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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 Sethi 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 Sethi determined a total volume of approximately 60 mL would be needed to create a field block at the surgical site. He expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 40 mL of normal saline. No additional bupivacaine HCl was added to the EXPAREL mixture because the patient received an interscalene nerve block with bupivacaine HCI.
20 to 30 mL of 0.5% bupivacaine HCI may be added to the EXPAREL mixture if the patient is not receiving an interscalene nerve block.
Dr Sethi 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 SIZES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE) AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION
For this procedure, Dr Sethi divided the injectate into three 20-mL syringes with 20-gauge spinal needles.
He then marked off the surgical site as follows:
After these lines were drawn, Dr Sethi planned to infiltrate as follows:
Inserted syringe 10° anteriorly at Point A until the tip of needle encountered the bony floor of the scapula. After aspirating to ensure needle was not intravascular, Dr Sethi injected 10 mL of expanded EXPAREL® (bupivacaine liposome injectable suspension). He then continued to inject 1 to 1.5 mL every 1 to 1.5 cm along the line between Points A and B.
FIGURE 1. Point A to Point B
Inserted needle at Point B down to the bone and injected 7.5 to 10 mL of expanded EXPAREL. Then Dr Sethi continued to inject 1 to 1.5 mL every 1 to 1.5 cm along the line between Points B and C.
FIGURE 2. Point B to Point C
You will likely run out of injectate in Syringe #2 before reaching Point C. Use Syringe #3 to complete infiltration to Point C.
Infiltrated 1 to 1.5 mL of expanded EXPAREL every 1 to 1.5 cm until Point C was reached. Then Dr Sethi continued to infiltrate along the line between Points C and A until all remaining injectate was used.
FIGURE 3. Point C to Point A
Injections from Points C to A must be lateral to the coracoid and should not be carried to the bone.
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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