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Anterior Total Hip Arthroplasty
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 Sah is a paid consultant for Pacira BioSciences, Inc.
Background
CASE INFORMATION
Physician Name
Alexander P. Sah, MD
Affiliation
Sah Orthopaedic Associates; Medical Co-director, Institute for Joint Restoration; Director, Outpatient Joint Replacement Program; Chair, IJRR Research and Education Committee, Fremont, CA
Surgical Case Performed
THR, anterior approach
Inpatient or Outpatient Procedure
Outpatient
PATIENT CHARACTERISTICS
Gender
Male
Age
70 years
Patient History and Characteristics
Patient presented with worsening right hip pain and concomitant limitations, as well as chronic increasing groin pain. X-rays confirmed bone-on-bone OA. Patient underwent a successful left THR with a mini-posterior approach 16 months prior and was prepared to proceed with a right THR using an anterior approach.
PROCEDURAL DETAILS
Incision Size
8 to 10 cm
Preoperative Medications Used
IV dexamethasone 10 mg, IV TXA 1 g
Preoperative Analgesics Used
PO 200 mg celecoxib, PO tramadol 100 mg, PO pregabalin 75 mg,
IV acetaminophen 1 g
IV acetaminophen 1 g
Intraoperative Analgesics Used
Upon induction of general anesthesia, 80 mL of expanded EXPAREL
for local infiltration
for local infiltration
Dose of EXPAREL and Total Volume Used
IV=intravenous; OA=osteoarthritis; PO=by mouth; TXA=tranexamic acid.
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 Sah determined 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 30 mL of normal saline and admixed this solution with 30 mL of 0.5% bupivacaine HCI. Bupivacaine HCI was admixed 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 MULTIPLE SYRINGES WITH NEEDLE SIZES APPROPRIATE FOR INFILTRATION (20 TO 25 GAUGE) AND INFILTRATED INTO THE SURGICAL SITE
Dr Sah divided the EXPAREL injectate into four 20-mL syringes with 22-gauge needles.
For a total hip replacement (anterior approach), the EXPAREL injectate should be infiltrated as follows: 40% in the deep tissues, 40% in the mid-level/anterior tissues, and 20% in the superficial tissues.
PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE
Dr Sah 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.
Step #1
Before placing the prosthesis, Dr Sah infiltrated 32 mL of expanded EXPAREL® (bupivacaine liposome injectable suspension) into the deep tissues surrounding the capsule (anterior capsule, superior capsule, posterior capsule, deep anterolateral capsule, psoas tendon), the obturator externus, and the periosteum.
FIGURE 1. Deep tissues
Care should be taken not to inject into the tissue posterior to the hip capsule due to the proximity of the sciatic nerve.
Step #2:
After placing the prosthesis, Dr Sah infiltrated 32 mL of expanded EXPAREL into the mid-level/anterior target sites superficial to the deeper capsular structures. These included the gluteus medius and minimus muscles, the rectus femoris muscle, the tensor fascia lata muscle, and the sartorius muscle.
FIGURE 2. Mid-level/anterior tissues
Step #3:
Dr Sah then injected 16 mL of expanded EXPAREL into the superficial fascia, subcutaneous layer, and skin surrounding the surgical site.
FIGURE 3. Superficial tissues
ASP, average sales price; CMS, Centers for Medicare and Medicaid Services.
Important Notice
- This site is intended to provide medical and product information to health care professionals in the United States.
- To report an adverse event, email drugsafety@pacira.com or call 1-855-793-9727.
- For medical inquiries related to EXPAREL, submit a request to Medical Information or call 1-855-793-9727.
- These are not all of the potential important safety considerations for EXPAREL; please see the full Prescribing Information.
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
