What blocks are you using exparel for?

[Outrigger]

Officially exparel is only approved for interscalene blocks. However, there are those in my group using exparel for adductor canal blocks and popiteal blocks among others. It saves a whole lot of time versus catheters when you are in a block heavy practice. I know medications are used off label all the time in medicine. Is anyone else out there using them for non interscalene blocks?

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[ucladoc2b]

Some of our surgeons love it for reasons rational to unrealistic.

I’m personally not convinced. But I acquiesce because I don’t have the energy to debate it.

So yes.

 

[Mehd School]

Interscalene and TAP. That's it

 

[UscGhost]

We introduced it for all blocks just to get the surgeons away from using catheters.

Now we are back to using bupiv 0.5% with decadron because exparel doesn't meaningfully work any better than marcaine.

The off label stuff doesn't matter

 

[GassYous]

Interscalene and TAP. That's it

I think it definitely helps for these but not really for the others

 

[abolt18]

None. Never used it before.

 

[rowsdower88]

I think the current data is suggesting we shouldn't even be using it for interscalene blocks on a cost effectiveness basis. There was at least one non-inferiority study I remember reading and then there's this study:

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial - PubMed

"Conclusion: When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine."

 

[JoelJoel84]

I think the current data is suggesting we shouldn't even be using it for interscalene blocks on a cost effectiveness basis. There was at least one non-inferiority study I remember reading and then there's this study:

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial - PubMed

"Conclusion: When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine."

I used exparel routinely until I got a MOCA question that suggested I should change my practice.

The only issue I’d have with that study is they only used half a vial of Exparel (133 mg) versus the 266 mg we use and see good results (for interscalene, supraclavicular, and adductor canal blocks. )

We also add in some plain 0.5% Bupi with the Exparel, just to make sure something is working by incision.

I’ve called a few patients out of curiosity , and the block has lasted 48-60 hours. Or at least the relief has.

 

[Anestheezee]

95% of Paciras revenue comes from exparel so they will defend it to the death.

As such, Pacira sued the ASA for libel for publishing studies demonstrating exparels lack of superiority.

They also were rejected in their initial application to the FDA because of it's lack of superiority when compared to marcaine. They then reapplied by comparing it to saline, saw a difference there, so got approved.

No, I don't use exparel and I encourage others to not.

 

[nimbus]

95% of Paciras revenue comes from exparel so they will defend it to the death.

As such, Pacira sued the ASA for libel for publishing studies demonstrating exparels lack of superiority.

They also were rejected in their initial application to the FDA because of it's lack of superiority when compared to marcaine. They then reapplied by comparing it to saline, saw a difference there, so got approved.

No, I don't use exparel and I encourage others to not.

I’ve never used exparel so I cannot weigh in with personal experience but this is exactly what happened.

 

[Dr. Rude]

I’ve never used exparel so I cannot weigh in with personal experience but this is exactly what happened.

Our surgeons say that they see a difference. So we use it. Interscalene and TAP blocks.

 

[Howard888]

The only issue I’d have with that study is they only used half a vial of Exparel (133 mg) versus the 266 mg we use and see good results (for interscalene, supraclavicular, and adductor canal blocks. )

We also add in some plain 0.5% Bupi with the Exparel, just to make sure something is working by incision.

I’ve called a few patients out of curiosity , and the block has lasted 48-60 hours. Or at least the relief has.

Yes!!! This is absolutely correct. For brachial plexus or sciatic blocks you must use 20 mls mixed with a little 0.5% bupivicaine. 10mls vastly inferior.

We have done thousands of each and called patients. Average around 60 hours for brachial plexus and 85 hours popliteals. Large range though.

Adductor canals we only use 10 mls but get around 40 hours.

It’s very dose dependent as far as length!

Vastly superior to catheters. Less failures. Less rebound pain.

