• Featured News

  • Exparel Seizure post op



    67 y/o Pt for a TKR

    Hx: HTN, DM
    Rx: metoprolol glucophage ASA
    NKDA

    Surgeons at this facility been using Exparel and are finding that the exparel used alone isn't working until approx 4-6 hrs after injection, even if the surgeon uses Bupivacaine along with it. They don't want femoral blocks anymore because of the exparel.

    The anesthetic for the procedure was as follows:

    Sedation with Propofol gtt
    Epidural running with Bupiv 0.125 @ 10cc/hr

    Patient Seizure occurred 5 hours after Exparel injected and approx 10 min after the epidural was topped off with 5 cc of 1.5% Lido with Epi. Negative test dose. Epidural was going @ 10cc/hr.


    What happened and why?
    This article was originally published in forum thread: Exparel Seizure post op started by ADMIN View original post
    Comments 37 Comments
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Is this for students or everyone?

      Sent from my SCH-I545 using Tapatalk
    1. MmacFN's Avatar
      MmacFN -
      ANyone can get it started
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Per the exparel literature I have seen (and verified here) lidocaine can cause the immediate release of the bupivacaine film the liposomal delivery system.

      I am guessing the surgical injection was systemically absorbed and the epidural was no longer working because it was now intravascular and the lido caused a large amount of marcaine to be available.

      However that's quite a bit of bad luck all occurring together so it's a bit of a zebra.

      The better question is what was the blood sugar?

      Sent from my SCH-I545 using Tapatalk
    1. J-Dubya's Avatar
      J-Dubya -
      Negative test dose huh? Scratching my head on this one.
    1. RAYMAN's Avatar
      RAYMAN -
      Why place an epidural if the surgeon is going to inject experal?
    1. LightsOut's Avatar
      LightsOut -
      Seems too easy so I'm skeptical. LAST happened. Two questions though. Whats the concentration of exparel? Whats the pt's weight?
      I vaguely remember something about lidocaine and exparel. But it was about the length of time that needs to pass after IV lido, to safely inject exparel.
    1. LightsOut's Avatar
      LightsOut -
      Quote Originally Posted by RAYMAN View Post
      Why place an epidural if the surgeon is going to inject experal?
      I agree. Pt's choice I'm guessing. We offer neuraxial to all knees though. Maybe a slow surgeon they didn't think a spinal would be long enough.
    1. MmacFN's Avatar
      MmacFN -
      Some answers:

      accucheck 105

      Exparel apparently was not working to solve pain well enough at all in surgeon injection. So instead of just doing a block and cath or just the epidural, they also like to spend a fortune in a exparel too :P

      The exparel dose was 40 diluted with 40 of n/s

      Pts weight is 88 Kg
    1. ccrn_csc's Avatar
      ccrn_csc -
      Quote Originally Posted by J-Dubya View Post
      Negative test dose huh? Scratching my head on this one.
      My thought also. Could the beta blocker mask a positive test dose? Was the test dose given in 3/2 ml increments or all 5 at once?
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by ccrn_csc View Post
      My thought also. Could the beta blocker mask a positive test dose? Was the test dose given in 3/2 ml increments or all 5 at once?
      Maybe. Good point. You would think the epi would do something though.

      Old study, http://www.ncbi.nlm.nih.gov/pubmed/1679842

      Also, most places uses multi-orifice catheters, studies seem to indicate that aspiration prior to injection is a very reliable indicator of inadvertent vascular placement/migration.
    1. MmacFN's Avatar
      MmacFN -
      this was an actual case (tho i changed lots)

      there isnt an actual answer no one knows what happened yet im told.
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by MmacFN View Post
      this was an actual case (tho i changed lots)

      there isnt an actual answer no one knows what happened yet im told.
      Keep us updated Mike, very interesting (and scary) case.
    1. MmacFN's Avatar
      MmacFN -
      Here is what my response was:

      Here is what the monograph says:

      - ok to dilute with saline


      - Using EXPAREL followed by other bupivacaine formulations has not been studied in clinical trials. Other formulations of bupivacaine
      should not be administered within 96 hours following administration of EXPAREL.


      - EXPAREL has not been evaluated for the following uses and, therefore, is not recommended for these types of analgesia or routes of
      administration: epidural, intrathecal, regional nerve blocks, intravascular or intra-articular use.




      So from what i read in the monograph using bupivicaine in the epidural (and possibly any other LA) could have been what caused the sz.

      This is from their website:

      from their website

      http://www.exparel.com/index.shtml

      EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age.

      Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL.

      Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations.

      In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting. Please see the full Prescribing Information for EXPAREL.



      Please note the immediate release of bupivicaine from EXPAREL if used in combination with other LA.
    1. LightsOut's Avatar
      LightsOut -
      Quote Originally Posted by MmacFN View Post

      Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally.
      this tidbit is what I was trying to remember. If epidural migrated IV this could be possible. But with neg test dose, seems like a longshot.
    1. ssrhythm's Avatar
      ssrhythm -
      How long does it take for an epidural catheter to migrate IV? How long does it take for the catheter to simply nick a vessel and open it for uptake of the fluid that is surrounding it? Negative test dose simply indicates that the catheter was not IV when the test dose was given. Was the patient moved from table to bed after the lido top-off? Repositioned? Did the patient move? According to the exparel literature, if it made it into the bloodstream and sometime shortly after topping off the epidural an epidural vessel was compromised, a very high dose of free bupiv in the bloodstream will likely be the result. Not saying that is what happened, but that is precisely why I did not like it when our knee surgeon would inject the max dose like he was hurriedly infuse-marinating a chicken breast.
    1. Burnt2's Avatar
      Burnt2 -
      Exparel and an epidural? If I was a patient I'd be pissed with that bill.

