Exparel users - question for you.

[caligas]

I’m mainly interested in whether these blocks could eliminate the need for interscalene catheters + onQ which are burdensome in many ways, but widely requested by the orthopods at my hospital.

Well that's the million dollar question ain’t it.

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[pgg]

Bringing this thread back a year later and am interested in hearing people's use of exparel with interscalene nerve blocks. Anyone been using it on supraclavicular nerve blocks?

A patient had a supraclavicular done with exparel and was having resp distress and needed her BiPAP 24/7 afterwards (rather than at night only). ICU said it was diaphragm paralysis due to the block, but it was hard to say. Lasted about 4 days.

It appears that IV intralipid will substantially reverse peripheral nerve blocks done with bupivacaine. There are a handful of case reports and small studies out there. It might work for Exparel too.

When I was a resident I caused respiratory distress with an interscalene catheter in a person with pre-existing contralateral vocal cord dysfunction (her RLN got whacked during a previous thyroidectomy). My block got the ipsilateral RLN and she had to be intubated until the block wore off. If that happened to me today I'd give intralipid.

 

[DJDakoo]

FYI, if you ever need to reverse the phrenic nerve paresis post ISB consider a 30 ml “washout” with normal saline. This is especially important if a long acting local like Exparel is utilized.

The saline will help washout the local on the Phrenic nerve helping restore function and vital capacity.

https://www.tandfonline.com/doi/pdf/10.1080/22201181.2018.1461318

Great to know! Ever had an ISB with exparel last longer than 72h? I think in the FDA info sheet it says nerve block duration can go up to 120h!

 

[BLADEMDA]

Great to know! Ever had an ISB with exparel last longer than 72h? I think in the FDA info sheet it says nerve block duration can go up to 120h!

So far I’ve seen 96 hours a few time but not 120 hours yet. That’s at full dose of 266 mg.

 

[BLADEMDA]

It appears that IV intralipid will substantially reverse peripheral nerve blocks done with bupivacaine. There are a handful of case reports and small studies out there. It might work for Exparel too.

When I was a resident I caused respiratory distress with an interscalene catheter in a person with pre-existing contralateral vocal cord dysfunction (her RLN got whacked during a previous thyroidectomy). My block got the ipsilateral RLN and she had to be intubated until the block wore off. If that happened to me today I'd give intralipid.

I remain unconvinced about lipids reversing a standard PNB. Will it shorten duration? Possibly. I much prefer the washout with saline as it makes sense and doesn’t involve the use of lipids.

Intralipid Therapy for Inadvertent Peripheral Nervous System Blockade Resulting from Local Anesthetic Overdose

 

[deleted162650]

How ‘bout an intralipid washout??

 

[Hoya11]

I’m mainly interested in whether these blocks could eliminate the need for interscalene catheters + onQ which are burdensome in many ways, but widely requested by the orthopods at my hospital.

For what its worth I have been getting the same block duration with Bupi/Dex as with Exparel ISB 133mg plus Bupi 0.5 30ml. Not impressed. I dont think it does anything...

But people use it as a means to stop doing silly catheters, which is good

Exparel: helping surgeons see that the catheter was never needed in the first place

 

[BLADEMDA]

For what its worth I have been getting the same block duration with Bupi/Dex as with Exparel ISB 133mg plus Bupi 0.5 30ml. Not impressed. I dont think it does anything...

But people use it as a means to stop doing silly catheters, which is good

Exparel: helping surgeons see that the catheter was never needed in the first place

I'm actually not sure if 133 mg of Exparel is superior to Bup plus decadron. At this point I'd say it isn't worth administrating that dosage over 0.5% Bup plus 4 mg of decadron.

Now, the full dosage (266 mg) seems to be longer duration and I'd use that to get 72 hours.

 

[okayplayer]

I'm actually not sure if 133 mg of Exparel is superior to Bup plus decadron. At this point I'd say it isn't worth administrating that dosage over 0.5% Bup plus 4 mg of decadron.

Now, the full dosage (266 mg) seems to be longer duration and I'd use that to get 72 hours.

FDA indication was for 133 mg dose, correct?