 

[Airway]

Yes!!! This is absolutely correct. For brachial plexus or sciatic blocks you must use 20 mls mixed with a little 0.5% bupivicaine. 10mls vastly inferior.

We have done thousands of each and called patients. Average around 60 hours for brachial plexus and 85 hours popliteals. Large range though.

Adductor canals we only use 10 mls but get around 40 hours.

It’s very dose dependent as far as length!

Vastly superior to catheters. Less failures. Less rebound pain.

Needs publication or I can't believe...

 

[Anestheezee]

Yes!!! This is absolutely correct. For brachial plexus or sciatic blocks you must use 20 mls mixed with a little 0.5% bupivicaine. 10mls vastly inferior.

We have done thousands of each and called patients. Average around 60 hours for brachial plexus and 85 hours popliteals. Large range though.

Adductor canals we only use 10 mls but get around 40 hours.

It’s very dose dependent as far as length!

Vastly superior to catheters. Less failures. Less rebound pain.

Also, how do you know the patient is actually experiencing a reduction in opioid consumption because of the exparel or are they just suffering with 6 days of a numb tingling arm unnecessarily?

 

[Ronin786]

We use it for every block. Interscalene, PVB, femoral, pop/sci, truncal blocks. I honestly can't say whether it works or not, but no way I'm going to be able to change practice with how everybody has adopted it.

 

[Maverikk]

I remember when it first came out a patient at a hospital I worked at came back after shoulder surgery for dyspnea, labs showed methemoglobinemia. Block with exparel, had to get methylene blue...three days in a row. Maybe it does last

 

[pgg]

It's interesting how Exparel advocates just kind of gloss over the question of whether or not a >24h block is even desirable in the first place. They start with the unspoken assumption that 36 or 48 or 72 hours is by definition a superior outcome, compared to a shorter duration block.

 

[Howard888]

Needs publication or I can't believe...

Fully agree with you. We are private practice….no studies here. We’ve told Pacira to do studies with 20mls.

I can tell you we didn’t want to use it or believe in it. Surgeons forced our hands as they had colleagues in other states using.

Hence we called the patients. It works. I’d choose Exparel for myself or family member every time over an OnQ.

The reps tell us Duke uses Exparel for most everything now. No catheters. HSS too.

Last I checked they were academic regional powerhouses

 

[JoelJoel84]

I’m no Pacira shill, and in PP. But I consistently have 2-3 day lasting blocks with the 20ml of Exparel and 10ml Bupi, where TKAs (!) , radius ORIFs, etc have used literally no narcotics at home post op, only NSAIDs.

 

[Maz777]

Yes!!! This is absolutely correct. For brachial plexus or sciatic blocks you must use 20 mls mixed with a little 0.5% bupivicaine. 10mls vastly inferior.

We have done thousands of each and called patients. Average around 60 hours for brachial plexus and 85 hours popliteals. Large range though.

Adductor canals we only use 10 mls but get around 40 hours.

It’s very dose dependent as far as length!

Vastly superior to catheters. Less failures. Less rebound pain.

That’s laughable. If you can’t do catheters, then it might be comparable. Exparel is worse than plain bupi, way worse than a well-placed catheter, and comparable to bupi surgical infiltration.

 

[nimbus]

Interesting case series describing bimodal kinetics in a couple of patients-“numb, not numb, then numb again.”

EXPAREL® (Long-Acting Liposomal Bupivacaine) Use for Popliteal Nerve Block in Postoperative Pain Control after Ankle Fracture Fixation

EXPAREL® has been used successfully to prolong postoperative pain control when applied as a wound infiltrate. EXPAREL® has not yet been approved for use in regional anesthesia to prolong postoperative pain control. We conducted a clinical ...

www.ncbi.nlm.nih.gov

 

[Hoya11]

It's interesting how Exparel advocates just kind of gloss over the question of whether or not a >24h block is even desirable in the first place. They start with the unspoken assumption that 36 or 48 or 72 hours is by definition a superior outcome, compared to a shorter duration block.

the kool aid drinkers believe there is a magic period where there is no motor block but a long sensory trail off that has no disadvantages or tingling just pure pain relief. and when patients complain of pain during this period "well then think of how bad it would be without the exparel" its insanity..

