PR2-169
Liposomal bupivacaine for postoperative pain control after abdominal surgery
Tanis-Arens C, Miles K
Loyola University Medical Center, May wood, Illinois, United states
Background
Liposomal bupivacaine (Exparel) is a local anesthetic formulation which is FDA approved for use in adult patients for surgical site infiltration for postoperative pain control. At our institution, the use of transversus abdominus plane (TAP) catheters for adults has been replaced by single-shot injections of Exparel mixed with bupivacaine 0.25%. The medication has not been studied for use in the pediatric population, and we present a case of successful postoperative pain control in a pediatric patient undergoing abdominal surgery.
Case
A 12-year-old, 45 kg previously healthy male presented to the ED with right upper quadrant abdominal pain which began one month after blunt trauma. Workup revealed a right hepatic mass, presumed to be an infected hematoma. The patient presented for right hepatic wedge resection with plan for general anesthesia and a multimodal approach for pain control. Due to the unilateral incision, ipsilateral TAP and rectus sheath blocks were chosen over an epidural catheter placement. After induction and intubation, the blocks were performed using a mixture of Exparel 20 mL and bupivacaine 0.25% 20 mL. Thirty mL was placed for the TAP block and the remaining 10 mL into the rectus sheath. Intraoperative analgesics included fentanyl (150 mcg), ketamine (15 mg), ketorolac (30 mg), and hydromorphone (0.4 mg). In the recovery room, he reported a pain score of 4/10 and refused any intervention. His postoperative day one and two pain was described as “sore†and ranged from 2-5/10 in severity, with an isolated score of eight.
Discussion
Exparel is a multivesicular liposomal bupivacaine formulated to allow extended release of the drug, prolonging duration of action and limiting peak plasma concentrations. According to the package insert, it is indicated for “administration into the surgical site†and epidural, intrathecal, peripheral nerve block, intravascular, and intra-articular routes of administration have not been evaluated and thus are not recommended. There have been multiple published reports regarding its off-label use for peripheral nerve blocks in adults, and at our institution Exparel has been adopted as the preferred local anesthetic for TAP blocks. In this use, it provides an alternative to indwelling catheters for postoperative pain control. For this case, liposomal bupivacaine was chosen in a pediatric patient for its prolonged duration of action, the need for a unilateral block, and the ease of performing the technique. Liposomal bupivacaine has not been studied or approved in the pediatric population, and the manufacturer indicates that post-market studies would be helpful in this population. One particular area of concern would be weight-based dosing, which has not been determined for adults either. In this case, we report on the successful use of Exparel for postoperative pain control in a 12-year-old patient. Research is needed to determine safe dosing of this medication in pediatric patients.
References
Chahar P, Cummings KC. Liposomal bupivacaine: a review of a new bupivacaine formulation. Journal of Pain Research. 2012;5:257-264. doi:10.2147/JPR.S27894.
Exparel prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022496s005lbl.pdf
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