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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 Gadsden 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 Gadsden determined that a total volume of 80 mL would be needed to cover the surgical site.
He admixed 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 analgesia provided by EXPAREL.
In cases that require a higher total volume, such as those involving larger incisions, Dr Gadsden may add normal saline 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 Gadsden divided the injectate into 4 syringes with 21-gauge needles, each containing 5 mL (66.5 mg) of EXPAREL and 15 mL (37.5 mg) 0.25% bupivacaine HCl.
Four-point TAP block was performed at the conclusion of the surgical procedure, after the surgical drapes were removed and before the patient emerged from anesthesia.
In obese patients, identification of the precise plane can be challenging because of the appearance of multiple “layers” to the abdominal wall. Toggling the probe back and forth in a cephalocaudal direction will cause the oblique muscles to appear as if moving in opposite directions, whereas the fat and transversus abdominis muscle remain static. This allows the operator to quickly recognize the internal oblique muscle.
A linear ultrasound probe was placed in a transverse orientation on the midaxillary line at the level of the umbilicus (approximately equidistant from the iliac crest and costal margin) (Figure 1). The transversus abdominis plane was then identified as a bright hyperechoic line between the internal oblique and transversus abdominis muscles (Figure 2A). A 21-gauge, 100-mm needle was advanced from the anterior aspect of the probe until the tip was observed entering the transversus abdominis plane. Small boluses (1 mL) of saline were injected to confirm needle position between the 2 muscles, and the needle was redirected to ensure the tip was not intramuscular. Once satisfied with the needle position, Dr Gadsden slowly infiltrated 20 mL of the EXPAREL mixture. The correct injection plane was confirmed by observing the 2 muscles “unzippering” (Figure 2B). The needle was advanced posteriorly in the plane as needed to continue to dissect the muscles. The block was then repeated on the contralateral side.
Despite our best efforts, occasionally the TAP plane fails to unzipper (“hydrodissect”) easily. In these cases, placing the EXPAREL® (bupivacaine liposome injectable suspension) mixture deep to the fascial plane (ie, on the surface of transversus abdominis muscle) provides the “next best” location for the injectate, as the nerves travel on the surface of this muscle, not superficial to the TAP plane.
A linear ultrasound probe was placed on the epigastrium parallel to the costal margin, 3 to 4 cm lateral to the midline (Figure 3). The lateral edge of rectus abdominis muscle was visualized on the screen, and the transversus abdominis muscle deep to it (Figure 4A). A 21-gauge, 100-mm needle was advanced from the medial aspect of the probe until the tip was observed entering the fascial plane between the rectus and transversus muscles. Small boluses (1 mL) of saline were injected to confirm needle position between the 2 muscles, and the needle redirected to ensure the tip was not intramuscular. Once satisfied with the needle position, Dr Gadsden slowly infiltrated 20 mL of the EXPAREL mixture. The correct injection plane was confirmed by observing the 2 muscles unzippering (Figure 4B). The needle was continuously advanced inferolaterally in the transversus abdominis plane as the rectus muscle disappeared from view and the internal oblique muscle appeared. Once it had traveled as far as possible between the internal oblique and transversus muscles, the needle was withdrawn and the block repeated on the contralateral side.
The more parallel the needle path with respect to the TAP plane, the easier the hydrodissection and needle advancement within the plane itself. Calculate the distance between the skin and the TAP plane, and insert the needle away from the probe by that distance (Figure 1). The needle should be advanced upward toward the probe surface initially, to avoid the abdominal cavity, then redirected as needed to enter the TAP plane.
Dr Gadsden always uses normal saline to hydrolocate the needle tip and ensure that the expanded EXPAREL mixture will be deposited in the correct fascial plane, minimizing wastage of EXPAREL within the muscle itself.
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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