ESP Block in Adolescent Idiopathic Scoliosis

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 Shah is a paid consultant for Pacira BioSciences, Inc.

Background

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CASE INFORMATION

Physician Name

Suken A. Shah, MD

Affiliation

Nemours / AI duPont Hospital for Children
Wilmington, DE

Surgical Case Performed

Posterior Spinal Fusion With Instrumentation for Adolescent Idiopathic Scoliosis

Inpatient or Outpatient Procedure

Inpatient

PATIENT CHARACTERISTICS

Gender

Female

Age

14 years

Patient Weight

45 kg

Patient History
and Characteristics

The patient is a 14-year-old female who presented with a large magnitude scoliosis that was not amenable to brace treatment and a posterior correction with instrumentation and fusion was recommended. She has normal neurologic function (MRI normal) with mild to moderate back pain but participates in light sports and dance. Scoliosis x-rays demonstrate a double major curve pattern (Lenke 3) with curves measuring 80 and 75 degrees in the thoracic and lumbar areas, respectively. Her diagnosis is consistent with progressive adolescent idiopathic scoliosis.

PROCEDURAL DETAILS

Incision Size

16 inches

Incision Type

Posterior spinal

Preoperative Analgesics Used

See appendix

Patient/Parent Education Regarding
Pain Management

Conducted at the preoperative visit by our nurse practitioners. Pain expectations are assessed and education is provided. Multimodal pain management with opioid avoidance is emphasized, medications discussed (inpatient and outpatient strategies), and expectations for discharge are set.

Dosing and Administration

45 kg x 4 mg/kg = 180 mg dose
180 mg ÷ 13.3 mg/mL = 13.5 mL of EXPAREL^® (bupivacaine liposome injectable suspension)
EXPAREL then expanded with 120 mL normal saline injectable
(Please refer to the Dosing and Administration Guide for calculations.)*

Needle Size, Number of Syringes

22-g spinal needles with 20-mL syringes (3) filled with EXPAREL and saline.

Premix or Administer EXPAREL Separately

EXPAREL mixed with normal saline for expansion.

Intraoperative Analgesic Used
Dose of EXPAREL and Total Volume Used

Maximum total volume: 45 kg patient x 4 mg/kg ÷ 0.89 mg/mL = 202.2 mL
202.2 mL - 13.5 mL of EXPAREL = 188.7 mL of normal saline. For this instance, only 120 mL of normal saline was needed. (Please refer to the Dosing and Administration Guide for calculations.)*

*EXPAREL is available in 10-mL and 20-mL vials.

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.

Injection sites are placed 1-1.5 cm apart in the erector spinae muscle plane (subfascial) and subcutaneously. Spinal needles are used to gain access a few centimeters lateral to the incision, penetrating the muscle in the subfascial location and injecting as needle is withdrawn from each injection site. This is repeated around the periphery of the incision, circumferentially, including the apices of the incision, since the soft tissues are subjected to trauma from the retractors.

This is done just prior to closure, or at the time of thoracodorsal fascial closure to view the anatomy and obtain precision with the injections.

EXPAREL was injected slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle). Infiltrate above and below the fascia and into the subcutaneous tissue. EXPAREL was injected frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage.

POSTSURGICAL INSTRUCTIONS INCLUDING PRESCRIPTIONS PROVIDED AND RECOVERY MILESTONES AND GOALS

Patient was instructed to sit up in bed and allowed oral intake with a regular diet on POD #0
POD #1 – out of bed to chair for 1-hour intervals (at least 2X) and ambulation in room or hall
POD #2 – ambulation outside of room for 100 meters (at least 2X) and attempt stair climbing in proportion to home requirement. Discharge anticipated
POD #3 – ambulation outside of room for >100 meters (at least 2X) and attempt stair climbing in proportion to home requirement. Discharge expected
Pain medications: as an inpatient, scheduled oxycodone, valium, non-narcotic adjuncts as described in appendix; schedule is switched to as needed by POD #2
Discharge medications: oxycodone (7 days), diazepam, ibuprofen, acetaminophen and stool softeners
Initially, for the first several days at home: scheduled naproxen (weight-based dosing) twice daily, acetaminophen every 4-6 hours, oxycodone for breakthrough pain unrelieved by this non-narcotic regimen, diazepam for severe spasm. Stool softeners may be used for constipation until off of all narcotics

PATIENT FOLLOW-UP

This patient did not use any IV narcotics after those received in the operating room and PACU
Postsurgical pain was well controlled with oral narcotics and multimodal pain regimen listed on previous page
Postsurgical visit at 4 weeks: patient was doing very well, had returned to school, and was interested in increasing her activity. She used less than ½ of the oxycodone prescribed and was off all pain medications in 1 week

For more information, please reference the corresponding PDF .

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