 

[BLADEMDA]

FDA indication was for 133 mg dose, correct?

Correct. That's the dosage which seems to be similar to Bup plus decadron.

 

[sigrhoillusion]

For those using Exparel for their blocks, are you using any other adjuncts for the case like decadron, acetaminophen, ketorolac? Or are you jsut relying on the block working and last 2-3 days? IS there any benefits to doing those adjuncts assuming you get a good block?

 

[okayplayer]

We are doing 15ml 0.5% bupi and 10ml/133mg Exparel per the manufacturer instructions for ISB. So far fairly good results and much less headache (and cost) than catheter/onQ pumps.

I would say block duration is averaging 36-48h with all falling between 24h and 96h (a few outliers).

We are still putting in catheters/onQ for COPD’ers given the titeatibility and ability to turn it off if they can’t tolerate phrenic nerve blockade.

Curious what other early adopters have seen in their initial experience.

 

[BLADEMDA]

We are doing 15ml 0.5% bupi and 10ml/133mg Exparel per the manufacturer instructions for ISB. So far fairly good results and much less headache (and cost) than catheter/onQ pumps.

I would say block duration is averaging 36-48h with all falling between 24h and 96h (a few outliers).

We are still putting in catheters/onQ for COPD’ers given the titeatibility and ability to turn it off if they can’t tolerate phrenic nerve blockade.

Curious what other early adopters have seen in their initial experience.

The problem with 133 mg of Exparel is the duration of analgesia is only slightly longer than 0.5% Bup with precedex and decadron. To really see a clinical difference (48-72 hours) all 266 mg of Exparel is needed. I'd mix 10 mls of 0.5% of Bup with 20 mls of Exparel for a nice reliable block with a long duration of analgesia.

If you are concerned about a phrenic nerve palsy in certain subsets I'd avoid the ISB altogether and go SSN (C5) or SCB. I like the catheter idea in this subset but if you can block C5 near the Omohyoid muscle the Exparel 266 mg would be a great choice too.

 

[BLADEMDA]

 

[deleted126335]

Does anybody have any thoughts as to why the new indication for exparel is “interscalene block” as opposed to “brachial plexus block”?


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[okayplayer]

Does anybody have any thoughts as to why the new indication for exparel is “interscalene block” as opposed to “brachial plexus block”?


Sent from my iPhone using SDN mobile

Just a theory, but I think the one (fairly flimsy) study that helped earn it FDA approval was based on ISBs.

Alternatively, perhaps it has to do with the slightly lower risk of vascular injection with ISB vs supraclavicular block due to proximity of the nerves while doing SCB? Although risk of intravascular injection in the age of ultrasound should be quite low with either.

Just spitballing here.

 

[agammaglobulin]

Yes. I've personally performed hundreds of adductor canal blocks with Exparel. I typically inject 133 mg of Exparel when I know more local anesthetic will be given by the surgeon.
The typical duration of analgesia from 133 mg of Exparel is about 48 hours.

So, in your situation I would perform a single shot adductor canal block utilizing about 133 mg of exparel along with a sciatic catheter and ON-Q type pump.

Blade, how come 133mg? I assume that's 10mls of Exparel unmixed? Lower volume less likely to get proximal spread and quad weakness?? This is one of the main concerns I've had with using Exparel for TKAs.

 

[AnesRunner]

Because of this singular study: link

This RCT was funded and run by Pacira. Comparator was placebo (and not plain bupi). Take with a giant grain of salt.

 

[BLADEMDA]

Blade, how come 133mg? I assume that's 10mls of Exparel unmixed? Lower volume less likely to get proximal spread and quad weakness?? This is one of the main concerns I've had with using Exparel for TKAs.

I'm mixing 10 mls of 0.5% Bup with 10 mls of Exparel (133 mg) which typically results in 48 hours of analgesia postop for ISB and Adductor canal blocks.

 

[BLADEMDA]

I utilize Exparel for all different types of peripheral nerve blocks. ISB is FDA approved but a brachial plexus block by any name is still a brachial plexus block. The mixture of Bupivacaine with Exparel provides sufficient motor block with sensory analgesia in the 48 hour range.

