Exparel dosing

[deleted875186]

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How is everyone dosing exparel? Do you add plain bupivacaine to your exparel to expand volume? What blocks are you adding it to beyond interscalene and TAPs? Are you ok with surgeon using some bupi local in the case after blocking with exparel?

 

[BLADEMDA]

How is everyone dosing exparel? Do you add plain bupivacaine to your exparel to expand volume? What blocks are you adding it to beyond interscalene and TAPs? Are you ok with surgeon using some bupi local in the case after blocking with exparel?

Exparel has been a disappointment for me over the past decade. Yes, I have been using it for 10+ years. I don't think it's worth the cost for ISB vs Bup with decadron. For Fascial plane blocks like TAP and ESP it does add some duration like 12 hours vs Bup with decadron. I utilize 2 full bottles for bilateral ESP blocks with decent results. The more you dilute Exparel (with Bup) the shorter the duration which resembles Bup with decadron. I typically dilute with 0.25% Bup quite liberally with no issues.

Liposomal Bup in the 10 ml bottle is practically worthless IMHO. The 20 ml is expensive but it does add analgesia duration for fascial plane blocks.

 

[deleted875186]

Exparel has been a disappointment for me over the past decade. Yes, I have been using it for 10+ years. I don't think it's worth the cost for ISB vs Bup with decadron. For Fascial plane blocks like TAP and ESP it does add some duration like 12 hours vs Bup with decadron. I utilize 2 full bottles for bilateral ESP blocks with decent results. The more you dilute Exparel (with Bup) the shorter the duration which resembles Bup with decadron. I typically dilute with 0.25% Bup quite liberally with no issues.

Liposomal Bup in the 10 ml bottle is practically worthless IMHO. The 20 ml is expensive but it does add analgesia duration for fascial plane blocks.

Let’s say you work in a hosptial setting and the cost is of no concern to you? Do you think exparel is superior in any way?

Is it safer than plain bupi? Is it problematic to use exparel, say if you do a block and it fails for some reason, could you repeat the block in PACU?

 

[deleted875186]

Exparel has been a disappointment for me over the past decade. Yes, I have been using it for 10+ years. I don't think it's worth the cost for ISB vs Bup with decadron. For Fascial plane blocks like TAP and ESP it does add some duration like 12 hours vs Bup with decadron. I utilize 2 full bottles for bilateral ESP blocks with decent results. The more you dilute Exparel (with Bup) the shorter the duration which resembles Bup with decadron. I typically dilute with 0.25% Bup quite liberally with no issues.

Liposomal Bup in the 10 ml bottle is practically worthless IMHO. The 20 ml is expensive but it does add analgesia duration for fascial plane blocks.

What type of duration are you getting in an interscalene from bupi and 4 mg dex? I see 24 hours max, typically somewhere between 12-24 hours? Maybe I’m not adding enough bupi. I typically see much longer duration with exparel.

 

[anbuitachi]

What type of duration are you getting in an interscalene from bupi and 4 mg dex? I see 24 hours max, typically somewhere between 12-24 hours? Maybe I’m not adding enough bupi. I typically see much longer duration with exparel.

how much longer

 

[Ronin786]

This is my go to from the manufacturer. Pretty much just use it for TAP/Rectus Sheath/external oblique blocks.

 

[2Fast2Des]

This is my go to from the manufacturer. Pretty much just use it for TAP/Rectus Sheath/external oblique blocks.

View attachment 366636

Same, this is what I refer to every time I ever have to. I just use plain bupi, the studies have shown exparel is not superior so why do we even continue using it...

 

[deleted87051]

This is my go to from the manufacturer. Pretty much just use it for TAP/Rectus Sheath/external oblique blocks.

View attachment 366636

Why is it okay to give more plain bupivacaine with the larger bottle of exparel? 208mg total bupivacaine on the left vs 416mg total bupivacaine on the right. Doesn’t make sense to me.

 

[Lecithin5]

Agree that exparel isn’t all that. When used for a fascial plane block (ie tap, serratus, ES, etc), I’ll mix 10cc exparel (ie 133mg) plus 10-15cc 0.25 percent bupi plus 10cc saline Per side.

 

[Planktonmd]

This old thread popped and it's funny to see people like Blade who were basically doing free marketing for this medication change their tone and realize that Exparel was nothing but an aggressive marketing campaign not based on science or evidence.

