My name is John Munz, I'm Orthopedic Trauma surgeon here at
McGovern medical school, I am here with a part of UT Health.
So, I first got started, actually from other colleagues in other disciplines
in the plastic surgery in general surgery divisions and after hearing
their successes with the product I was interested in trying this.
And I first started out in trauma, in patients that I previously would have
blocked with our anesthesia team, but now I'm able to do something
myself as part of a multimodal pathway.
Initially I would describe my EXPAREL experiences initially one
of intrigue, in that when I first started using the medication, I was
very excited about the potential 72-hour illusion of medication.
I think it's been a learning endeavor and that trying to hone my technique
of the actual infiltration. So, I'm very pleased with the experience
and the journey, but for sure they're still learning to do.
The biggest change is how you use EXPAREL, in regard to your
anesthesia team. In that, if you just rely upon blocks and regional
anesthesia, how to incorporate EXPAREL with those other pathways.
What has changed and I my practice is I would use EXPAREL and not
expand it and still use a popliteal block, but now I started using it on
its own with bupivacaine and then now not rely upon the block.
Another change of my practice is previously our anesthesia partners
would use the On-Q pumps and send patients home with that.
I found now that I can just use EXPAREL, and it completely
obviates the need for On-Q pump.
So I think the biggest issue in regard to learning how to use EXPAREL is the technique.
It's not just the medication that you can sprinkle into a wound I think the
actual administration technique of how you infiltrate the tissues is very important.
In regards to how you do that, unlike plain bupivacaine, EXPAREL does
not diffuse to the tissues, so where are you place that medication that's
where it stays, so this takes many more injections.
So, in regard to volumes, I tend to use 20 cc's of EXPAREL and then
depending upon the size of the wound and depth and the structures
I'm targeting I will expand that, usually with .25% bupivacaine.
In regards to the structures that are targeted, I like to in fracture
surgery, infiltrate the periosteum if I can, the surrounding
musculotendinous units and then subcutaneous tissues and skin
as I close the wound.
This particular patient was a 36 year-old female and initially
presented at 9 days prior with an ankle fracture dislocation,
she was initially placed into an external fixator and once the soft tissues were
optimized, she was brought back for a delayed open reduction internal
fixation of her right tirailleur ankle fracture dislocation.
For procedural details, the initial part of the procedure was a
prone posterolateral 15 cm approach.
This was followed by a supine 7 cm medial approach for the medial component.
During this particular operation, 35 mL of medication was infiltrated.
This was 20 mL of EXPAREL expanded with 15 mL of .25%
bupivacaine, for total of 35 mL using two 20 cc syringes and two 23-gauge needles.
After the completion of the open reduction internal fixation of the
postural malleolar and lateral malleolar components through this
posterolateral wound, the medication was infiltrated using a moving needle technique.
This is particularly important to use this technique to spread the
medication in a fan like pattern to make sure you have a maximal
coverage area.
I tend to start a deep to superficial in a clockwise or counterclockwise
fashion to make sure that you infiltrate the deeper layers,
more intermediate layers and finally the more superficial layers,
covering all important structures as you're infiltrating.
I tend to use 1 to 2 mL of medication every 1 to 1.5 cm in the deeper
layers including the periosteum, the muscular layers and the dermal
layers followed by of the subcutaneous layers.
The important part here is to use the moving needle technique to make
sure that you cover all particular aspects of your wound for maximal pain control.
After completion of this the infiltration at the posterior lateral
wound, this wound was closed, the patient was then repositioned,
re-prepped and draped and a supine a medial approach was performed.
After completing fixation of the medial malleolus component,
the medial incision 7 cm was then infiltrated in a similar technique
using a moving needle technique with 15 mL of expanded medication
in this systematic fashion.
The biggest barrier at my current institution is the interaction with anesthesia.
I think just engaging them and having certain patient populations
populations that you typically would not block and using EXPAREL in those
and being coordinated in our efforts. I look at a success with EXPAREL
and that any of these multimodal pathways, is if we can give less
narcotic medication, less opioids or a lower dose and less quantity,
I think that's a win.
I think we have an obligation as physicians to try to minimize our use
of opioids and what I found is that I'm prescribing less,
I'm prescribing smaller doses and less quantity.
When I first heard that one in 14 or up to 7% of patients who are
exposed to opioids go on to long-term addiction that was an eye-opener.
And I think just that fact and knowing the number of surgeries I do every
year and thinking of potentially how many patients I exposed to this,
that's what caused me concern.