A brachial plexus block with 0.5%Bupivacaine, 4 mg decadron and Precedex (1 ug/kg) provides close to 30 hours of analgesia with a much more pronounced motor block.

 

[BLADEMDA]

We are doing 15ml 0.5% bupi and 10ml/133mg Exparel per the manufacturer instructions for ISB. So far fairly good results and much less headache (and cost) than catheter/onQ pumps.

I would say block duration is averaging 36-48h with all falling between 24h and 96h (a few outliers).

We are still putting in catheters/onQ for COPD’ers given the titeatibility and ability to turn it off if they can’t tolerate phrenic nerve blockade.

Curious what other early adopters have seen in their initial experience.

1. No need for more than 20 mls of volume for a successful ISB under U/S. In fact, 15 mls will suffice. Try mixing 10 mls of 0.5% Bup with 10 mls of Exparel (133 mg).

2. If you do a PeriPlexus Block and reduce the volume to 15 mls ( 5mls of 0.5% Bup lus 10 mls of Exparel) the incidence and severity of dyspnea is significantly reduced.

3. I have utilized just 5 mls of Exparel in a COPD patient at C7. No Dyspnea (periplexus) but duration was only 20 hours.

4. For severe COPD Patients I have been doing 5 mls of my mixture at C7 and the remaining 15 mls of the mixture near the Omohyoid to block SSN/C5 (anterior approach). The results have been excellent so far with good analgesia extending into the 48 hour range.

5. A new study is now suggesting 15 mls at the superior trunk is as good as the ISB and better than an Anterior Suprascapular block. I will likely give that a try soon.

 

[BLADEMDA]

Anesthesiology. 2019 Sep;131(3):521-533. doi: 10.1097/ALN.0000000000002841.
Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial.
Kim DH1, Lin Y, Beathe JC, Liu J, Oxendine JA, Haskins SC, Ho MC, Wetmore DS, Allen AA, Wilson L, Garnett C, Memtsoudis SG.
Author information
1From the Departments of Anesthesiology (D.H.K., Y.L., J.C.B., J.L., J.A.O., S.C.H., M.C.H., D.S.W., L.W., C.G., S.G.M.) Orthopedic Surgery (A.A.A.), Hospital for Special Surgery, New York, New York.
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC:
Interscalene nerve block is commonly used for shoulder surgery for anesthesia and postoperative analgesiaUnfortunately, interscalene blocks commonly result in hemidiaphragmatic paralysis WHAT THIS ARTICLE TELLS US THAT IS NEW: When interscalene block was compared with superior trunk block, less frequent hemidiaphragmatic paralysis was seen in the superior trunk block groupSuperior trunk block was noninferior to interscalene block in terms of worst pain scores in the recovery room, and superior trunk block patients were more satisfied BACKGROUND:: Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve.
METHODS:
This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction.
RESULTS:
The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1.
CONCLUSIONS:
Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

 

[BLADEMDA]

 

[BLADEMDA]

I need to point out that the author used an INTRAFASCIAL ISB for their control arm and a Periplexus Superior Trunk block for the study arm. That is not a valid comparison as a PeriPlexus ISB would reduce dyspnea and phrenic nerve paresis especially using 15 mls of volume.

Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial †

AbstractBackground. Hemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We test

academic.oup.com

 

[BLADEMDA]

https://bjanaesthesia.org/article/S0007-0912(17)30410-5/pdf

 

[BLADEMDA]

 

[BLADEMDA]

So, I've utilized this ISB technique with 5-6 mls of local (periplexus) but my duration ranges from 12-16 hours (0.5% Bup with decadron 1 mg) to 20-24 hours with 5 mls of Exparel (no dilution). There is no free lunch. IMHO, duration of analgesia is shortened once the volume goes below 15 mls.

https://pdfs.semanticscholar.org/dff3/ddc37dc8395a3e8b62a1e03f2fc484fa8624.pdf?_ga=2.21302843.146658538.1568151034-430686255.1568151034

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block - PubMed

The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.

www.ncbi.nlm.nih.gov

 

[BLADEMDA]