Exparel and TKR

[krfuquamd]

I'm a private practice anesthesiologist and I thought I'd pose this question to those residents in teaching institutions or other practicing anesthesiologist for that matter.

Our ortho group at the hospital and in particular one orthopod has recently begun using exparel injected into the knee for their TKR's. Not all patients, just some, but they are definitely toying with this drug as a replacement for FNC's or adductor canal catheters for post op pain control. Their argument being that if it works then they no longer have to worry about quadriceps weakness with a FNC or posterior knee pain with either catheter.

Our concern as anesthesiologists is three fold:
1) The fudiciary impact on our group. Obviously losing the income derived from the placement of these post op blocks and catheters concerns us
2) There seems to be a lack of good info on this drug in this setting. Clearly not FDA approved for this so we seem to be conducting our own trial with this drug. As anesthesiologists what can we do or offer when the patient is completely unhappy with his/her pain control POD 1 s/p TKR? One of the ortho pods asked us to do a single shot femoral block. We declined because our experience with this drug was so limited and certainly based on the PI local anesthetic toxicity was a concern.
3) Cost of exparel vs other adjuncts

I guess I'm curious what others are doing or seeing with this drugs usage with TKR's. Thanks.

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[BLADEMDA]

http://journals.lww.com/ejanaesthes...block_provide_superior_analgesia_for.418.aspx


http://phx.corporate-ir.net/External.File?item=UGFyZW50SUQ9NzgyNDV8Q2hpbGRJRD0tMXxUeXBlPTM=&t=1

http://icjr.net/report_42_pain_management.htm#.Ug8JD4y9KK0

Local infiltration with Exparel is good. But, an adductor canal block with Exparel combined with a selective tibial nerve block wth Ropivacaine is better.

 

[krfuquamd]

No concern about local anesthetic toxicity with an adductor canal block +/- selective tibial nerve block preop followed shortly by exparel injection into the knee?

 

[BLADEMDA]

No concern about local anesthetic toxicity with an adductor canal block +/- selective tibial nerve block preop followed shortly by exparel injection into the knee?

Did you see how much Exparel these Orthopods are injection into the Knee? Some are using 400-500 mg of Exparel. FYI, a 20 ml bottle of Exparel is 266 mg.

I wouldn't worry about local anesthetic toxicity. Go with 15 mls of local or 133 mg of Exparel for the Adductor canal and 8 mls of local for the selective tibial block.

 

[Oggg]

If the hospital doesn't care about cost, why not do AC catheter plus ropivacaine single shot sciatic plus Exparel capsular injection? Everyone is happy.

 

[Planktonmd]

The future of this medication is very uncertain.

 

[Oggg]

The future of this medication is very uncertain.

Why is that? They have a femoral nerve block study and they have t cancelled it yet, so it must not be causing 3d of motor block -- that suggests it will be usable for any block where you aren't worried too much about motor weakness, which is basically everything except total knee femoral blocks. This, plus the anecdotal experience of some members on SDN that it works great in AC and TAP blocks. The company has a patent on liposomal delivery. Price will always be an issue, but if it works it is going to sell great

 

[Oggg]

http://r20.rs6.net/tn.jsp?e=001eL4o...rNpzDQIivUdgyKJ2GPnqA2FD3ks_E4b39oS_2Fo-uW4E=

Http://bit.ly/snb_vs_pcb

European journal of anesthesiology. sciatic beats LIA

 

[BLADEMDA]

If the hospital doesn't care about cost, why not do AC catheter plus ropivacaine single shot sciatic plus Exparel capsular injection? Everyone is happy.

Forget the catheter. Simply inject 133 mg of Exparel into the adductor canal (add some decadron as well ). Then single shot popliteal or selective tibial. Surgeon can inject 399 mg of Exparel with Epi into the knee. You end up using 2 bottles of Exparel but the evidence supports the 400 mg dose of Exparel for pain control.

The adductor canal block should last 72 hours and no catheter or extra work are required.

 

[Oggg]

I would love to do that Blade, but they won't let me get my grubby hands on any Exparel.