 

[triggermaster]

the kool aid drinkers believe there is a magic period where there is no motor block but a long sensory trail off that has no disadvantages or tingling just pure pain relief. and when patients complain of pain during this period "well then think of how bad it would be without the exparel" its insanity..

I used exparel for IS, Adductor, Popliteal, & TAP. I didn’t think TAP or adductor would show much benefit but the surgeons loved it and claimed to see a big difference.

With IS I’d have patients come back and say they had pain relief for 3-4 days and ask for the same thing. Unfortunately we no longer have exparel because of questionable studies and pick me pharmacists trying to score points.

 

[Dexmetaketapropofol]

ISB and erector spinae plane blocks for sternotomy, VATS or thoracotomy. I definitely see it useful in our practice and our cardiothoracic surgeons have noticed a difference for sure.

 

[vector2]

If only there was some way to figure out if exparel really worked beyond just the anecdotes from surgeons about how happy their patients are....

 

[Urzuz]

If only there was some way to figure out if exparel really worked beyond just the anecdotes from surgeons about how happy their patients are....

Well duh, that's why he posted on SDN!

Anecdotal experiences from surgeons that anonymous posters on SDN work with >>> double blind RCTs any day of the week

 

[nimbus]

Well duh, that's why he posted on SDN!

Anecdotal experiences from surgeons that anonymous posters on SDN work with >>> double blind RCTs any day of the week

Judging by the anecdotes, a DB RCT should be a slam dunk.

 

[Outrigger]

Interesting case series describing bimodal kinetics in a couple of patients-“numb, not numb, then numb again.”

EXPAREL® (Long-Acting Liposomal Bupivacaine) Use for Popliteal Nerve Block in Postoperative Pain Control after Ankle Fracture Fixation

EXPAREL® has been used successfully to prolong postoperative pain control when applied as a wound infiltrate. EXPAREL® has not yet been approved for use in regional anesthesia to prolong postoperative pain control. We conducted a clinical ...

www.ncbi.nlm.nih.gov

I can confirm the bimodal effect in interscalenes in my own practice. More than once patients have gotten worried when their block wore off and then later on their arm was as numb as ever.

 

[Howard888]

That’s laughable. If you can’t do catheters, then it might be comparable. Exparel is worse than plain bupi, way worse than a well-placed catheter, and comparable to bupi surgical infiltration.

Why do you think we didn’t want to try Exparel to start? We did thousands of catheters that worked well. Couple partners who actually worked with sonosite and OnQ and gave talks/seminars throughout country. Like many we didn’t think it worked either.

As another poster already mentioned, we still have 1-2 facilities where pharmacy won’t let us use Exparel and we still do catheters.

Our catheters work as well. But sometimes the catheter comes out, or disconnected. Patient calls. Hassles.

Our catheters work. Exparel just works better. Period. At least for brachial plexus and sciatic.

Do you think Duke doesnt know how to do catheters? HSS?

Odds are you are concerned about the loss of units going from a catheter to a single shot and don’t want to admit Exparel is as good. Or you think your skills with a catheter make you superior to those who just do single shots. That’s ok, I get that, but call it what it is. It’s financial or pride. But don’t say Exparel doesn’t work or that someone who says it does can’t do catheters.

Do 50 brachial plexus blocks with 20 mls Exparel and 5-10ccs 0.5% Bupivicaine. Call them day 1 and day 3. Let me know how turns out.

 

[Hoya11]

Why do you think we didn’t want to try Exparel to start? We did thousands of catheters that worked well. Couple partners who actually worked with sonosite and OnQ and gave talks/seminars throughout country. Like many we didn’t think it worked either.

As another poster already mentioned, we still have 1-2 facilities where pharmacy won’t let us use Exparel and we still do catheters.

Our catheters work as well. But sometimes the catheter comes out, or disconnected. Patient calls. Hassles.

Our catheters work. Exparel just works better. Period. At least for brachial plexus and sciatic.

Do you think Duke doesnt know how to do catheters? HSS?

Odds are you are concerned about the loss of units going from a catheter to a single shot and don’t want to admit Exparel is as good. Or you think your skills with a catheter make you superior to those who just do single shots. That’s ok, I get that, but call it what it is. It’s financial or pride. But don’t say Exparel doesn’t work or that someone who says it does can’t do catheters.

Do 50 brachial plexus blocks with 20 mls Exparel and 5-10ccs 0.5% Bupivicaine. Call them day 1 and day 3. Let me know how turns out.

this may come as a shock to your system but not everyone (especially those who have seen outside those walls in PP) considers those ivory towers to provide the best medical care, in fact many consider those type of institutions to be the ruined with bureaucracy, inefficiency and antiquated techniques..

i think the argument is not exparel vs catheter.. IMO both are unnecessary..

you never need a catheter and you never need exparel. you will get similar results with appropriately dosed bupivicaine and dex.

 

[triggermaster]

Well duh, that's why he posted on SDN!

Anecdotal experiences from surgeons that anonymous posters on SDN work with >>> double blind RCTs any day of the week

Yeah, poorly designed studies are no better than anecdotes.

 

[GassYous]

Our surgeons say they've seen a noticeable decrease in patient phone calls for pain after using exparel in their infiltration. Also anecdotally, had an orthopedic surgeon get a total shoulder with exparel and he was happy, >72 hours pain free.

 

[Maz777]

Why do you think we didn’t want to try Exparel to start? We did thousands of catheters that worked well. Couple partners who actually worked with sonosite and OnQ and gave talks/seminars throughout country. Like many we didn’t think it worked either.

As another poster already mentioned, we still have 1-2 facilities where pharmacy won’t let us use Exparel and we still do catheters.

Our catheters work as well. But sometimes the catheter comes out, or disconnected. Patient calls. Hassles.

Our catheters work. Exparel just works better. Period. At least for brachial plexus and sciatic.

Do you think Duke doesnt know how to do catheters? HSS?

Odds are you are concerned about the loss of units going from a catheter to a single shot and don’t want to admit Exparel is as good. Or you think your skills with a catheter make you superior to those who just do single shots. That’s ok, I get that, but call it what it is. It’s financial or pride. But don’t say Exparel doesn’t work or that someone who says it does can’t do catheters.

Do 50 brachial plexus blocks with 20 mls Exparel and 5-10ccs 0.5% Bupivicaine. Call them day 1 and day 3. Let me know how turns out.

Again. You are not doing your catheters well if you even remotely think that Exparel is better. That's just complete nonsense. Exparel is just ****ty bupivacaine.

People opt for Exparel over catheters due to convenience. That's it. Not analgesic benefit. Catheters are a hassle to manage. But saying that Exparel is better than a well-placed catheter is inane.

Doing a single-shot is easy peasy. There is an incredible artform to placing a well-functioning catheter. If you can't do a proper catheter, just do a bupi single-shot.

I do believe that local infiltration with ****ty bupivacaine makes sense (prolly not cost effective at all, but makes sense). You are essentially putting a patient on a low-dose bupivacaine infusion. It makes no sense comparing it to a bupivacaine-based nerve block. You just end up doing a ****tier block.

I'm not RVU-based. I actually do not enjoy placing catheters, but I do it because patients benefit. I'm not some jackal who is going to compare catheters to ****ty bupivacaine (aka Exparel).

 

[triggermaster]

Again. You are not doing your catheters well if you even remotely think that Exparel is better. That's just complete nonsense. Exparel is just ****ty bupivacaine.

