Exparel Dosing.

Started by sevoflurane
Get help with your application

Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.

Browse articles Compare schools My application plan Read Interview Feedback
Practice for interviews Ask an Advisor
sevoflurane

sevoflurane

Ride
20+ Year Member
1) How much are your orthopods using for a total knee (266mg?)?

2) How are you diluting it? NS or Marcaine?

3) Are you adding an adductor canal block? If so how much and what percent Marcaine?

Exparel takes time to take effect. You may have little actually working post-op, hence ACB.

I know it's a slow release mechanism, but anybody worried about toxicity? Manufacturer's insert says the maximum dose is one vial or 266mg.
 
sevoflurane said:
1) How much are your orthopods using for a total knee (266mg?)?

2) How are you diluting it? NS or Marcaine?

3) Are you adding an adductor canal block? If so how much and what percent Marcaine?

Exparel takes time to take effect. You may have little actually working post-op, hence ACB.

I know it's a slow release mechanism, but anybody worried about toxicity? Manufacturer's insert says the maximum dose is one vial or 266mg.
Click to expand...

They were using 2 vials of Exparel for local infiltration into the knee. Exparel takes 60-90 minutes to start working due to its slow release.

I've tried 1/2 and 1/2 with excellent results. I use 133 mg plus 5 mls of 0.25% Bup and 4 mg of decadron for the ACB. I give 133 mg of Exparel to the Ortho surgeon which he dilutes with 30 mls of saline and injects into the knee.

If your hospital can afford it the best combo is 133 mg for you and 399 mg for the Ortho Surgeon (2 vials). This should give the best results.
 
BLADEMDA said:
They were using 2 vials of Exparel for local infiltration into the knee. Exparel takes 60-90 minutes to start working due to its slow release.

I've tried 1/2 and 1/2 with excellent results. I use 133 mg plus 5 mls of 0.25% Bup and 4 mg of decadron for the ACB. I give 133 mg of Exparel to the Ortho surgeon which he dilutes with 30 mls of saline and injects into the knee.

If your hospital can afford it the best combo is 133 mg for you and 399 mg for the Ortho Surgeon (2 vials). This should give the best results.
Click to expand...

Holy Crap Blade... 2 vilas is a lot of bupivicaine = 532mg.
Toxic dose of regular bupivicaine in a 75kg individual= 2.5 x 75 = 187.5mg.

"Administration Precautions

The recommended dose of EXPAREL is based on the surgical site and the volume required to cover the area
The maximum dosage should not exceed 266 mg (one 20 mL vial)"

I know it's slow release, but I've heard the liposomal bupi can sometimes break down quickly.
 
I am going to an exparel dinner presentation tonight by Jacob Hutchins MD from the university of .minnesota. does anyone have any questions they would like me to ask?
 
stonemd said:
I am going to an exparel dinner presentation tonight by Jacob Hutchins MD from the university of .minnesota. does anyone have any questions they would like me to ask?
Click to expand...

I was on vaca for my rep dinner. Wish I was there.

Questions:

Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.

Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.

Can you use all 266 mg of liposomal in a 70 kg person? 300mg?

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.

I'd be nice to see a graphical lay out of plasma levels over 3 days.

TAP block, ACB, Femoral n. trials.
 
sevoflurane said:
I was on vaca for my rep dinner. Wish I was there.

Questions:

Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.

Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.

Can you use all 266 mg of liposomal in a 70 kg person? 300mg?

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.

I'd be nice to see a graphical lay out of plasma levels over 3 days.

TAP block, ACB, Femoral n. trials.
Click to expand...

I have performed over 30-40 blocks using Exparel 266 mg ( 1 vial) without a single complication. I typically allow the surgeons to infiltrate liberally as well (usually 30 mls of 0.25% Bup with Epi). Again, not a single incident.

THe Company, Pacira, is being very conservative in dosing the Exparel. They recommend 266 mg ( 1 vial) as the maximum even though heir own research shows much higher dosages. As for mixing the Exparel with local I do it often as this allows an immediate onset to the block.
 