Exparel and TKR

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...

forums.studentdoctor.net

 

[DocMcCoy]

When a drug company tries to sue a leading journal using science to show their snake oil doesn’t work they lose all credibility in my book.

 

[Anestheezee]

When a drug company tries to sue a leading journal using science to show their snake oil doesn’t work they lose all credibility in my book.

Pacira’s Lawsuit Against Anesthesiology Dismissed

The American Society of Anesthesiologists (ASA) is gratified that the lawsuit filed against ASA, the editor-in-chief of Anesthesiology – the official peer-reviewed journal of ASA – and 11 contributing authors by Pacira Biosciences Inc., has been dismissed by the United States District Court for...

www.asahq.org

The lawsuit was finally dismissed 2/2022. HOWEVER, I just went to an anesthesia conference a couple weeks ago where Pacira is not backing down and will re-open the libel suit. Keep an eye on the news for this one...

I refuse to use exparel. What a waste of money.

Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine - PubMed

Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that...

pubmed.ncbi.nlm.nih.gov

I typically do 4 mg decadron in a 20 mL syringe with bupi 0.5% plain and quote patients 18-24 hours. If no bupi available, I use ropi 0.5%. Works great.

 

[Ronin786]

Why is it okay to give more plain bupivacaine with the larger bottle of exparel? 208mg total bupivacaine on the left vs 416mg total bupivacaine on the right. Doesn’t make sense to me.

You're still limited by the toxic doses of bupivicaine. The idea is that the exparel dosage is one or two bottles, independent of how much bupi you use.

 

[Gern Blansten]

When a drug company tries to sue a leading journal using science to show their snake oil doesn’t work they lose all credibility in my book.

Yeah, the lawsuit pretty much turned me away from trusting anything that Pacira has to offer. Snake oil salesmen is an accurate assessment.
Here is a review of liposomal bupivacaine and adverse events related to toxicity:

Local anesthetics systemic toxicity association with exparel (bupivacaine liposome)- a pharmacovigilance evaluation - PubMed

The health care provider, including anesthetists, should be made aware that as with bupivacaine HCl, Local Anesthetic Systemic Toxicity, including seizures and cardiac arrest, could be induced by Exparel as well.

pubmed.ncbi.nlm.nih.gov

From that paper, you can see that the safety of the liposomal delivery system is not as safe as Pacira would have you believe.

The above table shows the analysis of the most critical events. When analyzed for all events, this review illustrated that, in the FDA adverse event reporting system, when liposomal bupivacaine was implicated in an adverse event (130 cases), 11 (or 8%) of the cases resulted in death. There are several factors that can result in disruption of the liposomal delivery system resulting in a release of far greater amounts of bupivacaine than expected. The premise just seems like a bad idea to begin with and the juice is not worth the squeeze, in my opinion. The squeeze includes the cost and the potential hazards of toxicity. Not to even mention the poor overall performance in providing clinical benefit. That, combined with the questionable safety marketing of Pacira coupled with the lawsuit against several people (including a few residents) and entities,...

 

[deleted875186]

This is my go to from the manufacturer. Pretty much just use it for TAP/Rectus Sheath/external oblique blocks.

View attachment 366636

I will add some plain bupi tk exparel, but nothing like what’s listed on the right of this diagram, 60 cc of bupi 0.25% and two vials of exparel, that last 150 plus 266 mg bupi. Also, I don’t know where the manufacturers gets this dosing regimen, because they don’t cite any papers, and it’s not mentioned at all in the package insert for exparel, in fact the package insert says you can mix exparel with bupi but that it may alter the pharmacokinetics of exparel, whatever that means.

 

[deleted875186]

how much longer

Typically a couple days. Have seen people still have motor block at day 3.

 

[Mehd School]

Y'all can keep your catheters, I'm going to keep my exparel. Routinely see 48 hours in my ISB, can rarely touch 24 hours single shot with decadron and precedex added in, which isn't without it's own complications. One of my colleagues routinely puts 1mcg per kg precedex in blocks and I had to sit on his healthy college athlete with a heart rate of 21 in the PACU after a shoulder scope.

I hated sending patients home with catheters just for them to get ripped out so I stopped.

