Treatment of Digital Ischemia with Liposomal Bupivacaine

Objective. This report describes a case in which the off-label use of liposomal bupivacaine (Exparel) in a peripheral nerve block resulted in marked improvement of a patient’s vasoocclusive symptoms. The vasodilating and analgesic properties of liposomal bupivacaine in patients with ischemic symptoms are unknown, but our clinical experience suggests a role in the management of patients suffering from vasoocclusive disease.Case Report. A 45-year-old African American female was admitted to the hospital with severe digital ischemic pain. She was not a candidate for any vascular surgical or procedural interventions. Two continuous supraclavicular nerve blocks were placed with modest clinical improvement. These effects were also short-lived, with the benefits resolving after the discontinuation of the peripheral nerve blocks. She continued to report severe pain and was on multiple anticoagulant medications, so a decision was made to perform an axillary nerve block using liposomal bupivacaine (Exparel) given the compressibility of the site as well as the superficial nature of the target structures.Conclusions. This case report describes the successful off-label usage of liposomal bupivacaine (Exparel) in a patient with digital ischemia. Liposomal bupivacaine (Exparel) is currently FDA approved only for wound infiltration use at this time.

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Shingles Following Axillary Nerve Block a Case Report

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681_86_90030-6 ◽

1986 ◽

Vol 11 (1) ◽

pp. 115-116

Author(s):

N. J. PERCIVAL

Keyword(s):

Case Report ◽

Herpes Zoster ◽

Nerve Block ◽

Upper Limb ◽

Axillary Nerve ◽

Nerve Blocks ◽

Upper Limb Surgery ◽

Axillary Nerve Block

Axillary nerve blocks are now frequently used for emergency and elective upper limb surgery. The method gives reliable anaesthesia with few complications. A case is described in which a patient developed Herpes Zoster following an Axillary Nerve Block, a hitherto unreported complication.

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A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty

Anesthesiology ◽

10.1097/aln.0000000000001586 ◽

2017 ◽

Vol 126 (6) ◽

pp. 1139-1150 ◽

Cited By ~ 44

Author(s):

Adam W. Amundson ◽

Rebecca L. Johnson ◽

Matthew P. Abdel ◽

Carlos B. Mantilla ◽

Jason K. Panchamia ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Peripheral Nerve ◽

Nerve Block ◽

Knee Arthroplasty ◽

Nerve Blocks ◽

Liposomal Bupivacaine ◽

Periarticular Injection ◽

Pain Scores ◽

Average Pain ◽

Total Knee

Abstract Background Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

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Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain

Anesthesiology ◽

10.1097/aln.0000000000003630 ◽

2020 ◽

Author(s):

Brian M. Ilfeld ◽

James C. Eisenach ◽

Rodney A. Gabriel

Keyword(s):

Postoperative Pain ◽

Peripheral Nerve ◽

Nerve Block ◽

Primary Outcome ◽

Peripheral Nerve Block ◽

Clinical Effectiveness ◽

Primary Outcome Measure ◽

Nerve Blocks ◽

Liposomal Bupivacaine ◽

Randomized Controlled

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.

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Popliteal Nerve Block as an Alternative to Spinal Anaesthesia for Ankle Surgery in Comorbid Patient- A Case Report

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/47579.14704 ◽

2021 ◽

Author(s):

Priya Kishnani ◽

Dharmishthaben Chakarani ◽

Jigisha Mehta ◽

Malini Mehta

Keyword(s):

Case Report ◽

High Risk ◽

Peripheral Nerve ◽

General Anaesthesia ◽

Nerve Block ◽

Nerve Blocks ◽

Neuraxial Blockade ◽

High Risk Patients ◽

Neuraxial Block ◽

Risk Patients

In high-risk patients with significant cardiovascular and other systemic disorders, administration of central neuraxial block or general anaesthesia is usually associated with adverse haemodynamic effects and high perioperative mortality. This case report is about a 57-year-old male patient with known case of Diabetes Mellitus (DM) posted for lower limb debridement. He had comorbidities like cellulitis, sepsis, uncontrolled diabetes, multiorgan dysfunction and was haemodynamically unstable. Peripheral nerve blockade keeps the haemodynamic more stable as compared to central neuraxial blockade and general anaesthesia. Therefore, popliteal nerve block was given to the patient in prone position. Peripheral nerve locator was used and after eliciting the response of foot twitch local anaesthetic drug was deposited. Adequate sensory motor block was achieved and surgery was carried out uneventfully. Patient was vitally stable throughout the surgery. Thus, it was seen that peripheral nerve blocks are an effective alternative to central neuraxial blockade and general anaesthesia in high risk patients undergoing below knee surgeries.

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Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

Anesthesiology ◽

10.1097/aln.0000000000003651 ◽

2020 ◽

Author(s):

Nasir Hussain ◽

Richard Brull ◽

Brendan Sheehy ◽

Michael K. Essandoh ◽

David L. Stahl ◽

...

