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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 Lieblich 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, the panoramic radiograph showed the soft tissue–impacted maxillary third molars and partial bony–impacted mandibular third molars.
Dr Lieblich assessed the surgical sites and determined he would need the following to provide analgesic coverage:
FIGURE 1. Panoramic radiograph
Dr Lieblich also determined that he would need a total volume of approximately 10 mL of EXPAREL® (bupivacaine liposome injectable suspension) (unexpanded).
Dr Lieblich used bupivacaine HCl with epinephrine for the long buccal nerve block because non–bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Formulations of bupivacaine other than EXPAREL should not be administered within 96 hours following administration of EXPAREL.
INFILTRATED INTO THE FOLLOWING AREAS USING A 22-GAUGE NEEDLE
Dr Lieblich planned to infiltrate as follows:
For teeth #1 and #16, Dr Lieblich infiltrated 1.7 mL of 2% lidocaine with 1:100,000 epinephrine into the buccal aspect and 0.2 mL into the palatal aspect.
For teeth #17 and #32, Dr Lieblich administered 1.7 mL of 2% lidocaine with 1:100,000 epinephrine into the inferior alveolar nerve and 1.7 mL into the lingual nerve in the mandible, on each side, to create nerve blocks.
Dr Lieblich infiltrated 1.5 mL of 0.5% bupivacaine HCl with 1:100,000 epinephrine into the inferior alveolar nerve and 0.3 mL into the long buccal nerve, on each side, to create nerve blocks.
Do not administer lidocaine into the soft tissues adjacent to the mandibular third-molar sites where EXPAREL® (bupivacaine liposome injectable suspension) is administered.
After primary closure, Dr Lieblich infiltrated 4 mL of EXPAREL along the lateral aspect of the mandible, on each side, as 4 separate 1-mL injections, for a total of 8 mL. For each injection, the needle was inserted into the base, aspirated, and then 1 mL of EXPAREL was injected as the needle was withdrawn, creating a column effect—ensuring maximum analgesic coverage.
FIGURE 4. Lateral aspect of mandible
Dr Lieblich then infiltrated 1 mL of EXPAREL into the buccal aspect of the upper third molars, on each side, for a total of 2 mL.
FIGURE 5. Buccal aspect of the upper third molars
Dr Lieblich 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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