I did a lot of regional anesthesia, ultrasound guided nerve blocks & catheters. I never got to use Exparel because the P & T committees would not approve it. I was on P & T committees and I learned, over the years, that they may discuss the science behind the use of a drug, but they only really care about the cost.
We have been using Exparel for over 5 years for proximal/above the clavicle brachial plexus approach with attention to administration into the subepineural space. Patients consistently report no pain for 3 days postoperative after arthroscopic shoulder surgery, shoulder arthroplasty, etc. Steve Orebaugh also reported on this in a similar fashion a couple of years ago. We have also used it successfully for femoral nerve blocks, with consistent 60-72 hours of postop analgesia. American academic anesthesiology is at best misguided.
Adding precedex and decadron to local anesthesia for nerve blocks prolongs pain relief while eliminating the prolonged paralysis effects of local anesthesia. This alone could makes liposomal bupiv unnecessary
These agents prolong sensory block minimally compared to liposomal formulations- no pain killers needed on day 2 post-op with Exparel. You won't get that with decadron, Epi, Precedex etc.
Why do you believe there is such a witch hunt... Trying to move practice away from blocks? Cost? I know some hospital pharmacists have pushed back but that seemed mostly related to block for the buck concerns.
That is a good question. It is multifactorial. I believe that at the core is the lack of understanding of how this drug formulation works and how it needs to be administered and dosed. It is not a solution like local anesthetics, but a suspension, its dose is not immediately available for nerve block but is slowly released. That is why studies like the one we critiqued in the video, even by experienced researchers, flow. I believe that Pacira Pharma should have invested more time in education and research on its best uses, especially since the drug is expensive - at $300/vial. Its expense is relative, as using a perineural catheter costs more in time, equipment, and complexity of management. If Exparel became generic/cheaper - EVERYONE would use it. However - the price of the drug and its effectiveness are two different things.
Viscousi et al. have published on this: Epidurally administered liposome bupivacaine 266 mg resulted in a longer duration of sensory blockade than liposome bupivacaine 89 or 155 mg or bupivacaine HCl 50 mg. Duration of motor blockade was shorter with liposome bupivacaine 266 mg versus bupivacaine HCl. Reg Anesth Pain Med . 2012 Nov-Dec;37(6):616-22
Huge thank you for this vital information
Glad if was helpful! Greetings!
More than Exparel I learned how swiftly you did the critical analysis of the journal publication. Superb 👌
I totally agree with your views Prof. Hadzic.
Glad to hear this! Greetings from NYSORA!
I did a lot of regional anesthesia, ultrasound guided nerve blocks & catheters. I never got to use Exparel because the P & T committees would not approve it. I was on P & T committees and I learned, over the years, that they may discuss the science behind the use of a drug, but they only really care about the cost.
We have been using Exparel for over 5 years for proximal/above the clavicle brachial plexus approach with attention to administration into the subepineural space. Patients consistently report no pain for 3 days postoperative after arthroscopic shoulder surgery, shoulder arthroplasty, etc. Steve Orebaugh also reported on this in a similar fashion a couple of years ago. We have also used it successfully for femoral nerve blocks, with consistent 60-72 hours of postop analgesia. American academic anesthesiology is at best misguided.
Nice informative analytics, thank you
Thank you for your comment! Greetings!
Adding precedex and decadron to local anesthesia for nerve blocks prolongs pain relief while eliminating the prolonged paralysis effects of local anesthesia. This alone could makes liposomal bupiv unnecessary
These agents prolong sensory block minimally compared to liposomal formulations- no pain killers needed on day 2 post-op with Exparel. You won't get that with decadron, Epi, Precedex etc.
Do you know why the drug is not available in Canada?
Agreed. 1000s of patients also agree.
Thank you for your comment! Greetings!
Why do you believe there is such a witch hunt... Trying to move practice away from blocks? Cost? I know some hospital pharmacists have pushed back but that seemed mostly related to block for the buck concerns.
Hospitals' pharmacy budget, they don't like us using exparel for every block. It's just expensive, but in my experience it works very well.
That is a good question. It is multifactorial. I believe that at the core is the lack of understanding of how this drug formulation works and how it needs to be administered and dosed. It is not a solution like local anesthetics, but a suspension, its dose is not immediately available for nerve block but is slowly released. That is why studies like the one we critiqued in the video, even by experienced researchers, flow. I believe that Pacira Pharma should have invested more time in education and research on its best uses, especially since the drug is expensive - at $300/vial. Its expense is relative, as using a perineural catheter costs more in time, equipment, and complexity of management. If Exparel became generic/cheaper - EVERYONE would use it. However - the price of the drug and its effectiveness are two different things.
If it is safe, then it is almost perfect.
Do you know anyone trying epidural exparel?
Viscousi et al. have published on this: Epidurally administered liposome bupivacaine 266 mg resulted in a longer duration of sensory blockade than liposome bupivacaine 89 or 155 mg or bupivacaine HCl 50 mg. Duration of motor blockade was shorter with liposome bupivacaine 266 mg versus bupivacaine HCl. Reg Anesth Pain Med
. 2012 Nov-Dec;37(6):616-22
I clean at the company who makes this
Necessary debate. Thanks for "sticking your neck out" :)
You bet
My hospital won’t buy it for us