People opt for Exparel over catheters due to convenience. That's it. Not analgesic benefit. Catheters are a hassle to manage. But saying that Exparel is better than a well-placed catheter is inane.

Doing a single-shot is easy peasy. There is an incredible artform to placing a well-functioning catheter. If you can't do a proper catheter, just do a bupi single-shot.

I do believe that local infiltration with ****ty bupivacaine makes sense (prolly not cost effective at all, but makes sense). You are essentially putting a patient on a low-dose bupivacaine infusion. It makes no sense comparing it to a bupivacaine-based nerve block. You just end up doing a ****tier block.

I'm not RVU-based. I actually do not enjoy placing catheters, but I do it because patients benefit. I'm not some jackal who is going to compare catheters to ****ty bupivacaine (aka Exparel).

This is a straw man argument. No one is saying exparel is better than a catheter. Exparel is better than single shot bupivicaine. The only argument against it is cost.
We don’t have disposable pumps available, so we switched from bupivicaine plus exparel to straight bupivicaine. It’s not as good for the patient but it saves $300.

On-Q provides better pain control for longer but costs far more when all the related costs are included. My hospital doesn’t want to pay for exparel. They sure as heck don’t want to pay for On-Q.

 

[abolt18]

Exparel is better than single shot bupivicaine.

Isn't this exactly what studies have consistently failed to demonstrate? Specifically studies not funded by pacira...

 

[Maz777]

This is a straw man argument. No one is saying exparel is better than a catheter. Exparel is better than single shot bupivicaine. The only argument against it is cost.
We don’t have disposable pumps available, so we switched from bupivicaine plus exparel to straight bupivicaine. It’s not as good for the patient but it saves $300.

On-Q provides better pain control for longer but costs far more when all the related costs are included. My hospital doesn’t want to pay for exparel. They sure as heck don’t want to pay for On-Q.

It's worse than a plain bupi block but better than a saline block. That's Exparel. It's well established now. Unless you work for Pacira or have Pacira stock...

 

[Urzuz]

Isn't this exactly what studies have consistently failed to demonstrate? Specifically studies not funded by pacira...

But the phone calls @abolt18 !!! THE PHONE CALLS!!!

Any time you try to have a rational, evidence based, scientific discussion with people about Exparel, it somehow always devolves into anecdotal experiences surrounding phone calls that anesthesiologists make or surgeons receive.

I never use Exparel and my surgeons don’t receive phone calls regarding pain control.

 

[triggermaster]

Isn't this exactly what studies have consistently failed to demonstrate? Specifically studies not funded by pacira...

Link a study with blocks done how they’re done in real life and with meaningful measures of successful block.

 

[pgg]

But the phone calls @abolt18 !!! THE PHONE CALLS!!!

Any time you try to have a rational, evidence based, scientific discussion with people about Exparel, it somehow always devolves into anecdotal experiences surrounding phone calls that anesthesiologists make or surgeons receive.

I never use Exparel and my surgeons don’t receive phone calls regarding pain control.

Hey, there's a long and glorious tradition of the surgeon's phone guiding therapy.

A couple hours ago I put a PA catheter in yet another normal EF CABG (same as every other patient who gets subjected to a sternotomy), largely to keep the CT surgeons' phones quiet at night.

 

[abolt18]

Hey, there's a long and glorious tradition of the surgeon's phone guiding therapy.

A couple hours ago I put a PA catheter in yet another normal EF CABG (same as every other patient who gets subjected to a sternotomy), largely to keep the CT surgeons' phones quiet at night.

What's funny is we have some CT surgeons who feel the same way, while others are the opposite. They say the swan just causes them to get more useless phone calls because of nurses staring at numbers they don't understand without any clinical change in the patient.

 

[Howard888]

I’ve done 2000 plus peripheral nerve catheters in my career. Swore by them. They work. Done them dry cath, stim cath, over needle, you name it.

