EXPAREL in colorectal/general surgery

Administration volume and technique are critical to achieving optimal results

The videos below include a variety of surgical procedures that demonstrate examples of how to administer EXPAREL for optimal pain control and coverage.

Open Abdominal Mesh Removal With Abdominal Wall Reconstruction With Transversus Abdominis Release (TAR) And Placement of New MeshPerformed by Dr Ramshaw

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This video represents an individual clinician experience with and methodology for using EXPAREL.

Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.

Please see Important Safety Information below and refer to the Full Prescribing Information.

More Videos

Open Abdominal Mesh Removal With Abdominal Wall Reconstruction With TAR And Placement of New Mesh

Open Abdominal Mesh Removal With Abdominal Wall Reconstruction With TAR And Placement of New Mesh Performed by Dr Ramshaw

Colectomy

Colectomy Performed by Dr Keller

Multimodal protocols and results: abdominal wall reconstruction

Study design1

Analysis comparing the efficacy of an ERAS protocol that included a TAP block with EXPAREL (n=42) compared with previously used standard of care.

Multimodal protocol

MULTIMODAL PAIN CONTROL

  • Intraoperative TAP block with EXPAREL 266 mg/20 mL expanded to 120 mL with normal saline
  • Hydromorphone HCl PCA of 0.2 mg every 6 minutes until able to administer orally
  • Acetaminophen 1000 mg intravenously every 6 hours for 48 hours; transition to acetaminophen 650 mg orally every 6 hours, along with oxycodone 5 to 10 mg orally every 4 hours as needed

ACCELERATION OF INTESTINAL RECOVERY

  • Gabapentin 300 mg orally 3 times daily until discharge
  • Diazepam 5 mg intravenously every 6 hours for 48 hours; hold for obstructive sleep apnea and one-half dose for patients aged >65 years
  • NSAIDs as needed, starting 48 hours postsurgically, with a hold for patients with any renal dysfunction
  • Minimization of opioids through multimodal pain control
  • Alvimopan 12 mg orally preoperatively in the holding area and every 12 hours postsurgically until discharge or POD 7

Patients who received multimodal analgesia with EXPAREL

Faster return to bowl function
  • 3.6 days vs 5.0 days (P<0.0001)
Shorter LOS
  • 4.4 days vs 5.8 days (P<0.0001)

LOS, length of stay; NSAID; non-steroidal anti-inflammatory drug; POD, postoperative day; TAP, transversus abdominis plane; PCA, patient-controlled analgesia; ERAS, enhanced recovery after surgery.

Multimodal protocols and results: laparoscopic colorectal surgery

Study design2

Retrospective trial comparing patients receiving local infiltration of EXPAREL (n=70) as part of an ERP with those being placed in an ERP (n=70).

Multimodal protocol

PREOPERATIVE

  • Gabapentin 300 mg orally the night before surgery and 2 hours before surgery
  • Celecoxib 400 mg orally 2 hours before surgery

INTRAOPERATIVE

  • Dexamethasone 8 mg and acetaminophen 1000 mg intravenously at induction of anesthesia
  • Ketorolac 30 mg intravenously 30 minutes before emergence from anesthesia
  • Acetaminophen 1000 mg intravenously 30 minutes before emergence from anesthesia
  • EXPAREL group: local infiltration at port sites with EXPAREL 266 mg/20 mL expanded with normal saline 20 mL and 0.25% regular bupivacaine 20 mL

POSTSURGICAL

  • Acetaminophen 1000 mg every 6 hours intravenously until oral form is tolerated, then transitioned to 650 mg orally every 6 hours
  • Ketorolac scheduled 30 mg intravenously every 6 hours for 48 hours, followed by celecoxib 400 mg orally twice daily
  • Gabapentin 300 mg orally every 8 hours

POSTSURGICAL

  • Oxycodone 5 to 10 mg orally every 6 hours as needed for breakthrough pain intensity of 4 to 8 on a scale of 10
  • Hydromorphone HCl 0.4 to 0.6 mg intravenously every 2 hours as needed for breakthrough pain intensity of 8 to 10 on a scale of 10

Patients who received multimodal analgesia with EXPAREL

Lower mean pain scores in PACU
  • 1.92 vs 4.71 (P=0.001)
Fewer opioids used in PACU*†
  • 1.16 vs 3.56 (P<0.01)
Shorter LOS*†
  • 2.96 days vs 3.93 days (P=0.003)

*Opioid use was measured by the defined daily dose, with 1 unit equaling 100 mcg of intravenous fentanyl, 2 mg of intravenous hydromorphone HCl, 4 mg of oral hydromorphone HCl, 20 mg of oral oxycodone, or 10 mg of oral hydrocodone.

The clinical benefit of the decrease in opioid consumption was not demonstrated in the pivotal trials.