 

[Hoya11]

Y'all can keep your catheters, I'm going to keep my exparel. Routinely see 48 hours in my ISB, can rarely touch 24 hours single shot with decadron and precedex added in, which isn't without it's own complications. One of my colleagues routinely puts 1mcg per kg precedex in blocks and I had to sit on his healthy college athlete with a heart rate of 21 in the PACU after a shoulder scope.

I hated sending patients home with catheters just for them to get ripped out so I stopped.

There have been a couple people saying that bupi and dex gets you less than 24hrs.

How much bupi are you using ?

30 of .5 plus 8 of decadron equals 36 hrs relief and sometimes more from my patient testimonials

 

[deleted87051]

There have been a couple people saying that bupi and dex gets you less than 24hrs.

How much bupi are you using ?

30 of .5 plus 8 of decadron equals 36 hrs relief and sometimes more from my patient testimonials

I wonder about this too. Some people say they only need 10-15ml local for an SCB or ISB. That’s true but the block doesn’t last as long.

 

[deleted87051]

Y'all can keep your catheters, I'm going to keep my exparel. Routinely see 48 hours in my ISB, can rarely touch 24 hours single shot with decadron and precedex added in, which isn't without it's own complications. One of my colleagues routinely puts 1mcg per kg precedex in blocks and I had to sit on his healthy college athlete with a heart rate of 21 in the PACU after a shoulder scope.

I hated sending patients home with catheters just for them to get ripped out so I stopped.

That is a ton of precedex. I’d be wary of giving that much.

 

[Mehd School]

There have been a couple people saying that bupi and dex gets you less than 24hrs.

How much bupi are you using ?

30 of .5 plus 8 of decadron equals 36 hrs relief and sometimes more from my patient testimonials

30cc's in an ISB is pretty stout. How long does their Horner's last

 

[Hoya11]

30cc's in an ISB is pretty stout. How long does their Horner's last

So you would prefer a shorter block to avoid horners ?

And if you have good technique to spread out the local throughout the plexus horners is rare, but really who cares ? I’d go for the longer block ..

 

[DocMcCoy]

So you would prefer a shorter block to avoid horners ?

And if you have good technique to spread out the local throughout the plexus horners is rare, but really who cares ? I’d go for the longer block ..

Seen an iatrogenic horners after ISB. It was pretty unsettling to the patient so yes. I typically use around 15mL with decadron. I like the idea of getting a patient through the perioperative period without opioids. I’m willing to accept 1-2 more Percocets to their total opioid consumption due to slightly less block duration while hopefully sparing some side effects and complications.

 

[Mehd School]

So you would prefer a shorter block to avoid horners ?

And if you have good technique to spread out the local throughout the plexus horners is rare, but really who cares ? I’d go for the longer block ..

I mean, yeah. People are dumb and one of my patients with a hx of CVA came to our ER at midnight and was stroke activated over horners(despite thorough education). I'm not calling the patient dumb, but the ER doc that activated the code stroke works in an extremely high volume ortho hospital and I have spoken to him about this before. That surgeon now only wants single shot blocks with straight 0.25% bupi because of the mess.

I'm in the camp that people don't need a dense motor block for 48+ hours. Get them through the first night and have them load up on Tylenol, an NSAID and a reasonable dose of opiate on night 2. When they wake up on POD 3 the worst is far behind them.

 

[Silo004]

What type of duration are you getting in an interscalene from bupi and 4 mg dex? I see 24 hours max, typically somewhere between 12-24 hours? Maybe I’m not adding enough bupi. I typically see much longer duration with exparel.

I add 4mg of decadron and 0.25 mcg/kg of dexmedetomidine for every 30 ml's of bupi for ~36 hrsish. Can get longer. I tell people 12-24 though and it might last longer.

 

[Silo004]

That is a ton of precedex. I’d be wary of giving that much.

That's a f*** ton of precedex.

 

[Hoya11]

Seen an iatrogenic horners after ISB. It was pretty unsettling to the patient so yes. I typically use around 15mL with decadron. I like the idea of getting a patient through the perioperative period without opioids. I’m willing to accept 1-2 more Percocets to their total opioid consumption due to slightly less block duration while hopefully sparing some side effects and complications.

my view is that you are not in reality sparing any complications and are depriving your patient of longer analgesia, no one wants complications but im not sure there is evidence that links 30cc to danger vs 20cc or less

 

[abolt18]

You guys all putting preservative free dexamethasone in these blocks? I've never added dexamethasone to my blocks because we don't have any preservarive-free stuff on formulary.

