270562a5 6b9d 42ad 93a4 866482bd38e5

: Pdf 270562A5-6B9D-42Ad-93A4-866482Bd38E5 270562a5-6b9d-42ad-93a4-866482bd38e5 8 2017 pdf

Open the PDF directly: View PDF .
Page Count: 3

Download
Open PDF In Browser	View PDF

Administration Case Report With EXPAREL
This case report represents the individual experience of Dr Stan Dysart and is intended to demonstrate his methodology for
using EXPAREL in a specific orthopedic procedure.
Pacira Pharmaceuticals, Inc., recognizes that there are alternative methodologies for administering local anesthetics, as well
as individual patient considerations, when selecting the dose for a specific procedure.
EXPAREL is indicated for administration into the surgical site to produce postsurgical analgesia.

CASE INFORMATION
Physician Name

Stan Dysart, MD

Affiliation

Pinnacle Orthopaedics/Wellstar Health System

Surgical Case Performed

Total knee arthroplasty (TKA)

Inpatient or Outpatient Procedure

Inpatient

PATIENT CHARACTERISTICS
Gender

Male

Age

81 years

Patient History and Characteristics

Patient previously underwent a successful left TKA

Pathology

Patient has right knee osteoarthritis and is now undergoing a right TKA
with an ERAS protocol

PROCEDURAL DETAILS
Incision Size

15 cm

Preoperative Analgesics Used

AC block—20 mL of 0.25% bupivacaine with epinephrine

Intraoperative Analgesics Used

TIVA general—150-200 mcg/kg/min propofol titrated based on surgical needs;
50-100 mcg fentanyl as needed
Periarticular injection with 20 mL EXPAREL and 50 mL 0.25% bupivacaine

Dose of EXPAREL and
Total Volume Used

20
mL

EXPAREL

+

50
mL

Bupivacaine
0.25%

+

50
mL

Normal
Saline

= 120
mL
Total

AC, adductor canal; ERAS, enhanced recovery after surgery; TIVA, total intravenous anesthesia.

T he recommended dose of EXPAREL is based on the size of the surgical site, the volume required to cover the area, and individual patient
factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg.
EXPAREL can be administered undiluted (20 mL) or diluted to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL
[ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.
Bupivacaine HCl may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram
dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physiochemical properties
of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should
be used with caution, including monitoring for neurological and cardiovascular effects related to toxicity. Other than with bupivacaine,
EXPAREL should not be admixed with other drugs prior to administration.
 lease see Important Safety Information on the last page and refer to the accompanying full Prescribing Information for
P
complete Dosage and Administration information before using EXPAREL.

INFILTRATION NOTES

INFILTRATION NOTES (cont)

ASSESSED THE SIZE OF THE SURGICAL SITE AND DEPTH OF TISSUE, THEN PREPARED INJECTION
MATERIALS ACCORDINGLY
In this procedure, Dr Dysart determined that a total volume of approximately 120 mL would be needed to cover the
surgical site. He expanded 20 mL of EXPAREL with 50 mL of normal saline and admixed this solution with 50 mL of
0.25% bupivacaine. Dr Dysart added bupivacaine to provide short-term local analgesia in the postanesthesia care
unit that overlapped with the long-term local analgesia provided by EXPAREL.
DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE GAUGES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE)
AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION

#

S
 yringe #2:

	Medial and lateral infiltration of femoral periosteal/synovial tissues and of
suprapatellar tissue with 20 needle sticks of 1 mL to 1.5 mL per injection
Inject until a noticeable bubble forms. It is normal for there to be
more dramatic swelling in this thick, fibrous layer than when soft
tissue is infiltrated.

FIGURE 2. Femoral periosteal/synovial
and suprapatellar tissues

For this procedure, Dr Dysart divided the injectate evenly into six 20-mL syringes using a 21-gauge needle and infiltrated
as follows:
#
#

6
#

5

#
#

2

3

6

■ Syringe #1: Posterior capsule

S
 yringe #3:
	Injection of fat pad, pes anserinus, MCL, and medial gutter,
saturating the area

■ Syringe #2: Femur

FIGURE 3. Fat pad, pes anserinus, MCL,
and medial gutter

■ Syringe #3: Tibia, pes anserinus,
2
#5

#

#

#

PRIOR TO CEMENTATION

1

medial collateral ligament (MCL), gutter

■ Syringe #4: Circumferential
periosteum

AFTER CEMENTATION

■ Syringe #5: Quadriceps tendon,
retinaculum, medial gutter

4

S
 yringe #4:
	Medial and lateral infiltration of the circumferential periosteum
of the tibia using 15 to 20 needle sticks

■ Syringe #6: Lateral gutter,

FIGURE 4. Circumferential periosteum
of tibia

subcutaneous tissue

#

3

#

3

Adapted with permission; International Guidelines Center (guidelinecentral.com)­—Erin Daniel, illustrator.

