So I’m Jacob Hutchins, an anesthesiologist in Minneapolis
Minnesota with a specialty and regional anesthesia and acute pain as well as
ambulatory surgery. Recently at our ambulatory surgery center we've been
using EXPAREL in the use in interscalene brachial plexus nerve
blocks. Prior to that we had previously used short-acting either bupivacaine
order ropivacaine nerve blocks and we found that often times those nerve
blocks would wear off sometimes in the middle of the night which will result in
patients calling their providers for additional uses of pain relief which
often times included opioids or resulted in them going to the emergency room
for additional pain relief or even being readmitted to the hospital for additional
pain relief. So with the ability to use EXPAREL in an interscalene nerve
block, we found that we’ve been able to provide a longer duration interscalene
nerve block for our patients and that ability has allowed us to really improve
our pain control in our patient population. Because of that we've been able to
decrease the amount of opioids that our patients are using. Some patients even
using no opioids after their shoulder surgeries. We’ve been able to allow our
patients to have improved satisfaction, they've been more comfortable.
Patients have less risk of calling in their providers in the middle of the night
due to increased pain from a short-acting nerve block worn off. With the long-acting
or block it decreases the amount of phone calls. But also with a goal of
really trying to find ways to improve patient outcomes so less phone calls,
less emergency room visits, less readmissions, but also trying to find
ways to really overall improve their benefit and at the same time decrease
the amount of opioids that they need after surgery.
So when we use EXPAREL in our interscalene nerve blocks, a lot of it is
managing patient expectations. A lot of times we’re combining EXPAREL with
bupivacaine. And so we're talking to patients ahead of time about how this
block is really going to work with them. Day 1, often times it's a dense block.
Patients have minimal to no pain. Day 2, the initial bupivacaine that we
combined with the EXPAREL slowly wearing off and they're starting to have
some soreness that may occur. It's a low amount of pain but they do feel a
difference from day 1 till day 2. So we talk to patients, say you're going to be
sore. There’s is going to be some soreness there. That's normal.
You have pain medication to take as needed. And we're very aggressive
with non-opioid pain medication. So our patients are instructed to take
acetaminophen, instructed to take NSAIDs to minimize their pain in the
short, acute postoperative period. After day 2, patients are instructed that on
3 is that's is when that block is going to wear off. So they're going to feel
decrease numbness on that third day and they should be comfortable after that.
Often times the motor block is disappearing in that first day.
They'll have a sensory, they’ll have numbness on that second and third
day, but their motor is back. And so we just really are instructing them to really
be careful, but to ensure that this is all a normal progression of how the nerve
block wears off and these are all normal expectations. Pain is normal,
but we're going to aggressively treat it with as much non-opioids as possible.
In order for us to bring EXPAREL to the ASC, we really had to look at what's the
benefit to our patient population. Because using EXPAREL in
interscalene nerve block at a surgery center isn't going to affect the length of
stay of our patients. Some of the goals that we have for patients and
out patients surgery are minimal pain. We want to have decreased opioids as
much as possible. And we want to have minimal amounts of provider phone
calls, readmissions to the emergency room, and readmissions to the hospital
for pain control.
So I have changed my injection technique since I started using
EXPAREL. Initially, when I started using EXPAREL, I did 1 injection
at the bottom part of the interscalene brachial plexus at the posterior border.
But I found when I did 2 injections, I would have better coverage with the
EXPAREL. Because EXPAREL doesn't spread as well as bupivacaine does.
So now I inject half of bupivacaine in my EXPAREL mixture at the bottom
part of the brachial plexus, the posterior border. And then the other half at the
top part of the brachial plexus posterior border in the interscalene brachial
plexus area. By doing it that way, I'm able to provide better coverage
and more consistent interscalene nerve block for shoulder.
I will use 10 mLs of half percent bupivacaine with 10 mLs of EXPAREL.
Again half at the bottom and half at the top.
In this video I will describe an interscalene brachial plexus block
performed with liposome bupivacaine and bupivacaine.
The patient was positioned supine with the head of the bed elevated 45 degrees and a head
looking in the opposite direction. A high-frequency linear ultrasound probe
was placed at the level of the clavicle to identify first, the supraclavicular
brachial plexus.
And then the probe was rotated cranially until the interscalene brachial
plexus was found positioned between the middle and anterior scalene muscles.
A 21 gauge, 50 mm echogenic blunt tip needle was
advanced in plane until the tip of the needle reached past the middle scalene muscle
and was positioned near the caudal border of the
interscalene brachial plexus. Then 5 mLs of 0.5% bupivacaine plain and
5 mLs of liposome bupivacaine were injected.
Then the needle was repositioned
to the cranial portion of the interscalene brachial plexus block
to ensure adequate spread of both of the bupivacaine and the liposome
bupivacaine around the brachial plexus.
Again, at this level
5 mLs of 0.5% bupivacaine plain and 5 mLs of 1.3% bupivacaine
were injected.
As the probe is moved up and down the brachial plexus, you're able to see nice
spread of local anesthetic in the interscalene groove covering
the entire interscalene brachial plexus with local anesthetic to ensure that the end
brachial plexus is surrounded by the liposome bupivacaine.
Once finished, the needle was removed and the patient proceeded to surgery.
So, we have found that we have been able to use EXPAREL in a wide range
of patient ages. It’s helpful in the young patients. 18, 19, 20 year old patients
that are young athletes, never maybe been exposed to opioids before. But it's
also helpful in the elderly patients to really minimize the opioids and really
hopefully minimize any of those opiate-related adverse events that can occur
in that patient population. So we use it in our young patients
but also in our old patients.