Exparel injection question

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caligas

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Say your doing ISB. After starting with the plain bupi, do you put your needle tip right in the center of the injected bupi deposit and then inject ALL the Exparel or do you move around to spread the Exparel?

any other pearls?
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sevoflurane said:
I take a simpler approach. Just mix 133mg with 10cc’s of .25% bupi. Then block as usual (medial and lateral to C5 with the last few cc’s caudad to C6/7)
Click to expand...

This is exactly how the hired suit explained he did things at an Exparel dinner I went to 2 years ago, and the few times I used it I would mix with plain bupivacaine.

Our hospital has since taken Exparel off formulary so I doubt I’ll get to go to such a dinner anytime soon.
 
caligas said:
ever use 266 for ISB?
Click to expand...

Yes, many times and that dose is superior to the 133 mg dose. I typically find the BEST block (single shot) to be 20 mls of Exparel mixed with 10 mls of 0,5% Bup for a total volume of 30 mls. This allows for a more dense block (it's still not very dense) than pure Exparel 266 mg.

IMHO, the use of 133 mg of Exparel is a total waste of money. I have tracked about 10 patients with 133 mg vs 0.5% Bup with decadron. The latter group has a longer duration of postop analgesia at a fraction of the cost. Only when utilizing 266 mg of Exparel does the ISB last longer than the conventional use of 0.5% Bup with decadron by about 6-8 hours.

Until proven otherwise the 133 mg dose of Exparel is NOT worth anywhere close to $180 per vial. For true enhanced postop analgesia the 266 mg dosage is needed for ISB and Femoral blocks or simply go with the $5 combo of 0.5% Bup with dexamethasone.
 
Blade, my group tracked our ISBs with 133mg Exparel for 2 years (probably in the neighborhood of 800-1000). Called on POD 1/2. Agree, highly underwhelming and no better than bupi/decadron.
 
As a group, we generally use 10cc exparel mixed with 15cc 0.5% plain marcaine for ISBs. Our experience has been that patients get a denser, lengthier block with the old marcaine/epi with another adjuvant (some used decadron, some clonidine). However, according to the orthopods, the patients are happier with the exparel. We suspect it's because the exparel wears off more progressively as opposed to blocks without the exparel, where pain can go from 0 to 10 in a matter of minutes as the block wears off. With exparel, seems to be a slower trend towards pain onset as the block wears off, and even if it didn't last as long or wasn't as dense, patients seem to like that better.
 
DrZzZz said:
As a group, we generally use 10cc exparel mixed with 15cc 0.5% plain marcaine for ISBs. Our experience has been that patients get a denser, lengthier block with the old marcaine/epi with another adjuvant (some used decadron, some clonidine). However, according to the orthopods, the patients are happier with the exparel. We suspect it's because the exparel wears off more progressively as opposed to blocks without the exparel, where pain can go from 0 to 10 in a matter of minutes as the block wears off. With exparel, seems to be a slower trend towards pain onset as the block wears off, and even if it didn't last as long or wasn't as dense, patients seem to like that better.
Click to expand...

I'm new to using Exparel for ACB. The Exparel package insert says do not exceed 1:2 mg ratio of plain bupiv to Exparel. So is it ok to exceed a little bit?
Used 10cc Exparel (133mg) + 10cc 0.25% plain bupiv for ACB this week for TKA... I agreed the result was disappointing and a waste of money. Excellent block visualization on U/S but pain was 8/10. The worst feeling was 4 months prior the pt had TKA done on the other knee with just ropiv without Exparel, and she reported no pain at all at that time.
 
DrZzZz said:
As a group, we generally use 10cc exparel mixed with 15cc 0.5% plain marcaine for ISBs. Our experience has been that patients get a denser, lengthier block with the old marcaine/epi with another adjuvant (some used decadron, some clonidine). However, according to the orthopods, the patients are happier with the exparel. We suspect it's because the exparel wears off more progressively as opposed to blocks without the exparel, where pain can go from 0 to 10 in a matter of minutes as the block wears off. With exparel, seems to be a slower trend towards pain onset as the block wears off, and even if it didn't last as long or wasn't as dense, patients seem to like that better.
Click to expand...

