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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 Ramshaw 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 Ramshaw determined that a total volume of approximately 150 mL would be needed to cover the entire abdominal wall bilaterally. He expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 30 mL of 0.25% bupivacaine and 100 mL of normal saline. The addition of 0.25% bupivacaine was to provide early, short-term local analgesia that overlapped with the long-term local analgesia provided by EXPAREL.
To ensure complete analgesic coverage of the surgical site, Dr Ramshaw assumes that 0.5 to 1 mL will be infiltrated per layer (peritoneal, musculofascial, and subdermal planes) for every 1 to 1.5 cm of surgical incision.
DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE GAUGES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE) AND INFILTRATED INTO THE SURGICAL SITE
For this procedure, Dr Ramshaw mixed EXPAREL® (bupivacaine liposome injectable suspension), 0.25% bupivacaine, and normal saline in a mixing bowl. He then filled two 10-mL syringes with 21-gauge needles and refilled these syringes as needed during the procedure.
Dr Ramshaw planned to infiltrate as follows:
Prior to the initial incision, Dr Ramshaw infiltrated approximately 50 mL of expanded EXPAREL laterally along the planned incision.
FIGURE 1. Skin and subdermal
In certain cases, the skin and subdermal infiltration can be done just prior to closure (ie, when additional skin and soft tissue excision is anticipated).
Dr Ramshaw dissected laterally in the retrorectus space, anterior to the posterior rectus fascia. This allowed him to visualize the neurovascular bundles traversing from the transversus abdominis posteriorly through the rectus muscle anteriorly.
He then infiltrated approximately 50 mL of expanded EXPAREL medial to the neurovascular bundles on both the left and the right sides of the abdominal wall (total volume of approximately 100 mL) to provide an anesthetic block and hydrodissection in the plane between the transversus abdominis and the peritoneum.
After completing bilateral infiltration and anesthetic block, Dr Ramshaw performed a transversus abdominis release by transecting the transversus abdominis vertically, just medial to the neurovascular bundles, for mesh placement.
FIGURE 2. Abdominal wall, transversus abdominis plane, surrounding tissues
The infiltration hydrodissection allows for easier separation of the transversus abdominis from the peritoneum. This facilitates the transversus release and potentially decreases the likelihood of damaging the peritoneum during dissection.
Because the patient had a previous open anterior component separation bilaterally, a permanent synthetic mesh was sewn bilaterally to the lateral cut transversus abdominis fascia.
Following placement of the new surgical mesh, Dr Ramshaw infiltrated any remaining expanded EXPAREL into the surrounding musculofascial tissue.
FIGURE 3. Musculofascial tissue
When infiltrating EXPAREL® (bupivacaine liposome injectable suspension), Dr Ramshaw makes sure to use an expansion volume that is appropriate for the size of the surgical site he is infiltrating. He then infiltrates using a 21- or 22-gauge, 1.5-inch needle. It is important to ensure all layers of the surgical incision are infiltrated in a controlled and meticulous manner, and that EXPAREL is injected within the tissue planes. To do this, Dr Ramshaw inserts the needle approximately 0.5 cm to 1 cm into the peritoneal, musculofascial, and subdermal tissue planes. Dr Ramshaw then uses a continuous motion fanning, or moving needle technique, where EXPAREL is slowly injected while withdrawing the needle in order to adequately infiltrate all layers of the skin. Dr Ramshaw aspirates prior to injection to reduce the risk of intravascular injection.
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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