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Dosing for local infiltration
Dosing for local infiltration
For adults, a maximum dose of 266 mg (20 mL) is recommended, based on:
- Size of the surgical site
- Volume required to cover the area
- Individual patient factors that may impact the safety of an amide local anesthetic
For pediatric patients aged 6 to less than 17 years, dosing is weight based: 4 mg/kg (up to a maximum of 266 mg)
Admixing bupivacaine HCl with 266 mg (20 mL) of EXPAREL
- 20 mL vial contains 266 mg of EXPAREL, which is equivalent to 300 mg of bupivacaine HCl
- 1:2 ratio allows 150 mg of bupivacaine HCl to 266 mg of EXPAREL
Case studies in bariatric surgery
See how your peers are using EXPAREL for optimal pain coverage
Multimodal protocols and results
Multimodal approaches with or without ERAS protocols have demonstrated benefits in bariatric surgery
Protocol implementation can positively impact recovery and costs1-6
- 50% shorter LOS
- 40% to 61% fewer opioids at 48 hours
- 86% fewer patients with itching, demonstrating an improvement in ORAEs
- Earlier ambulation, which may reduce the risk of VTE (PE and DVT)
- 50% fewer cases of respiratory dysfunction in patients not taking morphine
- 96% of patients without postoperative nausea/vomiting
- 19-hour earlier return of bowel sounds and flatus
DVT, deep vein thrombosis; ERAS, enhanced recovery after surgery; LOS, length of stay; ORAE, opioid-related adverse event; PE, pulmonary embolism; VTE, venous thromboembolism.
Societies recommend opioid-minimizing pain management platforms
Leading medical societies recommend opioid-minimizing pain management strategies to enhance recovery after bariatric surgery
ASA
Best Practices. Clinical Anaesthesiology, 2011
“Because of the high incidence of obstructive sleep apnea (OSA) in obese patients and other studies showing that morbidly obese patients have increased perioperative airway obstruction and desaturations even without OSA, the focus with regard to pain management has to be on opioid-sparing multimodal approaches.”7
ASA
2014 Practice Guidelines for OSA
“…regional analgesic techniques should be considered to reduce or eliminate the requirement for systemic opioids in patients at increased perioperative risk from OSA.”8
“For superficial procedures, consider the use of local anesthesia…”8
ASA, American Society of Anesthesiologists.
ASP, average sales price; CMS, Centers for Medicare and Medicaid Services.
Important Notice
- This site is intended to provide medical and product information to health care professionals in the United States.
- To report an adverse event, email drugsafety@pacira.com or call 1-855-793-9727.
- For medical inquiries related to EXPAREL, submit a request to Medical Information or call 1-855-793-9727.
- These are not all of the potential important safety considerations for EXPAREL; please see the full Prescribing Information.
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.
References
- Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100(4):482-489.
- Gonzalez AM, Romero RJ, Ojeda-Vaz MM, Rabaza JR. Intravenous acetaminophen in bariatric surgery: effects on opioid requirements. J Surg Res. 2015;195(1):99-104.
- Sandor A, Lane JM, Williams CH, Marfatia R, Carey EA, Clark NJ. Liposomal bupivacaine local infiltration of the surgical sites effectively reduces postsurgical opioid requirements following laparoscopic bariatric procedures. Poster presentation at: Obesity Week 2013: The American Society for Metabolic and Bariatric Surgery and the Obesity Society Joint Annual Scientific Meeting; November 11-16, 2013; Atlanta, Ga.
- Bartlett MA, Mauck KF, Daniels PR. Prevention of venous thromboembolism in patients undergoing bariatric surgery. Vasc Health Risk Manag. 2015;11:461-477.
- Bamgbade OA, Oluwole O, Khaw RR. Perioperative analgesia for fast-track laparoscopic bariatric surgery. Obes Surg. 2017;27(7):1828-1834.
- Song K, Melroy MJ, Whipple OC. Optimizing multimodal analgesia with intravenous acetaminophen and opioids in postoperative bariatric patients. Pharmacotherapy. 2014;34(suppl 1):14S-21S.
- Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol. 2011;25(1):73-81.
- American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014;120(2):268-286.
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EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration
