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days to go: ASP+6% CMS reimbursement for proven non-opioids used in all outpatient surgical settings is coming January 1, 2025.

Administration guidance for all procedures

Infiltration

Surgical site infiltration

  • Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
  • Inject slowly and deeply (generally 1-2 mL per injection) into the soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
  • Infiltrate above and below the fascia and into the subcutaneous tissue
  • Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage
  • Aspirate frequently to minimize the risk of intravascular injection
guidance body

Fascial plane infiltration for regional field blocks

  • Use a regional field block technique, such as ESP, PECS I and II, QL, RS, or TAP, for postsurgical regional analgesia
  • Multiple blocks can be used in combination to achieve full coverage of the surgical site(s)
  • Perform using ultrasound guidance or laparoscopic visualization to enable precise placement of EXPAREL within the plane
  • Deposit EXPAREL within the musculofascial plane so that it can spread and provide sensory blockade to the nerve(s) contained within the anatomical plane
classic tap block

Sonoanatomy showing abdominal wall muscles and the needle direction for the lateral TAP block. The pool of EXPAREL mixture is seen in the correct plane.

ESP, erector spinae plane; PECS, pectoralis; QL, quadratus lumborum; RS, rectus sheath; TAP, transversus abdominis plane.

  • The recommended dose of EXPAREL for ISBPNB in adults is 133 mg (10 mL) and is based on a study of patients undergoing either TSA or RCR
  • Do not exceed maximum dose of 133 mg (10 mL)
  • Administer EXPAREL with a 25-gauge or larger-bore needle to maintain the structural integrity of liposomal bupivacaine particles
classic tap block

STEP 1:Locate the interscalene brachial plexus

  • Place patient in the supine position, with the head of the bed elevated 45 degrees

STEP 2: Visualize the C5 to C7 nerve roots

  • Place an ultrasound probe on the patient’s neck superior to the clavicle to identify the interscalene brachial plexus between the anterior and middle scalene muscles
classic tap block
classic tap block

STEP 3: Perform ISBPNB with EXPAREL

  • Insert a 20- to 22-gauge echogenic needle into the plane from lateral to medial until the tip is just lateral to the bottom of the interscalene brachial plexus
  • Confirm needle position using nerve stimulation and hydrodissection
  • Deposit EXPAREL between the anterior and middle scalene muscles until the infiltration around the brachial plexus is documented by ultrasound

ASM, anterior scalene muscle; C5 to C7, cervical nerve roots; DSN, dorsal scapular nerve; LCa, longus capitis muscle; LTN, long thoracic nerve; MSM, middle scalene muscle; RCR, rotator cuff repair; SCM, sternocleidomastoid; TSA, total shoulder arthroplasty; VA, vertebral artery.

  • The recommended dose of EXPAREL for sciatic nerve block in the popliteal fossa in adults is 133 mg (10 mL), expanded with 20 mL of normal saline to a total volume of 30 mL, and is based on a study of patients undergoing bunionectomy
  • Do not exceed maximum dose of 133 mg (10 mL)
  • Administer EXPAREL with a 25-gauge or larger-bore needle to maintain the structural integrity of liposomal bupivacaine particles
classic tap block

STEP 1: Locate the popliteal fossa

  • Place patient in the supine position, with the knee flexed and hip internally rotated to allow access to the posterior thigh and popliteal fossa

STEP 2: Visualize the TN and CPN

  • Use an ultrasound probe to identify the elements just above the popliteal fossa crease
  • Move the probe proximally until the bifurcation of the TN and CPN is identified within the sciatic nerve sheath
classic tap block
classic tap block

STEP 3: Perform sciatic nerve block in the popliteal fossa with EXPAREL

  • Insert a 20- to 22-gauge needle into the plane in a lateral to medial orientation, bypassing the CPN laterally until adjacent to the TN
  • Confirm needle position using nerve stimulation and hydrodissection
  • Deposit EXPAREL slowly until adequate spread around the TN and CPN is achieved

CPN, common peroneal nerve; TN, tibial nerve.

  • The recommended dose of EXPAREL for adductor canal block in adults is 133 mg (10 mL) admixed with 50 mg (10 mL) 0.5% bupivacaine HCl,* for a total volume of 20 mL, and is based on a study of patients undergoing total knee arthroplasty
  • Do not exceed maximum dose of 133 mg (10 mL)
  • Administer EXPAREL with a 25-gauge or larger-bore needle to maintain the structural integrity of liposomal bupivacaine particles
classic tap block

STEP 1: Locate the adductor canal

  • Place patient in the supine position, with the hip and knee slightly flexed and the hip externally rotated to allow access to the medial thigh

STEP 2: Visualize the saphenous nerve and NVM

  • Use a probe to identify the elements of the sartorius muscle and femoral artery and the vastus medialis allowing visualization of saphenous nerve and NVM
classic tap block
classic tap block

STEP 3: Perform adductor canal block with EXPAREL

  • Insert a 20- to 22-gauge needle into the plane in an anterior medial to posterior lateral orientation and advanced toward the NVM
  • Confirm needle position using nerve stimulation and hydrodissection
  • Slowly deposit 10 mL of the EXPAREL admixture around the NVM until adequate spread is achieved
  • Reposition needle to the saphenous nerve, repeating the injection procedure for the remaining 10 mL of EXPAREL admixture

NVM, nerve to vastus medialis.

*Bupivacaine HCl is indicated for use in patients aged 12 years and older.

EXPAREL dosing and administration video

The broad indication of EXPAREL affords versatility of administration. Administer as surgical site infiltration to produce local analgesia, as a field block to produce regional analgesia, or in adults, as an interscalene brachial plexus nerve block.

Versatility of Administration

dosing video thumb

MOA and Dosing & Administration

dosing video thumb

ASP, average sales price; CMS, Centers for Medicare and Medicaid Services.

Important Notice

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, 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.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

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 paresthesia. 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.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

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