S
 yringe #5:

INFILTRATED AFTER THE BONY CUTS WERE PERFORMED
After completing the bony cuts, Dr Dysart inserted a laminar spreader between the cut femur and tibia,
exposing the posterior capsule of the knee. He then proceeded with infiltrating the injectate as follows:

	Injection of the synovial tissue beneath the quadriceps tendon
and the retinacular tissue medially from the femur to the tibia

S
 yringe #1:
	

FIGURE 5. Synovial tissue (quadriceps)
and medial retinacular tissue (femur to tibia)

Medial and lateral infiltration of the posterior capsule

	• Medial infiltration of posterior capsule with approximately 10 needle sticks
to create a field block

S
 yringe #6:

	• Lateral infiltration of posterior capsule with approximately 10 needle sticks
FIGURE 1. Posterior capsule

Before each injection, be sure to aspirate to minimize the risk of intravascular injection. Be sure not to inject
too far laterally, and monitor the volume injected because of the proximity of the peroneal nerve.

	
Injection of the lateral gutter and the lateral retinacular tissue from
the femur to the tibia. Residual volume is used in the subcutaneous tissue
medially and laterally. There will likely be swelling of the tissue from fluid volume
When infiltrating, stay in the tissue to reduce the amount
of extravasation.

FIGURE 6. Lateral gutter and retinacular
tissue (femur to tibia)

 lease see Important Safety Information on the last page and refer to the accompanying full Prescribing Information for
P
complete Dosage and Administration information before using EXPAREL.

INFILTRATION NOTES (cont)
PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE

EXPAREL

Bupivacaine

When infiltrating EXPAREL, Dr Dysart makes sure to infiltrate below the fascia, above the fascia,
and into the subcutaneous tissue using a moving needle technique. With a moving needle
technique, the injections are spread in a rapid and precise fan-like pattern to maximize the
number of injection areas. The tissues are infiltrated as the needle is advanced and withdrawn
to maximize the coverage area. This technique should be systematically and meticulously
repeated with each subsequent injection site, and the next site should overlap
with the prior infiltrated area to maximize effect.
W
 atch Dr Dysart infiltrate with EXPAREL at www.EXPAREL.com
Important Safety Information
EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea,
constipation, and vomiting.
EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or
pregnant patients.
Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used
cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize
local anesthetics normally, are at a greater risk of developing toxic plasma concentrations.
Warnings and Precautions Specific to EXPAREL
EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve
blocks, or intravascular or intra-articular use.
Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from
EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a
delay of 20 minutes or more. Formulations of bupivacaine other than EXPAREL should not be administered within 96 hours
following administration of EXPAREL.
Warnings and Precautions for Bupivacaine-Containing Products
Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of
local anesthetics. These include persistent anesthesia and paresthesias. CNS reactions are characterized by excitation
and/or depression.
Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may
lead to dysrhythmias sometimes leading to death.
Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of
hypersensitivity to the local anesthetic or to other formulation ingredients.
Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of
local anesthetics, which is an unapproved use.

	
Disclosure: Dr Dysart is a paid consultant for Pacira Pharmaceuticals, Inc.

©2017 Pacira Pharmaceuticals, Inc., Parsippany, NJ 07054						

PP-EX-US-2065

01/17



---

Source Exif Data:

File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.7
Linearized                      : Yes
Create Date                     : 2017:01:25 16:49:50-05:00
Creator                         : Adobe InDesign CC 2017 (Macintosh)
Modify Date                     : 2017:02:16 15:48:29-05:00
Language                        : en-US
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.4-c006 80.159825, 2016/09/16-03:31:08
Metadata Date                   : 2017:02:16 15:48:29-05:00
Creator Tool                    : Adobe InDesign CC 2017 (Macintosh)
Instance ID                     : uuid:f8a5e25b-3294-4a89-93cd-d374bbe1c18b
Original Document ID            : xmp.did:01801174072068119109C02C59B1E255
Document ID                     : xmp.id:c9ede9d2-055f-4570-bfe4-e925f7710c6a
Rendition Class                 : proof:pdf
Derived From Instance ID        : xmp.iid:f2a78c1a-67cd-4dae-83db-af83c05e1a31
Derived From Document ID        : xmp.did:f557333d-dddc-4447-b4ef-39ae3387fc8c
Derived From Original Document ID: xmp.did:01801174072068119109C02C59B1E255
Derived From Rendition Class    : default
History Action                  : converted
History Parameters              : from application/x-indesign to application/pdf
History Software Agent          : Adobe InDesign CC 2017 (Macintosh)
History Changed                 : /
History When                    : 2017:01:25 16:49:50-05:00
Format                          : application/pdf
Producer                        : Adobe PDF Library 15.0
Trapped                         : False
Slug Family                     : Minion Pro
Slug Version                    : 2.030
Slug Outline File Size          : 0
Slug Kerning Checksum           : 0
Slug Foundry                    : Adobe Systems
Slug Font Kind                  : OpenType - PS
Slug Checksum                   : 2771965578
Slug Post Script Name           : MinionPro-Regular
Slug Font Sense 12 Checksum     : 2771965578
Page Count                      : 3

EXIF Metadata provided by EXIF.tools