You are exceeding the allowable mixture of Bupivacaine. 133 mg of Exparel means you are limited to 66 mg of bupivacaine. You have diluted the Exparel so much with bupivcaine that it is essentially worthless IMHO. If you are happier with this placebo effect of Exparel then by all means continue to use it. I for one have found the exact opposite. Patients are happier with Bupivacaine plus dexamethasone because the duration of analgesia is actually superior.

I do like Exparel at the 266 mg dosage. I add 0.5% Bup (10 ml) to the 20 ml of Exparel. This block will last 30-36 hours for an ISB or a Femoral block. The marketing behind 133 mg is simply smoke and mirrors.

I have performed a thousand TAP blocks with Exparel. 266 mg. I dilute that up to a volume of 40 or 60 mls. The Tap blocks last around 36 hours give or take 4 hours.
 
BLADEMDA said:
You are exceeding the allowable mixture of Bupivacaine. 133 mg of Exparel means you are limited to 66 mg of bupivacaine. You have diluted the Exparel so much with bupivcaine that it is essentially worthless IMHO. If you are happier with this placebo effect of Exparel then by all means continue to use it. I for one have found the exact opposite. Patients are happier with Bupivacaine plus dexamethasone because the duration of analgesia is actually superior.

I do like Exparel at the 266 mg dosage. I add 0.5% Bup (10 ml) to the 20 ml of Exparel. This block will last 30-36 hours for an ISB or a Femoral block. The marketing behind 133 mg is simply smoke and mirrors.

I have performed a thousand TAP blocks with Exparel. 266 mg. I dilute that up to a volume of 40 or 60 mls. The Tap blocks last around 36 hours give or take 4 hours.
Click to expand...

According to the information directly off Exparel's website, you're incorrect. It recommends up to 15cc of 0.5% bupivacaine with 133mg Exparel (because that is a molar equivalent of 150mg, which = 15 cc of 0.5% bupivacaine). It also states for ISBs "Do not exceed maximum dosage of 133mg (10 mL) of EXPAREL." The company themselves is telling you to avoid using 20mL Exparel for ISBs. 20mL is only recommended for plane blocks. If you get into any type of lawsuit over a nerve injury, good luck defending yourself going beyond max dosage that the company (who wants you to use as much of their product as possible) is saying is safe. Do you get longer duration using 20mL? I'm sure you do. But I can top your duration if I just inject some alcohol into the sheath, too. Lastly, I believe Exparel is only FDA approved for ISBs and plane blocks. Our group does not use it for any lower extremity blocks. Would it be safe? Probably. But we've decided as a group not to use it outside of FDA approval.

www.exparel.com

EXPAREL | Non-opioid Analgesic Pain Management

EXPAREL provides significant long-lasting, non-opioid pain management across various surgical procedures. EXPAREL is indicated for postsurgical analgesia.
www.exparel.com
 
Despite the fact the company "recommends" 133 mg of Exparel for nerve blocks (ISB) the 266 mg dosage is perfectly safe.

academic.oup.com

Brachial Plexus Block with Liposomal Bupivacaine for Shoulder Surgery Improves Analgesia and Reduces Opioid Consumption: Results from a Multicenter, Randomized, Double-Blind, Controlled Trial

AbstractObjective. The utility of single-injection and continuous peripheral nerve blocks is limited by short duration of analgesia and catheter-related co
academic.oup.com academic.oup.com

Have any of you read the inserts for the use of LMAs? If you follow the insert then about 3/4 of the patients you use of them on are not in accordance with the package insert.

What about dexamethasone? Do you use it only in an FDA approved manner?