 

[deleted875186]

There have been a couple people saying that bupi and dex gets you less than 24hrs.

How much bupi are you using ?

30 of .5 plus 8 of decadron equals 36 hrs relief and sometimes more from my patient testimonials

Fair enough. I usually use 20 mL of 0.5% bupi and 4 of dex. See 24 hours, sometimes less.

 

[Mehd School]

You guys all putting preservative free dexamethasone in these blocks? I've never added dexamethasone to my blocks because we don't have any preservarive-free stuff on formulary.

No, and also we shouldn't be doing it because pretty much everyone gets IV decadron intraop and systemic administration has been shown to extend duration of block as much as it does as an additive in your block syringe.

 

[abolt18]

No, and also we shouldn't be doing it because pretty much everyone gets IV decadron intraop and systemic administration has been shown to extend duration of block as much as it does as an additive in your block syringe.

This was my understanding as well but you never really know.

 

[DocMcCoy]

my view is that you are not in reality sparing any complications and are depriving your patient of longer analgesia, no one wants complications but im not sure there is evidence that links 30cc to danger vs 20cc or less

Honestly I don’t have a full understanding of how much data there is supporting large volume over small volume nerve blocks in terms of complications, onset, and block duration… or vice versa.


My main argument is I don’t understand pushing block duration to the extreme by administering potentially near LAST levels of bupivacaine or adding extenders that can result in profound bradycardia and potentially cardiac arrest. In my mind we go too far sometimes in thinking narcs are evil and push multimodal at all costs to the detriment of the patient…. In order to save a couple of mg morphine equivalents in the long run.

Show me some quality evidence of a block with 72+ hrs duration and I might change my tune.

 

[deleted87051]

No, and also we shouldn't be doing it because pretty much everyone gets IV decadron intraop and systemic administration has been shown to extend duration of block as much as it does as an additive in your block syringe.

And dexamethasone has consistently been shown to reduce both postop pain scores and postop opioid consumption. This effect exists whether the patients had a block or not. So I’m not sure if the dexamethasone is “extending” the block or if decadron is just great analgesic adjuvant.

 

[Hoya11]

Honestly I don’t have a full understanding of how much data there is supporting large volume over small volume nerve blocks in terms of complications, onset, and block duration… or vice versa.


My main argument is I don’t understand pushing block duration to the extreme by administering potentially near LAST levels of bupivacaine or adding extenders that can result in profound bradycardia and potentially cardiac arrest. In my mind we go too far sometimes in thinking narcs are evil and push multimodal at all costs to the detriment of the patient…. In order to save a couple of mg morphine equivalents in the long run.

Show me some quality evidence of a block with 72+ hrs duration and I might change my tune.

i agree with the opiate sentiment.. not against opiates

but when i block i want it to last, i dont want to just do the minimum and get out of dodge

thats why exparel is on the market and catheters were on the market, the search is on to prolong analgesia and blocks despite your feeling that 12-24hrs is enough.

there is nothing wrong with being defensive but in my block heavy ortho asc this practice would not fly

anyways my question is answered.. those preferring exparel are probably the ones using the low volume no additive defensive medicine blocks

because with the appropriate amount of bupi - you dont need it

 

[deleted875186]

i agree with the opiate sentiment.. not against opiates

but when i block i want it to last, i dont want to just do the minimum and get out of dodge

thats why exparel is on the market and catheters were on the market, the search is on to prolong analgesia and blocks despite your feeling that 12-24hrs is enough.

there is nothing wrong with being defensive but in my block heavy ortho asc this practice would not fly

anyways my question is answered.. those preferring exparel are probably the ones using the low volume no additive defensive medicine blocks

because with the appropriate amount of bupi - you dont need it

I use bupi 0.5% 20 cc and dex 4 mg. I consistently see longer blocks with exparel mixed with bupi. Perhaps I will try a larger dose of dex. Anyone have any info on optimal dose of dex, from what I remember small doses perineurally where equally effective.

