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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 Routman 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 Routman determined that a total volume of 80 mL would be needed to cover the surgical site. He
expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 50 mL of normal saline and then admixed
10 mL of 0.25% bupivacaine HCl. Dr Routman added bupivacaine HCl to provide short-term local analgesia that overlapped
with the long-term local analgesia provided by EXPAREL.
A greater total volume may be needed for patients with more muscle mass in the shoulder and/or larger incision sizes. The total volume can be increased to as much as 100 mL by expanding with additional normal saline.
DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE GAUGES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE) AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION
For this procedure, Dr Routman divided the injectate into four 20-mL syringes with 22-gauge needles. He then infiltrated as follows:
Dr Routman infiltrated 20 mL of expanded EXPAREL® (bupivacaine liposome injectable suspension) as a single injection over the rim of the glenoid, directed at the undersurface of the supraspinatus muscle belly in the area of the suprascapular nerve.
FIGURE 1. Over the glenoid rim
Dr Routman inserted the needle into and through the conjoined tendon, and infiltrated 20 mL of expanded EXPAREL as a single injection into the base of the coracoid process, as well as into the muscle and tendon, to ensure analgesic coverage of the upper portion of the brachial plexus.
FIGURE 2. Base of coracoid process
Avoid injection into neurovascular structures.
Upon closing the deltopectoral interval, Dr Routman then infiltrated 20 mL of expanded EXPAREL along the length of the deltoid and pectoralis. He infiltrated 1 to 1.5 mL every 1 cm.
FIGURE 3. Deltoid and pectoralis
Before each injection, be sure to aspirate to minimize the risk of intravascular injection.
Dr Routman infiltrated 20 mL of expanded EXPAREL along the length of the surgical incision into the subcutaneous tissues before closure. He infiltrated 1 to 1.5 mL every 1 cm.
FIGURE 4. Subcutaneous tissues around incision
Dr Routman has not found infiltration into the periosteum around the proximal humerus to be necessary.
Dr Routman 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.
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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