The idea we are limited to practice based on an insert in ridiculous. The safety data around Exparel is excellent. The efficacy data is sparse.

I stand by my posts that the 133 mg dosage is merely "placebo" when mixed with Bupivacaine for ISB.
 
1605376938050.png
 
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By Mixing the Exparel (133 mg) with the full dosage of Bupivacaine (as noted above) the effect of the Liposomal Bupivacaine is minimal IMHO. That dosage of liposomal bupivacaine is inadequate to extend duration of analgesia more than the current practice of adding a small amount of dexamethasone to Bupivacaine.
 
In my practice I simply have stopped using Exparel for anything but TAP blocks. The cost/benefit ratio simply isn't there. If the company had solid data proving superior efficacy they would publish it by now. I have been using the drug since it came out. IMHO the company doomed itself by going with the 133 mg dosage as the recommended dose vs the 266 mg dose. The 266 mg dose actually works for nerve blocks to deliver superior duration of analgesia while the 133 mg dosage falls woefully short.
 
Here is the PACKAGE INSERT for SEVOFLURANE. Do you all follow it to the letter? I doubt it.

ULTANE can cause malignant hyperthermia. Postmarketing reports of malignant hyperthermia, some of which have been fatal, have occurred. ULTANE should not be used in patients with known sensitivity to sevoflurane or to other halogenated agents, or in patients with known or suspected susceptibility to malignant hyperthermia.

Findings taken from patient and animal studies suggest that there is a potential for renal injury when ULTANE is used at low flow rates, which is presumed due to Compound A. The level of Compound A exposure at which clinical nephrotoxicity might be expected to occur has not been established. To minimize exposure to Compound A, ULTANE exposure should not exceed 2 MAC-hours at flow rates of 1 to <2 L/min. Fresh gas flow rates <1 L/min are not recommended.

Because clinical experience in administering ULTANE to patients with renal insufficiency (creatinine >1.5 mg/dL) is limited, its safety in these patients has not been established.

ULTANE may be associated with glycosuria and proteinuria when used for long procedures at low flow rates.
 
LMAs are Contraindicated in OBESE patients per the package insert. Yet, I have personally placed tens of thousands of LMAs in this patient population over the course of my career.




What Is Morbid Obesity?

Morbid obesity is a condition in which you have a body mass index (BMI) higher than 35. BMI is used to estimate body fat and can help determine if you are at a healthy body weight for your size. BMI is not a perfect measurement but it does help give a general idea of ideal weight ranges for height.
 
You can throw all the examples you want at me. I'm not arguing that 266mg isn't safe, nor am I arguing that it isn't better than using 133mg. It very likely is safe, and it very likely gives a longer duration than 133mg. But there's a huge difference between all the examples you gave and Exparel. If I get sued for using an LMA in a patient with a BMI of 35, used heavy marcaine in a spinal (in spite of what the vial says), etc etc and I can confidently tell the jury that 99% of anesthesiologists practice in that manner. Exparel hasn't been around long enough. What am I going to say, "Well, @BLADEMDA said it was safe." I'm not going to have a slew of safety data or anesthesiologists backing me on that argument. It's not equivocal. I've got enough time horizon on my career to change my practice down the line if/when more data comes out on using higher Exparel dosages.
 
BLADEMDA said:
Despite the fact the company "recommends" 133 mg of Exparel for nerve blocks (ISB) the 266 mg dosage is perfectly safe.

academic.oup.com

Brachial Plexus Block with Liposomal Bupivacaine for Shoulder Surgery Improves Analgesia and Reduces Opioid Consumption: Results from a Multicenter, Randomized, Double-Blind, Controlled Trial

AbstractObjective. The utility of single-injection and continuous peripheral nerve blocks is limited by short duration of analgesia and catheter-related co
academic.oup.com academic.oup.com

Have any of you read the inserts for the use of LMAs? If you follow the insert then about 3/4 of the patients you use of them on are not in accordance with the package insert.

