Guessing you’ve never used it. You’re like listening to a broken record.
What blocks are you using exparel for?
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Why did you start using 20cc and not the 10cc that pacira recommends for interscalene, adductors, and popliteal blocks? What sort of follow up do you have with patients?
I can make sense of the fact that 20cc lasts longer than 10cc. I’m just trying to figure out why a group would use it effectively off label and what led to that decision?
So several other groups around us were using 20ccs but to your point and because cost I wanted to make sure too.
Again private practice so take for what you will but we started with two groups, one using 10/10 exparel/0.5% bup and another 20/10 exparel 0.5%. Our nurses called postop day 1 until block resolved. It only took a couple dozen patients before it was obvious that 20/10 lasted much longer. As we’ve used a ton now many of us have gone to 20/5 just as don’t need 30cc volume. Takes a little longer to setup-so couldn’t just use propofol-need full GA but patients good in recovery and block set up by then.
As I’ve said before it’s a true shortcoming of Pacira to not have a 20cc study and only reason I can think no academic group has done a study with 20ccs is either the initial indication with 10 or they don’t want to lose their revenue from catheters.
Again private practice so take for what you will but we started with two groups, one using 10/10 exparel/0.5% bup and another 20/10 exparel 0.5%. Our nurses called postop day 1 until block resolved. It only took a couple dozen patients before it was obvious that 20/10 lasted much longer. As we’ve used a ton now many of us have gone to 20/5 just as don’t need 30cc volume. Takes a little longer to setup-so couldn’t just use propofol-need full GA but patients good in recovery and block set up by then.
As I’ve said before it’s a true shortcoming of Pacira to not have a 20cc study and only reason I can think no academic group has done a study with 20ccs is either the initial indication with 10 or they don’t want to lose their revenue from catheters.
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I'm not sure you understand how poorly reimbursed catheters/infusions are. No one places catheters to make money. We do them because they are vastly superior to watered-down bupivacaine (aka liposomal bupivacaine). Everyone knows catheters are a gigantic hassle to place and manage. If I got the same analgesic result with watered-down bupi, I would switch in a heartbeat.
Actually catheters generate significantly more units than single shots. For groups, private or academic, who do a large number of catheters, the revenue loss of going from catheters to single shots can be high six figures. I know this has motivated some groups not to try exparel and bash it. Again, please don’t portray false statements about exparel if you haven’t used it. Try 20ml for brachial plexus blocks, call the patients, if you still feel the same than by all means give your opinion.
What's the difference in wRVUs between a sciatic single-injection block and a sciatic catheter?
Now what is the cost difference between a sciatic single-injection block and a sciatic catheter (catheter kit, home pump, ropi bag, dermabond, etc.)?
I'll wait.
“Hello, Medicare? Yes, this is the guy, right here.”
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Hello Urzuz, we hear you. Realize though a large number multiplied by an extremely small number (our reimbursement for your services) equates to a small number. We hear you loud and clear.
Regards,
Medicare
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Do there exist any private groups that do a large number of catheters? It would surprise me.
It's one thing if you're in academics and you can scut out some poor resident to do the daily post care for them. When I was a resident we were doing catheters for lots of procedures. TKAs would get femoral and sciatic catheters. Some attendings wanted ACLs to go home with disposable pumps. (I thought and think that's dumb for multiple reasons, but I did what I was told.)
In private practice, the amount of labor associated with placing and following up on catheters is an enormous negative. Single shot, do it and forget it, is the ceiling I've observed over the years. There's just too much real work to do, without screwing around with unnecessarily extended daily pain rounds.
Second, and I've said this before, but I still dispute that premise that a long duration (>24h) block is even desirable in the first place, for the great majority of cases. Amputations in non-neuropathic limbs are about all I can think of off the top of my head.
Third, beyond all that, as more and more anesthesiologists wind up in employed (i.e. salaried or hourly) positions ... what one can or can't bill for something ceases to be of interest.
Actually quite a few private groups that do few thousand catheters a year. They’re usually orthopedic heavy practices with decent commercial mixes. Those units they get paid for the catheter vs single shot by the commercial payers add up very quickly.