They still work. But Exparel works just as well if you dose it correctly for brachial plexus and sciatic..unless you want a block over 60 hours which I don’t think is warranted unless a trauma pt. The patient goes home with no hardware for equivocal pain control. It’s just better.

Again. Do 50. Follow up with the patients. If you haven’t tried it yourself you really shouldn’t discount it-enough very reputable regional anesthesiologists support it for you to at least try it before listing a study that wasn’t dosed properly and discounting it.

The bup/Dex single shot argument valid but we will have many surgeons that want 48-60 hours and I’ve only seen that hit 30-36

 

[pgg]

Sometimes I think we learned the wrong lesson from the opioid epidemic.

 

[Ronin786]

Sometimes I think we learned the wrong lesson from the opioid epidemic.

It's interesting how Exparel advocates just kind of gloss over the question of whether or not a >24h block is even desirable in the first place. They start with the unspoken assumption that 36 or 48 or 72 hours is by definition a superior outcome, compared to a shorter duration block.

But the whole argument for exparel is based off a comparison to catheters that last 36 or 48 or 72 hours. I personally find it puzzling that a number of folks that I respect have found exparel to work successfully while another number of folks that I respect have a vehement disregard for it.

And the truth is there are actually no randomized clinical trials out there showing that exparel doesn't work. Which is also quite puzzling, you'd think a busy academic center could just randomize patients to catheter vs exparel vs plain bupi and see what happens. Instead it's all intercostal nerve blocks and penile blocks that folks are publishing on, all techniques that are pretty irrelevant to our day to day and are traditionally blocks that are difficult to assess (intercostal).

 

[Gasworks]

Catheter guys/gals: what are your protocols for who pulls the catheter and who gets called to troubleshoot postop? My partner gives out his personal cell and has patients pull the cath at home 72 hours post. All of that sounds horrifying to me so I’m pushing for Exparel approval asap. Surgeons don’t care which but want one or the other.

 

[GassYous]

Catheter guys/gals: what are your protocols for who pulls the catheter and who gets called to troubleshoot postop? My partner gives out his personal cell and has patients pull the cath at home 72 hours post. All of that sounds horrifying to me so I’m pushing for Exparel approval asap. Surgeons don’t care which but want one or the other.

Nurse to do postop home visit + education

 

[Burned_Out]

I do believe that local infiltration with ****ty bupivacaine makes sense (prolly not cost effective at all, but makes sense). You are essentially putting a patient on a low-dose bupivacaine infusion. It makes no sense comparing it to a bupivacaine-based nerve block. You just end up doing a ****tier block.

Pacira actually recommends that you do not use Exparel for local (skin/dermis) infiltration. They say there is no benefit to using it in that manner vs. a peripheral nerve block.

 

[nimbus]

Pacira actually recommends that you do not use Exparel for local (skin/dermis) infiltration. They say there is no benefit to using it in that manner vs. a peripheral nerve block.

Don’t they market it for local infiltration for hemorrhoids and bunions? I thought ISB is the only nerve block approval.

 

[Burned_Out]

Don’t they market it for local infiltration for hemorrhoids and bunions? I thought ISB is the only nerve block approval.

I don't know about the marketing, but my discussion with a Pacira rep and a colleague who is a paid consultant for Exparel told me their trials showed no benefit for local skin infiltration.

 

[nimbus]

I don't know about the marketing, but my discussion with a Pacira rep and a colleague who is a paid consultant for Exparel told me their trials showed no benefit for local skin infiltration.

https://www.exparel.com/hcp/EXPAREL_Fast_Facts.pdf

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

 

[Maz777]

Pacira actually recommends that you do not use Exparel for local (skin/dermis) infiltration. They say there is no benefit to using it in that manner vs. a peripheral nerve block.

Go ahead and link that.

Other than the new addition of ISBs, local infiltration is the only FDA approved indication for Exparel.

Package insert: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/022496s9lbl.pdf