What about dexamethasone? Do you use it only in an FDA approved manner?

The idea we are limited to practice based on an insert in ridiculous. The safety data around Exparel is excellent. The efficacy data is sparse.

I stand by my posts that the 133 mg dosage is merely "placebo" when mixed with Bupivacaine for ISB.
Click to expand...
Especially considering the other thread about isobaric vs heavy bup for spinals. One is DEF not approved for intrathecal use.
 
DrZzZz said:
You can throw all the examples you want at me. I'm not arguing that 266mg isn't safe, nor am I arguing that it isn't better than using 133mg. It very likely is safe, and it very likely gives a longer duration than 133mg. But there's a huge difference between all the examples you gave and Exparel. If I get sued for using an LMA in a patient with a BMI of 35, used heavy marcaine in a spinal (in spite of what the vial says), etc etc and I can confidently tell the jury that 99% of anesthesiologists practice in that manner. Exparel hasn't been around long enough. What am I going to say, "Well, @BLADEMDA said it was safe." I'm not going to have a slew of safety data or anesthesiologists backing me on that argument. It's not equivocal. I've got enough time horizon on my career to change my practice down the line if/when more data comes out on using higher Exparel dosages.
Click to expand...

I am just pointing out that package inserts have little to do with actual practice. Exparel 266 mg doesn't cause nerve injury any more than the 133 mg dose. All I am pointing out is that the 266 mg dose is effective while the 133 mg dosage when used for brachial plexus blocks doesn't prolong analgesia.

One more thing an ISB is a brachial plexus block. If I utilize Exparel for an Infraclavicular block is that also "forbidden" due to the insert? Ridiculous of course. If you can safely perform an ISB with 133 mg of Exparel then you can safely do a Femoral with Exparel as well. In fact, the Femoral nerve is much more resilient than the cervical nerve roots in terms of injury.

I have no doubt you will change your practice over time because Pacira is doomed if they stick with the 133 mg dosage. That will put pressure on Pacira to do more clinical studies showing safety data for their 266 mg vial.


Anesthesiology

pubs.asahq.org pubs.asahq.org
 
In conclusion, a single administration of EXPAREL was demonstrated to be safe by peripheral nerve block in rabbits and dogs when tested in comparison with bupivacaine HCl and saline. EXPAREL did not cause overt irritation or local tissue damage even when injected at high dose or concentration around the brachial plexus nerve bundle.


The Safety of EXPAREL ® (Bupivacaine Liposome Injectable Suspension) Administered by Peripheral Nerve Block in Rabbits and Dogs

A sustained-release DepoFoam injection formulation of bupivacaine (EXPAREL, 15 mg/mL) is currently being investigated for postsurgical analgesia via peripheral nerve block (PNB). Single-dose toxicology studies of EXPAREL (9, 18, and 30 mg/kg), bupivacaine solution (Bsol, 9 mg/kg), and saline...
www.hindawi.com www.hindawi.com


I don't want anyone of this thread to miss the main point of my posts here. EXPAREL at 133 mg dosage is relatively worthless vs the standard Bupivacaine for peripheral nerve blocks. I utilize Exparel only for fascial plane blocks and even then the dilution does cause a drop-off in the duration of analgesia. I suspect the 133 mg dosage to be limited to a total volume of 30 ml (add in 20 ml of 0.25% Bup or saline) to maintain a duration of analgesia of over 24 hours. This is based on my experience of using Exparel 266 mg for Tap blocks where the duration of analgesia decreased to 24 hours once the mixture exceeded 60 mls.
YMMV, I have nothing against PACIRA but Exparel has been a disappointment to me in terms of clinical efficacy. Good Luck and by all means practice safely.
 
Last edited:
BLADEMDA said:
LMAs are Contraindicated in OBESE patients per the package insert. Yet, I have personally placed tens of thousands of LMAs in this patient population over the course of my career.




