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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 Sharan 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.
After induction of spinal anesthesia, Dr Sharan performed an ultrasound-guided bilateral TLIP injection at L4, with the patient in the prone position. Dr Sharan used a 40-mL total volume admixture of 20 mL of EXPAREL and 20 mL of bupivacaine HCI 0.5%, which was divided equally for bilateral injection.
Using a linear probe, Dr Sharan used a medial-to-lateral scanning technique to identify the L4 spinous process and transverse process (TP) in a transverse view on each side. The Multifidus muscle can be found directly lateral to the spinous process bilaterally and directly posterior to the lamina. The Longissimus muscle can be found lateral to the Multifidus muscle and posterior-lateral to the TP.
Using a lateral-to-medial needle approach, a 20-gauge, 4-inch echogenic needle was positioned within the fascial plane between the Multifidus (M) and Longissimus (L) muscles directly posterior to the ipsilateral TP. After negative aspiration, a test dose of 0.5 mL was injected to confirm the correct location. Then 15 mL of the EXPAREL admixture was injected at the interface between the Multifidus and Longissimus muscles, and 5 mL was infiltrated above the fascia. The same technique was used bilaterally.
Dr Sharan used a 4-inch echogenic needle advanced in plane to ensure adequate visualization on the ultrasound monitor and to provide sufficient needle depth to reach the interface between muscles.
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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