Presentation

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