What Is Morbid Obesity?

Morbid obesity is a condition in which you have a body mass index (BMI) higher than 35. BMI is used to estimate body fat and can help determine if you are at a healthy body weight for your size. BMI is not a perfect measurement but it does help give a general idea of ideal weight ranges for height.
Click to expand...

You are such a clown
 
Archibald Brain

The laryngeal mask was invented by British anaesthesiologist/anaesthetist Archibald Brain in the early 1980s and in December 1987 the first commercial laryngeal mask was made available in the United Kingdom. The laryngeal mask is still widely used today worldwide and a variety of specialised laryngeal masks exist.



By January of 1988 it was possible to finalise the design and order three other sizes, the dimensions of which were based on prototypes made in either latex or silicone by Dr. Brain. The first hospital to purchase the LMA Classic™ was the Royal East Sussex Hospital, Hastings, where it has been in use from mid-1988. Twelve months later more than 500 other U.K. hospitals were using the device. Currently, the LMA™ airway product range is available throughout the world and has been used in over 300 million surgeries.

In the United States, the FDA cleared the LMA Classic™ for marketing in February 1991. By that time many forward-thinking anesthesiologists had become aware of the device and its use in Europe and around the world. Before it was cleared for marketing by the FDA, several U.S. pioneering anesthesiologists acquired the LMA Classic™ either through their contacts in the U.K. or through colleagues in Canada.

In 1992, The Laryngeal Mask Company concluded arrangements for the commercial sale of the LMA Classic™ in the United States.
 
Dr. Brain's invention was very popular in the UK and many visiting anesthesiologists made sure to acquire those devices for their own practices. I was one of those early adopters of the LMA and began using them frequently in my practice.
 
DrZzZz said:
You can throw all the examples you want at me. I'm not arguing that 266mg isn't safe, nor am I arguing that it isn't better than using 133mg. It very likely is safe, and it very likely gives a longer duration than 133mg. But there's a huge difference between all the examples you gave and Exparel. If I get sued for using an LMA in a patient with a BMI of 35, used heavy marcaine in a spinal (in spite of what the vial says), etc etc and I can confidently tell the jury that 99% of anesthesiologists practice in that manner. Exparel hasn't been around long enough. What am I going to say, "Well, @BLADEMDA said it was safe." I'm not going to have a slew of safety data or anesthesiologists backing me on that argument. It's not equivocal. I've got enough time horizon on my career to change my practice down the line if/when more data comes out on using higher Exparel dosages.
Click to expand...
I'm not aware of ANY successful lawsuits against a physician because of off-label use of anything. Is there such a case?
 
epidural man said:
I'm not aware of ANY successful lawsuits against a physician because of off-label use of anything. Is there such a case?
Click to expand...

I can't say that I'm aware of any. But like I said, I just don't think personally there's enough safety data out there on Exparel for me to use it off label, or worse, directly ignoring the company's own statement that max dose for an ISB is 133mg. People get sued for stupid s**t and even if the nerve injury was unrelated to the exparel, I wouldn't want to have given the opposing lawyer any additional ammo. Maybe I'm just more risk averse than others.
 
DrZzZz said:
I can't say that I'm aware of any. But like I said, I just don't think personally there's enough safety data out there on Exparel for me to use it off label, or worse, directly ignoring the company's own statement that max dose for an ISB is 133mg. People get sued for stupid s**t and even if the nerve injury was unrelated to the exparel, I wouldn't want to have given the opposing lawyer any additional ammo. Maybe I'm just more risk averse than others.
Click to expand...


Since the 133 mg really doesn't do much in terms of prolonging analgesia vs plain 0.5% Bup I doubt you need to worry much about lawsuits with ISB.

The unfortunate thing is that the 266 mg dose actually DOES work to provide analgesia over 30-36 hours. The company, Pacira, made a huge tactical error in going with the 133 mg dosage.
 
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