 

[pmichaelmd]

I use 0.25% bupiv 20ml mixed with 10ml Exparel (133mg) x 2 (draw up two 30ml syringes with the 20:10 mix). Have had good success with bilateral TAP blocks, 4 quadrant TAPs, ESP, and PECS blocks with the Exparel. Granted we also use IV adjuvants (Decadron, etc), but the surgeons report 2-4 days of analgesia after the bupiv/exparel blocks.

 

[ASA6]

My groups standard protocol for ISB is 10cc 0.5% bupi + 10cc exparel. We get 36-48 hours. Our surgeons all love it and say they get much better pain relief and satisfaction from the patients. For adductors I will do 15cc 0.25% bupi + 5cc exparel. For pops 15cc 0.5% bupi + 5cc exparel. Same duration here. For ESP, TAP, and PENG block its 20cc 0.25% + 10cc exparel per side. 48-72 hours.

 

[Aether2000]

Here is the study for dex IV vs dex mixed with the local: Intravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block: A Randomized, Triple-arm, Double-Blind, placebo-Controlled Trial | Regional Anesthesia & Pain Medicine

Intravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block: A Randomized, Triple-arm, Double-Blind, placebo-Controlled Trial

1. Faraj W. Abdallah, MD*, et.al

Abstract​

Background and Objectives Perineural dexamethasone prolongs the duration of single-injection peripheral nerve block when added to the local anesthetic solution. Postulated systemic mechanisms of action along with theoretical safety concerns have prompted the investigation of intravenous dexamethasone as an alternative, with decidedly mixed results. We aimed to confirm that addition of intravenous dexamethasone will prolong the duration of analgesia after single-injection supraclavicular block compared with conventional long-acting local anesthetic alone or in combination with perineural dexamethasone for ambulatory upper extremity surgery.
Methods Seventy-five patients were randomized to receive supraclavicular block using 30-mL bupivacaine 0.5% alone (Control), with concomitant intravenous dexamethasone 8 mg (DexIV), or with perineural dexamethasone 8 mg (DexP). Duration of analgesia was designated as the primary outcome. To test our hypothesis, the superiority of DexIV was first compared with Control and then with DexP. Motor block duration, pain scores, opioid consumption, opioid-related side effects, patient satisfaction, and block-related complications were also analyzed.
Results Twenty-five patients per group were analyzed. The duration of analgesia (mean [95% confidence interval]) was prolonged in the DexIV group (25 hours [17.6–23.6]) compared with Control (13.2 hours [11.5–15.0]; P < 0.001) but similar to the DexP group (25 hours [19.5–27.4]; P = 1). The DexIV group experienced longer motor block (30.1 hours) compared with DexP (25.5 hours) and Control (19.7 hours) groups. Both DexIV and DexP had reduced pain scores, reduced postoperative opioid consumption, and improved satisfaction compared with Control.
Conclusions In a single-injection supraclavicular block with long-acting local anesthetic, the effectiveness of intravenous dexamethasone in prolonging the duration of analgesia seems similar to perineural dexamethasone.

 

[Mehd School]

Bingo. I've stopped giving it perineurial. It gets absorbed systemically there too and unless someone's about to herniate their brain they don't need 6 of decadron from me then 8 of decadron in the OR.

 

[repititionition]

I am always interested by people’s brachial plexus block experiences. 15cc 1/4, 40mcg precedex, and 10 of epi gets me 24+ hours of excellent pain relief. Is it two or three days? No. But I also think I’ve anecdotally seen more iatrogenesis from blocks with exparel. I never use perineurial decadron. It only increases risk of neural injury.

 

[epidural man]

Y'all can keep your catheters, I'm going to keep my exparel. Routinely see 48 hours in my ISB, can rarely touch 24 hours single shot with decadron and precedex added in, which isn't without it's own complications. One of my colleagues routinely puts 1mcg per kg precedex in blocks and I had to sit on his healthy college athlete with a heart rate of 21 in the PACU after a shoulder scope.

I hated sending patients home with catheters just for them to get ripped out so I stopped.

Well I wish you would reconsider.

But I get it. I really do. I have tried to free myself from Google because of how evil they are - I tried moving all my email to another server, I use Duck Duck Go, etc....but it is hard to "vote with your dollar" when the company that sucks balls has great products. And being principled is difficult. I'm there with you.

HOWEVER,

Pacira SUED because they didn't like the results of a study. They sued all the authors, AND the journal, AND the editor of the journal. By the way, EVERY article funded by Pacira shows efficacy. EVERY study not funded by Pacira shows NO BENEFIT. You don't find that strange?