Background: DepoBupivacaine (DB) is a controlled-release formulation of
bupivacaine contained within multivesicular liposomal [DepoFoam®]
particles that release bupivacaine over several days, prospectively designed
to provide three days of analgesia following a single administration to
patients undergoing surgery.
Objectives: In this study, we sought to evaluate the efficacy, safety, and
comparative systemic bioavailability of a single administration of DB
compared with bupivacaine HCl with epinephrine (Bup/epi) in patients
undergoing unilateral total knee arthroplasty (TKA).
Methods: We compared three doses of DB to commercial Bup/epi in the
first two cohorts of an ongoing, randomized, double-blind, parallel-group,
dose-ranging study. During surgery, 60 mL of DB or Bup/epi was infiltrated
into the tissue surrounding the wound. Ketorolac 30 mg was administered
to all subjects at the end of surgery. Subjects also received acetaminophen
1000 mg orally three times a day for at least 24 h preoperatively and for
96 h postoperatively. Rescue medication consisted of parenteral opioid
followed by oral oxycodone. In the first cohort, 15 subjects were randomized
into three groups: Bup/epi 150 mg, or DB 150 mg, or DB 300 mg.
Following review by an unblinded safety and efficacy committee, an
additional 10 subjects were randomized into each of the three groups, and
a fourth group of 25 subjects received DB 450 mg. After surgery, the
following decision-making top-line results were assessed by an unblinded
safety and efficacy committee: safety, pain, and total opiate rescue.
Results: DB administration was associated with wound-healing scores
equivalent to Bup/epi over the first five days following surgery and was not
associated with clinical signs of cardiac or CNS adverse events. DB 150 mg
was ineffective in reducing pain compared with an equivalent dose of
Bup/epi. DB at 450 mg statistically significantly reduced pain (P<0.05)
when assessed at the end of general anesthesia (mean 7.0, 6.2, and 5.0 for
DB at 150, 300, and 450 mg, respectively, compared with 7.0 Bup/epi). DB
300 mg and 450 mg statistically significantly reduced pain at the time of first
rescue opioid use (mean 7.7, 6.4, and 6.1 for DB at 150, 300, and 450 mg,
respectively, compared with Bup/epi, 7.8). DB 450 mg reduced opioid rescue
(cumulative mg morphine equivalents) throughout the observation period:
 
•Do not admix EXPAREL with other drugs prior to administration1
•When administering lidocaine or other non-bupivacaine based local anesthetics into the surgical site, wait at least 20 minutes before administering EXPAREL1
•Allow topical antiseptics (e.g., Betadine®) to dry before administering EXPAREL into the same surgical site
•When administering bupivacaine HCl before EXPAREL, 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)1

Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL.1

Do Not Interchange with Other Formulations of Bupivacaine

, it Different formulations of bupivacaine are not bioequivalent, even if the milligram strength is the same. Thereforeis not possible to convert dosing from any other formulations of bupivacaine to EXPAREL.1
 
chart_5.jpg
 
Am J Sports Med. 1988 May-Jun;16(3):295-300.

Plasma bupivacaine levels following single dose intraarticular instillation for arthroscopy.

Meinig RP, Holtgrewe JL, Wiedel JD, Christie DB, Kestin KJ.


Source

Department of Orthopaedics, University of Colorado Health Sciences Center, Denver.


Abstract


Arthroscopy of the knee was performed using 30 ml single dose intraarticular instillations of 0.5% or 0.25% solutions of bupivacaine (Marcaine). A total of 18 patients (mean age, 34 years), divided into two groups, participated in this study. Venous plasma levels were measured at 0, 10, 20, 30, 45, 60, 90, 120, and 240 minute intervals following a single instillation into the knee joint. All patients had suspected traumatic internal derangement of the knee. Electrocardiogram tracings, blood pressure, and neurologic assessment were monitored at each venous sampling interval or more often if clinically indicated. The type and amount of supplemental anesthesia were also recorded. None of our 18 patients required a general anesthetic because of pain although the following procedures were performed: meniscectomy, plica release, abrasion chondroplasty, loose body retrieval, and limited meniscal repair. A new methodology for the measurement of plasma bupivacaine using the gas chromatograph mass spectrometer is described. Monitoring specific molecular mass fragments allows the measurement of picogram per milliliter levels of bupivacaine. The highest peak plasma concentration occurred 20 minutes after instillation of 30 ml of 0.5% bupivacaine. The 625 +/- 225 ng/ml level was well below the 2,500 to 4,000 ng/ml reported to elicit early subjective CNS symptoms of bupivacaine toxicity. Thus, a single dose intraarticular instillation of 30 ml 0.5% or 0.25% bupivacaine is convenient, efficacious, and pharmacologically safe for routine clinical arthroscopy
 
So, if we use 1 vial of exparel (266 mg) combined with 30 mls of 0.5% Bupivacaine the highest expected blood level would be about 1,000 ng/ml.

