munz divided the injectate into two 20-mL syringes using 23-gauge needles and infiltrated as follows:

injection

Dr Munz did not use a smaller needle (eg, 27 gauge) due to concerns about shearing of liposomes and the early release of EXPAREL.

PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE

Dr Munz 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 fanlike pattern and occurred as the needle was both inserted and 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.

technique

Step 1: Posterolateral incision

After completion of the posterolateral approach and fixation, the incision was irrigated and infiltrated with 20 mL of the EXPAREL® (bupivacaine liposome injectable suspension) (266 mg/20 mL) injectate. 1 to 2 mL was infiltrated every 1.0 to 1.5 cm into the deepest layers (periosteum, muscular, and dermal layers) and the subcutaneous layers.

posterolateral-1
posterolateral-2

Step 2: Medial incision

After completion of the medial approach and fixation, the incision was irrigated and infiltrated with 15 mL of the EXPAREL injectate. 1 to 2 mL was infiltrated every 1.0 to 1.5 cm into the deepest layers (periosteum, muscular, and dermal layers) and the subcutaneous layers.

medial-1
medial-2

Ankle FracturePerformed by: Dr. John W. Munz

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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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