Keyword(s):

Side Effects ◽

Peripheral Nerve ◽

Nerve Block ◽

Local Anesthetics ◽

Peripheral Nerve Block ◽

Length Of Hospital Stay ◽

Nerve Blocks ◽

Liposomal Bupivacaine ◽

Pain Scores ◽

The Difference

Background Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. Methods The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h. Results Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [−0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported. Conclusions Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Ultrasound-guided percutaneous cryoneurolysis providing postoperative analgesia lasting many weeks following a single administration: a replacement for continuous peripheral nerve blocks?: a case report

Korean Journal of Anesthesiology ◽

10.4097/kjae.2017.70.5.567 ◽

2017 ◽

Vol 70 (5) ◽

pp. 567 ◽

Cited By ~ 13

Author(s):

Brian M. Ilfeld ◽

Rodney A. Gabriel ◽

Andrea M. Trescot

Keyword(s):

Case Report ◽

Peripheral Nerve ◽

Postoperative Analgesia ◽

Single Administration ◽

Ultrasound Guided ◽

Nerve Blocks ◽

Peripheral Nerve Blocks

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Proper Postsurgical Pain Management in Orthopaedics: Reviewing the Efficacy of Wound Infiltration with Liposomal Bupivacaine (EXPAREL)

The Duke Orthopaedic Journal ◽

10.5005/jp-journals-10017-1048 ◽

2015 ◽

Vol 5 (1) ◽

pp. 6-9

Author(s):

Vani Sabesan ◽

Timothy R Jelsema ◽

Daniel J Lombardo

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Postoperative Pain Management ◽

Well Being ◽

Multimodal Approach ◽

Wound Infiltration ◽

Nerve Blocks ◽

Liposomal Bupivacaine ◽

Postsurgical Pain ◽

Limited Efficacy

ABSTRACT Adequate postoperative pain management after an orthopaedic procedure is critical for patient well-being, acceptable clinical outcomes and patient satisfaction. Current literature suggests over 80% of surgical patients’ state they have moderate to severe pain within 24 hours postoperatively. The standard in pain management for more than 40 years has been opioids, medications known for their many adverse effects and limited efficacy. Recently, a multimodal approach to pain control has been sought after for optimal postoperative pain management. This approach utilizes multiple methods of pain management, such as nerve blocks, wound infiltration with local anesthetics and oral analgesics, to concomitantly reduce postoperative pain. Liposomal bupivacaine, EXPAREL, has been shown to reduce pain for as long as 96 hours postoperatively in select studies. These studies have included both hard and soft-tissue procedures. The goal of this review is to examine the literature on EXPAREL and provide a comprehensive presentation for orthopaedic surgeons to apply to their practices. Sabesan V, Jelsema TR, Lombardo DJ. Proper Postsurgical Pain Management in Orthopaedics: Reviewing the Efficacy of Wound Infiltration with Liposomal Bupivacaine (EXPAREL). The Duke Orthop J 2015;5(1):6-9.

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Combined epidural anesthesia and ultrasound guided peripheral nerve block for wound revision in a patient with peripartum cardiomyopathy -A case report-

Korean Journal of Anesthesiology ◽

10.4097/kjae.2010.59.5.353 ◽

2010 ◽

Vol 59 (5) ◽

pp. 353 ◽

Cited By ~ 1

Author(s):

Tai Kyung Gong ◽

Seong Su Kim

Keyword(s):

Case Report ◽

Peripheral Nerve ◽

Nerve Block ◽

Epidural Anesthesia ◽

Peripheral Nerve Block ◽

Peripartum Cardiomyopathy ◽

Ultrasound Guided

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Time Sequence of Sensory Changes after Upper Extremity Block

Anesthesiology ◽

10.1097/00000542-200407000-00025 ◽

2004 ◽

Vol 101 (1) ◽

pp. 162-168 ◽

Cited By ~ 23

Author(s):

Xavier Paqueron ◽

Marc E. Gentili ◽

Jean Claude Willer ◽

Pierre Coriat ◽

Bruno Riou

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Clinical Test ◽

Sensory Impairment ◽

Sensory Testing ◽

Early Assessment ◽

Sensory Assessment ◽

Nerve Blocks ◽

Sensory Fibers

Background Sensory assessment to estimate spread and effectiveness of a peripheral nerve block is difficult because no clinical test is specific for small sensory fibers. Occurrence of a swelling illusion (SI) during a peripheral nerve block corresponds to the impairment of small sensory fibers. The authors investigated the usefulness of SI in predicting successful peripheral nerve block by assessing the temporospatial correlation between progression of sensory impairment in cutaneous distributions anesthetized and localization of SI during peripheral nerve block installation. Methods Interscalene, infracoracoid, or sciatic nerve blocks were performed using a nerve stimulator and 1.5% mepivacaine in 53 patients, with a total of 201 nerves to be anesthetized. Pinprick, cold, warm, touch, and proprioception were assessed every 3 min, while patients were asked to describe their perception of size and shape of their anesthetized limb and localization of these illusions. Data are presented as mean +/- SD and percentage (95% confidence interval). Results Failure occurred in 12 cutaneous distributions out of a total of 201 theoretically blocked nerves. SI appeared earlier than warmth impairment (4.3 +/- 2.7 vs. 6.2 +/- 2.0 min; P < 0.05), always corresponding to successfully anesthetized cutaneous distributions, with the exception of 1 patient, who developed SI in 2 cutaneous distributions while sensory testing indicated failure in 1 distribution. SI successfully predicted the blockade of a cutaneous distribution with a sensitivity of 1.00 (0.98-1.00), a specificity of 0.92 (0.65-0.99), and an accuracy of 0.99 (0.97-1.00). Conclusions Swelling illusion may provide an early assessment of the success of a peripheral nerve block in unsedated patients.

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