Clearly, we can infiltrate with a lot of local or use 2 vials of Exparel and NEVER get anywhere near Toxic levels.
 
Good stuff. Thanks. 👍

I'm slightly skeptical of mixing 20 cc's of .5% bupi with 20 or 40 cc's of exparel (LIA) and then adding 20cc's of .5% bupi into the adductor canal.
I've heard of early exparel breakdown and fast metabolizers thus far. This worries me a bit more, but I think I might be a bit overly cautious at this point. First, do no harm.

I've yet to have one of my patients seize, but I've seen a handful of my collegues patients seize... usually in the elderly.
 
I can tell you that all my knees woke up with zero pain today.

LIA with exparel + ACB.

Zero motor weakness and will be doing laps on the floor today. 😀
 
sevoflurane said:
I was on vaca for my rep dinner. Wish I was there.

Questions:

Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.

Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.

Can you use all 266 mg of liposomal in a 70 kg person? 300mg?

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.

I'd be nice to see a graphical lay out of plasma levels over 3 days.

TAP block, ACB, Femoral n. trials.
Click to expand...

1. Toxicity- 10 mg/kg of Exparel. So, 2 vials isn't an issue (532 mg). That said, the company says 1 vial even though the evidence clearly shows 2 vials are safe.

2. Yes, you can use 266mg -532 mg in a 70 kg patient. The expected MAX blood levels would be 500 ng/ml with 2 vials (well below the 4,000 ng/ml toxic levels)

3. The toxicity may be additive for the first several hours. 30 mls of 0.5% Bup may mean blood levels of 800-850 ng/ml plus the Exparel blood level of 250 ng/ml per vial of 266 mg. I suspect actual blood levels would be lower at 2 hours.

4. I have explained how to "add" for toxicity. Do you need more help here?

5. I mix it with Bupivacaine all the time with no issues. I make sure never to mix more than 50% in MG of Bupivacaine to the Exparel. So, If use 133 mg of Exparel I limit my Bupivacaine to 66 mg.

6. We are using a wide safety margin for blood levels. I use MAX blood levels of 1500 ng/ml for the Exparel and The Bupivacaine added together (based on previous research for each drug). In actuality, we could be using DOUBLE my comfort zone and still be safe.
 
sevoflurane said:
I can tell you that all my knees woke up with zero pain today.

LIA with exparel + ACB.

Zero motor weakness and will be doing laps on the floor today. 😀
Click to expand...

I agree with you here. It is the way to go. If it was me having the knee replacement I would prefer 2 vials of Exparel. 1.5 vials mixed with Bupivacaine for injection and 1/2 vial mixed with Bupivacaine and decadron for the ACB.

2 vials of Exparel or 532 mg with a blood level of 500 ng/ml
0.5% Bupivacaine 40 mls or 200 mg with a blood level of maybe a 1,000 ng/ml

The surgeon gets 35 mls of 0.5% Bup mixed with the Exparel plus Normal saline and Toradol for LIA. Sevo gets 5 mls of 0.5% Bup to mix with the Exparel (10 mls) plus decadron 4 mg for the ACB.
 
stonemd said:
I am going to an exparel dinner presentation tonight by Jacob Hutchins MD from the university of .minnesota. does anyone have any questions they would like me to ask?
Click to expand...

Don't believe all the hype. We are using Exparel routinely and it lasts 24 hours when given via wound infiltration. When used for TAP blocks the duration of action is correlated to how highly diluted the vial is with saline. With ZERO dilution I'm seeing up to 48 hours of analgesia. With dilution I'm seeing 36 hours or so. Hence, I have started adding Decadron to the Exparel in the hopes of getting 40-44 hours.

We have NEVER Had a single patient get 72 hours of analgesia from an Exparel block yet.
But, all patients get a minimum of 28 hours even with heavy dilution.
 
Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.
266 mg
Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.
266mg if greater than 50kg
Can you use all 266 mg of liposomal in a 70 kg person? 300mg?
266mg

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.
266mg exp with 133mg plain bupic

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%
No give separately

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.
More vascular space means more rapid release of bupic icing

I'd be nice to see a graphical lay out of plasma levels over 3 days.
I think blade has posted this

TAP block ongoing
ACB planned
Femoral n. ongoing
 
ChiDO said:
20 mL of 266mg liposomal bupivacaine, 20 mL of 0.25% marcaine with epinephrine, 40 mL of sterile 0.9% isotonic sodium chloride solution

No blocks.
Click to expand...

The point of the block is to have postop pain relief once the Exparel wears off in 24 hours.
An Adductor Canal block with Exparel would provide 48 hours of postop pain relief vs. only 24 hours with infiltration.

Even an ACB with 0.5% Bup plus decadron and buprenorphine would provide 30-35 hours of postop pain relief.

If your patients are happy in the PACU with no blocks then that's fine but pain scores vary from patient to patient so keep that in mind.
 
Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.
266 mg
Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.
266mg if greater than 50kg
Can you use all 266 mg of liposomal in a 70 kg person? 300mg?
266mg

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.
266mg exp with 133mg plain bupic

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%
No give separately

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.
More vascular space means more rapid release of bupic icing

I'd be nice to see a graphical lay out of plasma levels over 3 days.
I think blade has posted this

Studies involving
TAP block ongoing
ACB planned
Femoral n. ongoing
 
Last edited:
I don't rely on company reps to tell me the truth. I prefer to analyze the data from the animal and the human clinical studies. Based on that data available so far (and available online and to the FDA) the maximum dosage of Exparel is NOT 266 mg. In fact, that maximum dosage makes no sense from a scientific analysis. Clearly, the company has decided that dosage is best for sales, marketing and cost of production.

By keeping the MAX Dosage extremely low the company ensures not even one patient will have an Exparel related event (Seizure, CV collapse, etc).

Based on published evidence (which I have referenced on this thread) a 20 ml Vial of Exparel can safely be used with 0.5% Bupivacaine 40 mls.
But, only 26 mls of the 0.5% Bupivacaine can be given in the same area (local infiltration) as the Exparel. The other 14 mls of 0.5% Bup must be used at another injection site.

This means an Ortho surgeon can use 20 mls of 0.5% Bup with Epi followed by Exparel 20 mls mixed with 20-50 mls of NS into the knee. In addition, the anesthesiologist can do a ACB with 15-20 mls 0.5% Bup with decadron plus/minus buprenorphine
 
Last edited:
I am not advocating the dosages being discussed in this thread. As a specialty we are extremely conservative and that was my main point here.

That said, I feel comfortable giving a patient 1.5 vials of exparel but the cost is too high ($560).
So, we should stick with one vial. I would also prefer the surgeons inject with 0.25% Bup with Epi instead of 0.5% Bup with Epi to give me more of a cushion for my ACB.

The real question is this:

Is it better to use the Exparel with decadron for the ACB and regular Ropivacaine with Toradol plus Epi for the LIA or the Exparel for the LIA with 0.5% Bup with decadron for the ACB?
 
stonemd said:
Toxicity. How much can you use? Conventional toxicity = 2.5mg/kg.
266 mg
Say you have a 70 kg patient for a total knee. 70 x 2.5mg/kg = 175 max plain dose bupi.
266mg if greater than 50kg
Can you use all 266 mg of liposomal in a 70 kg person? 300mg?
266mg

How does toxicity differ when adding regular bupi?
ie: What if you add an ACB. How do you calculate toxicity.
266mg exp with 133mg plain bupic

Can you mix it with marcaine instead of NS- I've put a stop to this with my patients at the moment. Website says that if you use marcaine before exparel, to decrease the dose by 50%
No give separately

Ask about liposomal breakdown. Any evidence that some patients metabolize it faster increasing plasma levels? I've heard YES to this question.
More vascular space means more rapid release of bupic icing

I'd be nice to see a graphical lay out of plasma levels over 3 days.
I think blade has posted this

TAP block ongoing
ACB planned
Femoral n. ongoing
Click to expand...

