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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 Bains 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.
Dr Bains determined a total volume of 90 mL would be needed to cover the surgical site. He admixed 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 30 mL of 0.5% bupivacaine HCI and 40 mL of normal saline before dividing the total volume into 3 needles of 30 mL each.
Prior to the incision for a 3-level decompression laminectomy, the ESP block is performed under fluoroscopy using a 20-gauge, 3.5-inch spinal needle.
Two needles are directed through the muscle until the needle contacts the lateral aspect of the transverse process.
The first needle with 30 mL is injected on the right side through the paraspinal muscles from dorsal fascia at the L1 transverse process. The same is done on the left side with the second 30-mL needle.
FIGURE 1.
FIGURE 2.
PROPER TECHNIQUE FOR SURGICAL INFILTRATION
Before closure, the last needle with 30 mL is injected within the fascia and subcutaneous tissue about 1 to 1.5 cm apart. This is repeated with 1 to 2 mL per injection around the periphery of the incision, including the incision, using a moving needle technique while withdrawing the needle.
FIGURE 3.
ADDITIONAL EXAMPLES OF ESP BLOCKS PERFORMED UNDER FLUOROSCOPY
FIGURE 4.
FIGURE 5.
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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