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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 Barber is a paid consultant for Pacira BioSciences, Inc.
IV=intravenous; MRI=magnetic resonance imaging; PO=by mouth; prn=as needed; q8h=every 8 hours.
*Surgeons may choose to use PO celecoxib 200 mg in place of PO meloxicam 15 mg.
†Surgeons may choose to use PO ketorolac 10 mg 3 times daily for 3 days in place of PO meloxicam.
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 Barber determined a total volume of 80 mL would be needed to cover the surgical site. Since no adductor canal block was performed in this case, he expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 60 mL of bupivacaine HCl 0.25%. Bupivacaine HCl was added to provide early-onset analgesia and bridge the time to onset of the long-acting local analgesia provided by EXPAREL.
If admixing with bupivacaine HCl 0.5%, use normal saline to account for the difference in concentration and ensure a total volume of 80 mL. For example, 60 mL bupivacaine HCl 0.25% can be replaced with 30 mL of bupivacaine HCl 0.5% + 30 mL normal saline to achieve the same volume and concentration of the mixture.
In cases where an adductor canal block is performed with bupivacaine, many surgeons will admix 20 mL of EXPAREL with 30 mL of bupivacaine HCl 0.25% and 30 mL of normal saline, for a total of 80 mL.
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 Barber divided the injectate into a total of four 20-mL syringes, 2 using 21-gauge 1.5-inch needles and 2 using 20-gauge 3.5-inch spinal needles.
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. Dr Barber infiltrated as follows:
Preincision
Dr Barber began by infiltrating 7 to 10 mL of EXPAREL® (bupivacaine liposome injectable suspension) around the midpatellar lateral portal using a 1.5-inch needle. He created a field block around the lateral branch of the anterior femoral cutaneous nerve by infiltrating 1.5 mL of EXPAREL every 1 to 2 cm.
He then infiltrated 7 to 10 mL of EXPAREL into the areas around the superior lateral portal using a 3.5-inch spinal needle. This created a field block of the lateral and intermediate branches of the anterior femoral cutaneous nerve, as well as the femoral pin exit.
Using a 3.5-inch spinal needle, Dr Barber infiltrated 7 to 10 mL of EXPAREL to create a field block of the anterior femoral cutaneous nerve where it branches into the intermediate and medial branches. Starting from the superior medial portal, he infiltrated in an arc across the lateral side of the patella to merge with the superior lateral portal site.
Dr Barber then infiltrated 7 to 10 mL of EXPAREL around the inferior anterior medial portal using a 1.5-inch needle. He infiltrated every 1 cm around the portal to establish a field block of the infrapatellar branch of the saphenous nerve.
He then infiltrated 7 to 10 mL of EXPAREL into the subcutaneous tissue surrounding the inferior anterior lateral portal site using a 1.5-inch needle. Dr Barber made sure to reach the posterior and inferior lateral tissues and merge this area with the medial portal infiltration area.
Dr Barber then infiltrated 7 to 10 mL of EXPAREL to establish a field block around the graft harvest sites. He made sure to infiltrate around the incision line and tissues overlying the harvest locations for both patellar and tibial grafts.
Postincision
Using a 3.5-inch spinal needle, Dr Barber infiltrated 7 to 10 mL of EXPAREL around the tibial graft harvest site, making sure to infiltrate into the periosteum and subcutaneous tissues.
After harvesting the grafts, the bone donor sites were infiltrated with 7 to 10 mL of EXPAREL under direct visualization. Dr Barber then closed the tendon and covered the donor sites with available tissue. The remaining fluid should be injected into these donor sites, leaving some fluid in place.
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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