 

[Mofeen]

Any recent updates to this topic? Our pharmacy just put Exparel on formulary. We do about 20 TKA's per weak at our facility. They all get AC catheters until post op day 2. Would love to try Exparel. Anyone seen any negatives so far? What doses are you using?

 

[Sufenta]

Like the OP, our orthopods are injecting the knee with Exparel, and declining nerve blocks. It does take time to take effect so smoother course if pt had a spinal anesthetic. Results in significant loss of revenue for us.

We have had a cpl failures, and again like OP, feel uncomfortable with high doses of bupiv for a repeat single shot block in short time span. Mostly it is successful tho. Pts could be more comfortable I think, but are satisfied.

I have also seen a gen surgeon inject it SQ in exlap incision instead of epidural.

 

[sevoflurane]

We can do better than LIA. Adding AC single shot improves analgesia.

 

[Sufenta]

But if we block medicare/ medicaid pt, surgeon has to give up a portion of his fee for us to do pain mgmt. Im not sure about the privt insurance. We were doing AC catheters before Exparel was available.

 

[BLADEMDA]

Here is a great way to go:

Preop Adductor Canal Block with Exparel 10 mls plus 5mls of saline and decadron 2-4 mg.
Give the remaining 10 mls of Exparel to the Ortho Surgeon for injection into the knee. Dilute Exparel with NS, Bupivacaine, Clonidine, Toradol, epi, etc.

End result: Happy Patient without any motor block.

FYI, it's what I'd want for my total knee (but throw in an extra 10 mls of Exparel for the local injection portion for me). The Adductor Canal Block should last 48 hours.

 

[BLADEMDA]

Like the OP, our orthopods are injecting the knee with Exparel, and declining nerve blocks. It does take time to take effect so smoother course if pt had a spinal anesthetic. Results in significant loss of revenue for us.

We have had a cpl failures, and again like OP, feel uncomfortable with high doses of bupiv for a repeat single shot block in short time span. Mostly it is successful tho. Pts could be more comfortable I think, but are satisfied.

I have also seen a gen surgeon inject it SQ in exlap incision instead of epidural.

I do "rescue blocks" For surgeons injecting Exparel into the knee all the time. Failure rate is about 30% so I frequently use 0.5% Rop with decadron in the PACU to rescue the patients from severe pain. There are NO ISSUES doing this for patients and failure to offer a single shot rescue block is poor care. With U/S all you need is 10 mls of local but I use up to 15 mls without any issues whatsoever.

 

[BLADEMDA]

We can do better than LIA. Adding AC single shot improves analgesia.

Absolutely True and accurate. My case volume clearly shows this is the situation and only 1 surgeon isn't onboard with the adductor canal block. As a side note another Ortho Surgeon who has been using LOCAL only into the knee is NOW INSISTING we do an Adductor canal block preop because postop pain control the next day is superior when 0.5% Bup with decadron (15-20 mls) is utilized for an adductor canal block.

 

[sleepallday]

Did you see how much Exparel these Orthopods are injection into the Knee? Some are using 400-500 mg of Exparel. FYI, a 20 ml bottle of Exparel is 266 mg.

I wouldn't worry about local anesthetic toxicity. Go with 15 mls of local or 133 mg of Exparel for the Adductor canal and 8 mls of local for the selective tibial block.

Blade,
The Exparel package insert advises against using any other local once Exparel is injected. How are you calculating the maximum allowable dose?

 

[GaseousClay]

Here is a great way to go:

Preop Adductor Canal Block with Exparel 10 mls plus 5mls of saline and decadron 2-4 mg.
Give the remaining 10 mls of Exparel to the Ortho Surgeon for injection into the knee. Dilute Exparel with NS, Bupivacaine, Clonidine, Toradol, epi, etc.

End result: Happy Patient without any motor block.

FYI, it's what I'd want for my total knee (but throw in an extra 10 mls of Exparel for the local injection portion for me). The Adductor Canal Block should last 48 hours.

Hey Blade what is your thought on the BJA article that was implying IV dexamethasone prolongs the block equally to perineural dexamethasone? My attendings are not convinced about the benefits of perineural decadron and since its not FDA approved for perineural injection they refuse to do it. Other studies and all of your and other members here empiric data tells me otherwise.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013;111:445-52.