Nice. Thanks.

I wonder what plasma levels are when injected intercostally vs in the hip/knee.
 
BLADEMDA said:
Nice cocktail. No toradol?


http://www.ncbi.nlm.nih.gov/pubmed/20860447



http://www.ncbi.nlm.nih.gov/pubmed/20450425


http://www.ncbi.nlm.nih.gov/pubmed/19404806
Click to expand...


No toradol with our attendings...but nice studies.

Trying to publish our results right now, but our attending went from FNB with local + PCA to Exparel, No Block, No PCA. Post-op they are receiving some fentanyl per anesthesia in the PACU...but from ortho standpoint, 20mg Oxy * 1 on POD 0, then Norco 5/Ultram 50 is the standard order.

Patients are using less opioids, shorter hospitalization stays, lower pain scores, and less total cost (all statistically significant).
 
ChiDO said:
No toradol with our attendings...but nice studies.

Trying to publish our results right now, but our attending went from FNB with local + PCA to Exparel, No Block, No PCA. Post-op they are receiving some fentanyl per anesthesia in the PACU...but from ortho standpoint, 20mg Oxy * 1 on POD 0, then Norco 5/Ultram 50 is the standard order.

Patients are using less opioids, shorter hospitalization stays, lower pain scores, and less total cost (all statistically significant).
Click to expand...

This is good news. I'm still curious if pain scores would be lower with an Adductor Canal Block plus LIA by the Ortho surgeon.

I do agree the trend is away from Femoral Nerve blocks so motor strength is preserved and patients ambulate earlier.
 
BLADEMDA said:
This is good news. I'm still curious if pain scores would be lower with an Adductor Canal Block plus LIA by the Ortho surgeon.

I do agree the trend is away from Femoral Nerve blocks so motor strength is preserved and patients ambulate earlier.
Click to expand...

Have no experience with ACB, but you are correct that FNB slowed down therapy with PTs and they were staying till POD 2 usually; now majority go home POD 1. Maybe I can convince our attending to do ACB + Exparel and send patients home on POD 0 (ie. outpatient). :naughty:
 
ChiDO said:
No toradol with our attendings...but nice studies.

Trying to publish our results right now, but our attending went from FNB with local + PCA to Exparel, No Block, No PCA. Post-op they are receiving some fentanyl per anesthesia in the PACU...but from ortho standpoint, 20mg Oxy * 1 on POD 0, then Norco 5/Ultram 50 is the standard order.

Patients are using less opioids, shorter hospitalization stays, lower pain scores, and less total cost (all statistically significant).
Click to expand...

yeah, the busiest (and loudest) orthopod at our place flew through the doors today, "no blocks at all on my patients, we're moving to this new special marcaine!" and then his patients suffer because...we don't have it here lol. we will be moving to a regimen just like yours. i'm glad to hear that it works.
but he will get his way. he doesn't want to wait for us to put in the blocks, and it will help prevent falls.
I guess I don't mind, we don't have a block room, so all are done in the OR's. I don't get paid any extra for the blocks, so if the patient is happy with this new technique and I have a little less liability from nerve blocks, it's a win-win.
plus if he gets it put on formulary, I get to play with it in my other blocks👍
 
Last edited:
Exparel has its limitations. Especially intra-op and immediately post op. It's not a silver bullet. ACB + exparel is the sweet spot. Surgeons will be surgeons.
 
We are in the middle of the big switch away from femoral blocks for TKA

Currently recommending
LAI Rop 0.2% + 30mg toradol + 2.5mcg/ml epinephrine MAX 150ml
ACB Bup 0.25% + dexameth 4mg + 5mcg/ml epinephrine 10-20ml

When we get exparel
LAI Bup 0.25% + 30 mg toradol + 5mg/ml MAX 60ml followed by
Exparel 266mg +/- saline dilation to ??ml
ACB Bup 0.25% + dexameth 4mg + 5mcg/ml epinephrine 10-20ml

What do you think?
Anyone mixing bup or rop or toradol or epi with the exparel for LAI?
What is the max mg bup or rop you are mixing with 266mg bup in the exparel?
What is the optimal volume to do a complete LAI of the knee?
Do you treat uni different from TKA?
How do you manage ACL?
 
You must log in or register to reply here.