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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 Bowers 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 Bowers determined a total volume of 50 mL would be needed to cover the surgical site.
He admixed 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 30 mL of bupivacaine HCl 0.5%. Bupivacaine HCl was added to provide early-onset analgesia and bridge the time to onset of the long-acting analgesia provided by EXPAREL. Dr Bowers infiltrated the surgical site with the EXPAREL admixture prior to surgery. He identified his initial incision point and infiltrated EXPAREL; then, under direct visualization, he infiltrated the remaining incisional sites with the EXPAREL admixture.
In cases that require a higher total volume, such as those involving larger incisions, Dr Bowers may add normal saline or lactated Ringer’s solution to increase the total volume to 100 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 Bowers divided the injectate into two 20-mL syringes with 21-gauge, 1.5-inch needles and refilled one syringe with the remaining 10 mL.
When infiltrating EXPAREL, Dr Bowers makes sure to infiltrate above and below the fascia and into the subcutaneous tissue using a moving needle technique to ensure coverage across all port/incisional sites. The injections were spread in a fan-like pattern and occurred as the needle was withdrawn, to maximize the coverage area.
Dr Bowers began by infiltrating 20 mL of the EXPAREL® (bupivacaine liposome injectable suspension) solution bilaterally from transverse abdominis. He infiltrated in a fan-like pattern, delivering 3 to 4 mL of EXPAREL mixture with each injection, for a total of 10 mL on each side. Dr Bowers infiltrated above and below the fascia and into the subcutaneous tissue, parallel and along the natural lateral descending curvature of the fascial plane.
Dr Bowers then performed an incision at Palmer’s point. He infiltrated 10 mL of EXPAREL solution above and below the fascia and into the subcutaneous tissue. He delivered approximately 3 to 4 mL of EXPAREL solution every 1 to 2 cm deep into the tissue with each injection to ensure optimal coverage of the area.
Finally, Dr Bowers infiltrated 20 mL of EXPAREL solution bilaterally below the fascia into the subcutaneous layer. He infiltrated 10 mL of EXPAREL on each side of the incision, injecting parallel to the surgical plane in a fan-like pattern. Dr Bowers delivered approximately 3 to 4 mL of EXPAREL mixture every 1 to 2 cm deep into the tissue with each injection to ensure optimal coverage of the area.
Dr Bowers infiltrated EXPAREL® (bupivacaine liposome injectable suspension) into each port site with a moving needle technique. The needle was injected down to the preperitoneal space and slowly withdrawn to the dermis level. With a moving needle technique, the injections were spread in a fan-like pattern as the needle was withdrawn to maximize the coverage area. The goal was to create a column of EXPAREL injectate from the preperitoneal space up to the dermis for maximal 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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