 

[psychbender]

I have not been able to replicate the findings in the BJA article, nor have any of my colleagues. As such, I continue to add decadron to my blocks, when I and the patient want the extra several hours of block duration.

 

[Noyac]

Hey Blade what is your thought on the BJA article that was implying IV dexamethasone prolongs the block equally to perineural dexamethasone? My attendings are not convinced about the benefits of perineural decadron and since its not FDA approved for perineural injection they refuse to do it. Other studies and all of your and other members here empiric data tells me otherwise.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013;111:445-52.

I'm having a difficult time believing this article. It isn't what I see in practice.

 

[epidural man]

Well there is this...

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012348/

 

[epidural man]

Why not use buprenorphine, and then give dexamethasone systemically?

I think decadron increases neural toxicity - i'd rather give it systemically.

 

[sevoflurane]

Decadron is used for LESIs and TFESIs all the time. I have no objection using it for PNBs... if anything, the space isn't as tight as for LESIs and TFESIs. Isn't it a membrane stabilizer as well?

 

[pgg]

Hey Blade what is your thought on the BJA article that was implying IV dexamethasone prolongs the block equally to perineural dexamethasone? My attendings are not convinced about the benefits of perineural decadron and since its not FDA approved for perineural injection they refuse to do it. Other studies and all of your and other members here empiric data tells me otherwise.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013;111:445-52.

I think the conclusion of that article is garbage.

I almost always chase my propofol inductions with 4 mg IV dexamethasone, have been doing so since my CA1 year, and when I started adding it to my blocks their duration was greatly increased.

IV dexamethasone does have analgesic enhancing effects though. Maybe what they measured or think they found was simply related to adding another pain relieving drug to the anesthetic cocktail.

IV dex absolutely doesn't prolong block duration to the degree perineural dex does, I'm very confident of that.

 

[risnwb]

Are you guys using pf decadron or just the regular stuff in the cart? I can't find anything in the label that delineated what preservative is/is not present... Also how much are you using for isb/supraclavicular vs pop vs adductor?

 

[pgg]

I use PF stuff. I know people who use the stuff with preservative and I can't really argue that a quarter mL of dex with a tiny amount of preservative in it, diluted in 30 mL of local, is surely harmless. But I don't like the thought of injecting even a little bit of benzene onto a nerve.

I use 4 mg in normal people and 2 mg in well controlled diabetics and none in uncontrolled diabetics. Some people argue it should be even less.

 

[sleepallday]

Did you see how much Exparel these Orthopods are injection into the Knee? Some are using 400-500 mg of Exparel. FYI, a 20 ml bottle of Exparel is 266 mg.

I wouldn't worry about local anesthetic toxicity. Go with 15 mls of local or 133 mg of Exparel for the Adductor canal and 8 mls of local for the selective tibial block.

Blade,

Can you back this up in any way? I'm having similar issue with my orthopods. They are using exparel in the knee and have been requesting pre-op adductor canal blocks. So far, I have been declining. The exparel package insert states not to use any other LA in a patient that receives exparel.

 

[Planktonmd]

Blade,

Can you back this up in any way? I'm having similar issue with my orthopods. They are using exparel in the knee and have been requesting pre-op adductor canal blocks. So far, I have been declining. The exparel package insert states not to use any other LA in a patient that receives exparel.

The meaning of the insert (I think) is to not mix Exparel with any other local anesthetic at the injection location...

 

[BLADEMDA]

Blade,

Can you back this up in any way? I'm having similar issue with my orthopods. They are using exparel in the knee and have been requesting pre-op adductor canal blocks. So far, I have been declining. The exparel package insert states not to use any other LA in a patient that receives exparel.

So far I have performed about 200 Adductor canal blocks with Bupivacaine preoperatively and the Ortho dudes inject 1 bottle of Exparel into the knee; so far, not a single complication or issue.

FYI, I have also performed a few Adductor Canal blocks with Exparel followed by the Ortho dudes using one bottle of Exparel for local infiltration. My anecdotal reports from the Ortho surgeons are lower pain scores (36-48 hrs postop) utilizing Exparel for adductor canal blocks.