ERP, enhanced recovery pathway; ERAS, enhanced recovery after surgery; LOS, length of stay; PACU, postanesthesia care unit; TAP, transversus abdominis plane.

Multimodal protocols and results: open ventral hernia repair

Study design3

Retrospective, observational study comparing patients who received an ERAS protocol with EXPAREL (n=100) with a historical group prior to the introduction of the protocol (n=100).

Multimodal protocol

ERAS

PREOPERATIVE

  • Alvimopan 12 mg orally
  • Gabapentin 100 to 300 mg orally

INTRAOPERATIVE

  • Minimization of opioids and paralytics
  • Intraoperative TAP block with EXPAREL 266 mg/20 mL expanded to 200 mL (100 mL per side)

POSTSURGICAL

  • Hydromorphone intravenously in PCA: 0.2 mg every 6 to 10 minutes with no breakthrough dose or basal rate; stopped on POD 2 once on clear liquids
  • Oxycodone 5 to 10 mg orally every 4 hours as needed once off intravenous PCA
  • Acetaminophen 650 mg orally every 6 hours immediately after surgery
  • Gabapentin 100 to 300 mg orally every 6 hours 3 times daily starting on POD 1
  • Diazepam 5 mg intravenously every 6 hours as needed; 2.5 mg for patients >65 years old. Not used for patients with OSA, sedation, or any respiratory compromise
  • NSAID 600 to 800 mg orally every 6 to 8 hours as needed; held for patients with renal dysfunction and substituted with ketorolac 15 to 30 mg intravenously every 6 hours
WITHOUT ERAS

INTRAOPERATIVE

  • Opioids and/or paralytics per anesthesia

POSTSURGICAL

  • Hydromorphone intravenously in PCA: 0.2 mg every 6 minutes, 0.6 mg/hr breakthrough or basal rate as needed until tolerating full liquids or regular diet
  • Oxycodone 5 to 10 mg orally every 4 hours as needed once tolerating full liquids and/or regular diet
  • Acetaminophen 650 to 975 mg orally as needed once tolerating oral intake
  • Diazepam 5 mg intravenously every 6 hours

Patients who received multimodal analgesia with EXPAREL

Shorter time to liquids and regular diet
  • Liquid: 1.1 days vs 2.7 days (P<0.001)
  • Regular: 3.0 days vs 4.8 days (P<0.001)
Shorter time to flatus and bowel movement
  • Flatus: 3.1 days vs 3.9 days (P<0.001)
  • Bowel movement: 3.6 days vs 5.2 days (P<0.001)
Fewer 90-day readmissions
  • 4% vs 16% (P=0.008)

ERAS, enhanced recovery after surgery; NSAID, nonsteroidal anti-inflammatory drugs; OSA, obstructive sleep apnea; PCA, patient-controlled anesthesia; POD, postoperative day.

Multimodal protocols and results: laparoscopic donor nephrectomy

Study design4

Retrospective analysis comparing live kidney donors undergoing a laparoscopic nephrectomy under an ERAS protocol with EXPAREL (n=39) with live kidney donors under standard of care (n=40).

Multimodal protocol

PREOPERATIVE

  • Acetaminophen 975 mg orally
  • Gabapentin 600 mg orally

INTRAOPERATIVE

  • Fentanyl boluses
  • Subfascial EXPAREL
  • Dexamethasone 4 mg intravenously at start of case
  • Acetaminophen 1000 mg intravenously toward end of case
  • Ketorolac 15 mg intravenously toward end of case

POSTSURGICAL

  • Acetaminophen orally Ketorolac intravenously within first 24 hours
  • Gabapentin orally
  • Tramadol orally as needed

Patients who received multimodal analgesia with EXPAREL

Decreased pain scores morning after surgery
  • 3 vs 7 (P<0.001)
Shoter LOS
  • 1 day vs 2 days (P<0.001)

ERAS, enhanced recovery after surgery; LOS, length of stay.

The ERAS Society, ASCRS, and SAGES support the use of opioid-minimizing pain management strategies

  • “Strong recommendation for the use of TAP blocks for minimally invasive colorectal surgery, noting that shorter acting local anesthetics have limited duration. Liposomal bupivacaine is included as an alternative to extend the duration.” 5

    - ERAS Society, Colorectal Surgery 2018
  • “Strong recommendation for the use of a perisurgical multimodal, opioid-sparing, pain management plan, noting that liposomal bupivacaine wound infiltration and transversus abdominis plane (TAP) blocks “have shown promising results in patients undergoing open and laparoscopic colorectal surgery.’” 6

    - ASCRCS and SAGES, Colorectal Surgery 2016

ASCRS, American Society of Colon and Rectal Surgeons; ERAS, enhanced recovery after surgery; SAGES, Society of American Gastrointestinal Endoscopic Surgeons.