Even if it works, it BARELY works - and letting them get a dollar when you could choose otherwise, I don't think, is worth the 3-4 hours extra of pain relief.

 

[2Fast2Des]

We get 2 units for single shots, 4 for catheter. Guess which block I'm going to do, as appropriate of course 😉

 

[deleted875186]

Well I wish you would reconsider.

But I get it. I really do. I have tried to free myself from Google because of how evil they are - I tried moving all my email to another server, I use Duck Duck Go, etc....but it is hard to "vote with your dollar" when the company that sucks balls has great products. And being principled is difficult. I'm there with you.

HOWEVER,

Pacira SUED because they didn't like the results of a study. They sued all the authors, AND the journal, AND the editor of the journal. By the way, EVERY article funded by Pacira shows efficacy. EVERY study not funded by Pacira shows NO BENEFIT. You don't find that strange?

Even if it works, it BARELY works - and letting them get a dollar when you could choose otherwise, I don't think, is worth the 3-4 hours extra of pain relief.

So are you saying if some other company started making a liposomal bupivacaine you would start using it?

Do you also stand up against using chlorhexidine for instance because a lot of the studies had huge conflicts of interest and duraprep has pretty much equivalent success?

From the point of view of the patient, 4 hours extra pain relief is probably worth it, they don’t see any extra cost.

 

[epidural man]

So are you saying if some other company started making a liposomal bupivacaine you would start using it?

Do you also stand up against using chlorhexidine for instance because a lot of the studies had huge conflicts of interest and duraprep has pretty much equivalent success?

From the point of view of the patient, 4 hours extra pain relief is probably worth it, they don’t see any extra cost.

Yes I would (use an extended release local)!

Review my posts. I was a HUGE supporter of Exparel. I was a co-author on one of the (funded) earliest papers on the stuff.

Every company has conflicts of interest.

That is a WORLD APART from suing a resident for publishing a paper that you don’t like.

 

[Straight2eight]

Agree with @dipriMAN and @Hoya11. I consistently get 48 hours from bupi 0.5 + exparel ISB. Very common to see longer, very uncommon to see less. Who cares if your eye droops when you get an extra day of pain free recovery. Too easy to disregard pain you never see after the patient is gone home. Going to the ER for Horner’s or shortness of breath is a failure of patient education on possible side effects.

Don’t know what to make of negative studies in light of our experience but I will say that I have watched a lot of atrocious interscalene technique. Exparel is not going to diffuse from inside the middle scalene to the plexus even if the plain bupi will.

Won’t defend Pacira though…

 

[epidural man]

I would have loved to be in the board meeting with legal when this was discussed.

CEO: I’m pissed. I’m so sick of people publishing studies showing our (ONLY) product doesn’t work. Didn’t they read our hemorrhoidectomy study!!?

bystander worker bee: well, some are arguing that company sponsored studies are sometimes not as reliable as people who do studies who have no bias or dog in the fight and just want to get at the truth. I’m not saying I agree; just that some are saying that.

CEO: WTF!!!!? I have no bias. I just want what’s best for patients. Someone fire that guy. You know what? I’m so pissed I want blood. Let’s sue those guys. Sue them all! The authors, the editor, the journal, and whoever else even remotely associated with publishing the journal. We will show them!

Legal: are you sure? That has never been done before. Plus, it will make the physicians who use our product mad and make them trust us less. Some would argue that if your product works and you trust it, you should fund investigator initiated studies and relinquish data control. Don’t fight this battle in courts. Fight this battle with science. Show the truth. But that is only if you believe you have a product that works.

CEO: (silence, blank stare)

Primary company scientists (silence, blank stares)

Uncomfortable silence for several minutes…

CEO: okay so let’s get this law suite moving.

 

[Mehd School]

I use bupi 0.5% 20 cc and dex 4 mg. I consistently see longer blocks with exparel mixed with bupi. Perhaps I will try a larger dose of dex. Anyone have any info on optimal dose of dex, from what I remember small doses perineurally where equally effective.

what I like to do with dex is grab a 4mg/cc vial and draw 1-2 of those up depending on the patient then inject it in their IV after they go to sleep so their butthole doesn't get set on fire.