I now no longer perform a Sciatic or popliteal or tibial block preoperatively but instead offer the block postop in PACU if needed. I am doing a rescue block (Sciatic) about 5% of the time and Femoral blocks are also about 3-5% of the time. 90% of the time (or more) the local injection plus adductor canal block preoperatively gets the job done as far as postop pain is concerned.

If I was having a total knee performed I would request an Adductor canal block utilizing Exparel followed by local injection with Exparel into/around the knee at the end of the case. Only if my pain scores were high after a little IV MSO4 or Dilaudid IV would I request any other block.

 

[Noyac]

If I was having a total knee performed I would request an Adductor canal block utilizing Exparel followed by local injection with Exparel into/around the knee at the end of the case. Only if my pain scores were high after a little IV MSO4 or Dilaudid IV would I request any other block.

Why not do an adductor canal block with the usual Bupiv or Ropiv and let the surgeons exparel work once this wears off? It seems like you don't need both the add canal and the local Infiltration to be performed with exparel.

 

[BLADEMDA]

Why not do an adductor canal block with the usual Bupiv or Ropiv and let the surgeons exparel work once this wears off? It seems like you don't need both the add canal and the local Infiltration to be performed with exparel.

I do most of my total knees on medicare patients. This means the Exparel isn't covered by Medicare. Hence, the vast majority of patients receive an adductor canal block with 0.5 percent Bup combined with decadron 1-2 mg. the surgeon performs LIA with Exparel at the end if the case (266 mg of Exparel).

For non CMS cases I have utilized Exparel for the adductor canal block (266 mg with Decadron 2 mg) and the surgeon does LIA with a second bottle of Exparel at the end of the case. I'm told the analgesia from an adductor canal block utilizing Exparel plus decadron exceeds 48 hours. Hence, I've received requests to use Exparel for adductor canal blocks.

 

[deleted162650]

Why are you adding Decadron to the Exparel? Seems unnecessary when the drug itself already lasts 48H.

 

[deleted126335]

Assuming costs are not an issue, would you prefer your technique or a continuous catheter technique with 0.2% Ropivicaine?

 

[BLADEMDA]

Why are you adding Decadron to the Exparel? Seems unnecessary when the drug itself already lasts 48H.

My anecdotal experience of 500 cases shows Exparel will consistently give analgesia over 36 hours with the addition of decadron. But, Exparel without decadron may last only 24 hours in certain patients. PF decadron is cheap, safe and effective when added to local anesthetics in low concentrations.

 

[BLADEMDA]

Assuming costs are not an issue, would you prefer your technique or a continuous catheter technique with 0.2% Ropivicaine?

It's a wash. A single injection with Exparel plus decadron is technically easier to perform than a catheter technique and the block lasts 48 hours. As long as my Anesthesiologist offered me either the Exparel or the continuous catheter for my adductor canal block I would be quite happy.

 

[Noyac]

The vast majority of our TKAs are going home on POD#2 with one surgeon and maybe 50/50 with another surgeon. We now have a new fellowship trained joint guy and his are probably staying 3 days. None of them are using exparel at this time. But the new guy wants to give it a go since he used it in training. I'm fine with this but don't think it will add a whole lot to the picture since we have shown that it s easy to send pt's home comfortable on POD#2. So it is very surgeon dependent, not anesthesiologist dependant.

His concoction is 40cc exparel in 60cc NS and 30cc marcaine. So I am proposing that we do adductor canal blocks pre-op with Ropiv or bupiv in order to assist this process.

 

[deleted162650]

My anecdotal experience of 500 cases shows Exparel will consistently give analgesia over 36 hours with the addition of decadron. But, Exparel without decadron may last only 24 hours in certain patients. PF decadron is cheap, safe and effective when added to local anesthetics in low concentrations.

My adductors with 0.5% Bupi + PF Decadron are lasting reliably 24-30 hours so I'm really not convinced that Exparel is worth the significant added cost. I'd be happy to give it a go though if they OK it for us which hasn't happened yet.

His concoction is 20cc exparel in 100cc NS and some marcaine (not sure how much right now). This seems like a poor recipe to me and that we will be doing many rescue blocks. So I am proposing that we do adductor canal blocks pre-op with Ropiv or bupiv in order to assist this process. What do you guys think of his concoction?

About 6-8 months ago we switched from Fem caths to ACB's with Exparel local by the surgeon. The results have been quite positive with pain control pretty much equivalent or better than the old recipe. I'm not sure what the exact Exparel concoction is the orthopods are using but I'll find out. I have found that how good the Exparel by surgeon works is highly technique dependent as some surgeons end up with much more comfortable patients than others. We have also had a few cases of foot drop that lasted until the Exparel "local" wore off.

 

[BLADEMDA]

My adductors with 0.5% Bupi + PF Decadron are lasting reliably 24-30 hours so I'm really not convinced that Exparel is worth the significant added cost. I'd be happy to give it a go though if they OK it for us which hasn't happened yet.



About 6-8 months ago we switched from Fem caths to ACB's with Exparel local by the surgeon. The results have been quite positive with pain control pretty much equivalent or better than the old recipe. I'm not sure what the exact Exparel concoction is the orthopods are using but I'll find out. I have found that how good the Exparel by surgeon works is highly technique dependent as some surgeons end up with much more comfortable patients than others. We have also had a few cases of foot drop that lasted until the Exparel "local" wore off.

$280 per bottle of Exparel. It does last 48 hours when utilized for an adductor canal block (266 mg)

 

[BLADEMDA]

http://www.jscimedcentral.com/Orthopedics/orthopedics-sp-id-modern-anesthesia-1025.pdf


Most of my Ortho surgeons use a volume of 60 mls for LIA. A few add 20 mls of 0.25 percent BUP but most just dilute with NS. A few add toradol and epi along with PF decadron.

 

[painstop]

Nice article Blade. As most here know, the liposomal bupivacaine pretty much stays at the spot it is injected and so there is not as much forgiveness via passage through tissue planes if the surgeon does a rush job of injecting. Diluting it out to the proper volume and getting the medicine where it needs to be is key. Passing along that advice as well as this article which defines the anatomical spots in which to inject would likely help those surgeons who are not getting optimal results. As far as dosing issues, I copied and pasted this paragraph from Blade's article:

The recommended maximum daily dose of bupivacaine is 400 mg. The typical total knee arthroplasty patient will undergo spinal anesthesia which requires 10-14 mg of bupivacaine. Our cocktail contains 40cc of .25% bupivacaine or 100 mg. The long acting liposomal bupivacaine ExparelR contains 266 mg, which elutes over 72 hours. When administering bupivacaine before EXPAREL, it is important to use no more than 50% of the total EXPAREL dose (266 mg) (e.g., 50 mL of 0.25% and 25 mL of 0.5% bupivacaine HCl) both equate to a total dose of 125 mg. Adherence to this dosing regimen will ensure that the maximum recommended dose is not exceeded. ExparelR has also been shown to be efficacious and safe at higher doses. In a phase I clinical trial ExparelR given subcutaneously in doses of up to 750mg did not harm the patients.

 

[Bull Gator]

It's a wash. A single injection with Exparel plus decadron is technically easier to perform than a catheter technique and the block lasts 48 hours. As long as my Anesthesiologist offered me either the Exparel or the continuous catheter for my adductor canal block I would be quite happy.

Do you get any quad weakness with the Adductor canal block. I am doing ambulatory TKA's with ADD canal block, and my own cocktail into the knee and they go home with NO pain - even days and weeks later, have min to no pain. My problem is with quad weakness and they fall, causing a retinaculum tear necessitating re-op.

 

[Bull Gator]

$280 per bottle of Exparel. It does last 48 hours when utilized for an adductor canal block (266 mg)

http://www.jscimedcentral.com/Orthopedics/orthopedics-sp-id-modern-anesthesia-1025.pdf


Most of my Ortho surgeons use a volume of 60 mls for LIA. A few add 20 mls of 0.25 percent BUP but most just dilute with NS. A few add toradol and epi along with PF decadron.

Do you get any quad weakness with the Adductor canal block. I am doing ambulatory TKA's with ADD canal block, and my own cocktail into the knee and they go home with NO pain - even days and weeks later, have min to no pain. My problem is with quad weakness and they fall, causing a retinaculum tear necessitating re-op.

 

[Vergie]

There was a question this year at the NYSORA symposium this year about combining Adductor cannal block with exporell and Dr. Hadzic himself said he thinks it's acceptable. Our Regional guru does both without any problems so far but I am having a hard time convincing some of our other hospital attendings to try it

 

[sigrhoillusion]

I think the issue is that since Exparel hasn't been FDA approved for perineural use, any post-op nerve issues are going to be directed right at the block. That being said, I agree that it is probably safe. But most if not all the people in my institute just use 0.5% bupi

 

[Noyac]

I am doing ambulatory TKA's with ADD canal block, and my own cocktail into the knee and they go home with NO pain - even days and weeks later, have min to no pain.

I find this hard to believe. Either you have the toughest pts in the country or you are not seeing them soon enough to get the real story. I believe that they had very little pain for the most part but "No" pain just doesn't fit all the data. The ADD canal block is not a comprehensive block for the TKA. but I think if you are sending your pts home that day, it is the right block.

I do have some concerns regarding nerve injury with exparel. Just like when the orthopods were putting the catheters intraarticular and we found chondrolysis, we may find neurolysis with the long term deposition of local on the nerve. I don't have data obviously but it is conceivable, at least in my mind.

 

[Planktonmd]

I find this hard to believe. Either you have the toughest pts in the country or you are not seeing them soon enough to get the real story. I believe that they had very little pain for the most part but "No" pain just doesn't fit all the data. The ADD canal block is not a comprehensive block for the TKA. but I think if you are sending your pts home that day, it is the right block.

I do have some concerns regarding nerve injury with exparel. Just like when the orthopods were putting the catheters intraarticular and we found chondrolysis, we may find neurolysis with the long term deposition of local on the nerve. I don't have data obviously but it is conceivable, at least in my mind.

That whole statement: "my patients have no pain even days or weeks later", sounds like a typical surgeon's view of his extraordinary skills!

 

[BLADEMDA]

Do you get any quad weakness with the Adductor canal block. I am doing ambulatory TKA's with ADD canal block, and my own cocktail into the knee and they go home with NO pain - even days and weeks later, have min to no pain. My problem is with quad weakness and they fall, causing a retinaculum tear necessitating re-op.

Since this thread was started I have performed 200 adductor canal blocks with Exparel. The results (along with surgeon LIA and ipack) are excellent. Average discharge time is under 2 days.
In addition, motor weakness is minimal with the block. There are isolated case reports of Quadriceps weakness after an adductor canal block but the vast majority (90% plus) have good quadriceps motor strength.

I think the issue is that since Exparel hasn't been FDA approved for perineural use, any post-op nerve issues are going to be directed right at the block. That being said, I agree that it is probably safe. But most if not all the people in my institute just use 0.5% bupi

Exparel is FDA approved for TAP blocks. Hence, I use it for TAP and Adductor canal blocks which are primarily sensory in nature.

 

[BLADEMDA]

I find this hard to believe. Either you have the toughest pts in the country or you are not seeing them soon enough to get the real story. I believe that they had very little pain for the most part but "No" pain just doesn't fit all the data. The ADD canal block is not a comprehensive block for the TKA. but I think if you are sending your pts home that day, it is the right block.

I do have some concerns regarding nerve injury with exparel. Just like when the orthopods were putting the catheters intraarticular and we found chondrolysis, we may find neurolysis with the long term deposition of local on the nerve. I don't have data obviously but it is conceivable, at least in my mind.

With a typical Exparel dose of 133 mg the block lasts about 48 hours. There is no data showing injury to the nerve especially at the 133 mg dosage.

 

[Noyac]

With a typical Exparel dose of 133 mg the block lasts about 48 hours. There is no data showing injury to the nerve especially at the 133 mg dosage.

I'll let others like yourself do the experimentation. Thanks.