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By: Joseph Westlake, SPTSUNY at Buffalo - Doctor of Physical Therapy Program
Exparel: The local anesthetic
A transition to advanced post-operative pain management and improved functional outcomes after total joint arthroplasty.
Traditional management includes...
Post-operative pain control through:1) Regional Nerve Blocks - Brachial Plexus - Femoral/Spinal2) Systemic - Opioids - Epidural 3) Wound site - Hypothermia - Local block - Anti-inflammatory
The problem is:
❖ Over-reliance of single-modal treatment
❖ Particularly Anesthetic Blocks and Opioids => Opioid Related Adverse Effects (ORAE)
❖ Effects on CNS, GI motility, & general well-being
❖ Hampering functional mobility and therapy participation
Switching lanes
❖ Recent shift in management to address these ORAE's - 10 year old data by Lombardi et al.
❖ Use of Peri- and intra-articular injections for TKA
❖ Significant reduction in: 1) rescue opioids 2) pt confusion 3) blood loss 4) lower bleeding index
What is being replaced
❖ Instead of using peripheral nerve blocks, surgeons are now transitioning to using Exparel
❖ Associated impacts from this include: improved motor function of the target area, decreased risk of falls, decreased occurrence of REBOUND pain, significant decrease in opioid usage.
Multimodal regimens now...
❖ Are increasing effectiveness with time consideration of all anesthetics being used.
❖ Exparel is an extended release anesthetic injected into the peri- and intra-articular site, 60- 1cc locations.
❖ Continuous release for up to 72 hours, begins working 6 hours post-op. A bridge may be necessary.
What studies* are showing❖ Decreased resting pain at 72
hours. ❖ Inc Amb distance by average of
16 feet post-op day 0❖ Less assistance level for amb (2
therapist assist to Mod 1)❖ Decreased LOS by 1/2 day❖ Positive trends for improved
ROM at D/C. and less need for manipulation long term.
Cost benefits for Hospitals❖ Exparel - $299/cocktail
❖ Peripheral nerve block (Sciatic/Femoral) - $527.22/block
❖ The extra costs are from anesthesia, ultrasound needed, immobilizer, ball and tubing necessary.
❖ Total reductions in THA and TKA are $348 and $411 respectively. Multiply that by ~1200 joint replacements performed at BI in 2014.
Outpatient surgeries❖ Case studies with ankle replacements, bunionectomies,
ankle fractures/dislocations benefitted as well.
❖ Pt's report good satisfaction with pain levels, particularly at 30 hours.
❖ For Out-pt procedures that allow WB, Exparel can preserve motor strength greater than sciatic/ankle blocks
❖ Total efficacy time: 6 vs 72hrs (Local vs Exparel)
Questions?
Bibliography❖ Lombardi AV Jr., Berend KR, Mallory TH. Soft tissue and intra-articular injection of
bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res. 2004;(428):125-130
❖ Lombardi AV Jr. Recent advances in Incorporation of Local Analgesics in Postsurgical Pain Pathways. AM J Orthop. 2014;43(10 suppl):S2-S5
❖ Springer, B. Transition from nerve blocks to periarticular injections and emerging techniques in total joint arthroplasty. AM J Orthop. 2014;43(10 suppl):S6-S9
❖ Bergese SD, Ramamoorthy S, Patou G, Bramlett K. Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for post-surgical analgesia. J Pain Res. 2012;5:107-126.
❖ Herbst, S. Local infiltration of liposome bupivacaine in foot and ankle surgery: Case-based Reviews. AM J Orthop. 2014;43(10 suppl):S10-S12
❖ Tayrose G, Newman D, Slover J, Jaffe F. Rapid mobilization decreases length of stay in joint replacement patients. Bull Hosp Jt Dis (2013). 2013;71(3):222-226