      Sent from my Nexus 4 using Tapatalk
    1. GoodnightMoon's Avatar
      GoodnightMoon -
      Quote Originally Posted by Burnt2 View Post
      Exparel and an epidural? If I was a patient I'd be pissed with that bill.
      I don't have any experience with Exparel, but according to the website it is meant only for soft tissue pain. So ostensibly, an epidural could still be needed for other types of pain, right? It's not used at any of my clinical sites, but I'd love to hear about everyone's experiences with it post-op.
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by GoodnightMoon View Post
      I don't have any experience with Exparel, but according to the website it is meant only for soft tissue pain. So ostensibly, an epidural could still be needed for other types of pain, right? It's not used at any of my clinical sites, but I'd love to hear about everyone's experiences with it post-op.
      An epidural doesn't need help from exparel for pain relief. it just needs nurses who don't keep the operative side up for a whole shift.

      it's true, exparel is basically for local infiltration right now, but it's expensive...and at least at my hospital (in the States) jury is still out with exparel vs blocks for knees.

      I've done TAP blocks with exparel, works great.
    1. ssrhythm's Avatar
      ssrhythm -
      Y'all can look up my inital post about exparel in the passing gas forum if you like. I could not get an answer from the exparel rep about the possibility of an IV dose of lidocaine freeing a large quantity of bound bupivicaine (that would not be detected by clinical signs and symptoms) if there were and IV uptake of exparel. He was going to ask his medical liason to conference call with me to answer my questions, but for various reasons, that never happened. In the meantime, the results we were getting (surgeons using it in ortho cases) were not what they expected and the cost too great to continue using it, so it is not being used here anymore. I never followed up with the rep or the medical liason, but the fact that I had a serious safety concern and questions, we stopped using the drug, and the rep has never followed up with me make me think that they simply don't have an answer...or they have an answer that we don't want to hear.

      Regardless, I have not been at this for nearly as long as most of you, but I've never seen or heard tales of a drug hitting the ORs and being used for off-label, unproven, and untested reasons/methods so quickly...especially given the potential catastrophic dangers that exist with its use. Theoretically, the advantages of the drug are, in my mind, less than the theoretical dangers of using it...theoretical. That said, I would think that its efficacy and its potential dangers would have been extensively tested prior to it hitting the ORs. This obviously is not the case, as there are more reports on here of it not working anywhere near as well as advertised than there are of it working well. Now we can add the fact that we have a clinical case that highly suggests that a small amount of lidocaine administered epidurally after a negative test dose was at least partially taken up systemically and possibly freed enough IV exparel to cause seizures. The whole exparel roll-out has, quite frankly, stunned me.

      I still believe, more firmly now than ever, that we are administering huge quantities of drug that can make its way into the bloodstream either by IV uptake or direct, inadvertent IV administration and remain circulating for extended periods of time with absolutely no signs or symptoms of LA uptake. Until it can be and IS proven that a subsequent dose or previous does of IV lidocaine will not cause the rapid release of free bupivicaine from that circulating exparel, I wont use it and will encourage those around me not to. Theoretically, IV lido would cause the release of free bupivicaine from circulating exparel, and there is nothing that I've seen that refutes that. This case we are discussing only serves to strengthen that theory. I think using it in large quantities where immediate CP bypass is not available...until it is proven that IV lidocaine will not free the bupivicaine from IV exparel...is wreckless and irresponsible at best. Overly cautious? Maybe, but if I'm face to face with a snake that I can't identify, I'm going to assume its poisonous and back out.
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by ssrhythm View Post
      Y'all can look up my inital post about exparel in the passing gas forum if you like. I could not get an answer from the exparel rep about the possibility of an IV dose of lidocaine freeing a large quantity of bound bupivicaine (that would not be detected by clinical signs and symptoms) if there were and IV uptake of exparel. He was going to ask his medical liason to conference call with me to answer my questions, but for various reasons, that never happened. In the meantime, the results we were getting (surgeons using it in ortho cases) were not what they expected and the cost too great to continue using it, so it is not being used here anymore. I never followed up with the rep or the medical liason, but the fact that I had a serious safety concern and questions, we stopped using the drug, and the rep has never followed up with me make me think that they simply don't have an answer...or they have an answer that we don't want to hear.

      Regardless, I have not been at this for nearly as long as most of you, but I've never seen or heard tales of a drug hitting the ORs and being used for off-label, unproven, and untested reasons/methods so quickly...especially given the potential catastrophic dangers that exist with its use. Theoretically, the advantages of the drug are, in my mind, less than the theoretical dangers of using it...theoretical. That said, I would think that its efficacy and its potential dangers would have been extensively tested prior to it hitting the ORs. This obviously is not the case, as there are more reports on here of it not working anywhere near as well as advertised than there are of it working well. Now we can add the fact that we have a clinical case that highly suggests that a small amount of lidocaine administered epidurally after a negative test dose was at least partially taken up systemically and possibly freed enough IV exparel to cause seizures. The whole exparel roll-out has, quite frankly, stunned me.

      I still believe, more firmly now than ever, that we are administering huge quantities of drug that can make its way into the bloodstream either by IV uptake or direct, inadvertent IV administration and remain circulating for extended periods of time with absolutely no signs or symptoms of LA uptake. Until it can be and IS proven that a subsequent dose or previous does of IV lidocaine will not cause the rapid release of free bupivicaine from that circulating exparel, I wont use it and will encourage those around me not to. Theoretically, IV lido would cause the release of free bupivicaine from circulating exparel, and there is nothing that I've seen that refutes that. This case we are discussing only serves to strengthen that theory. I think using it in large quantities where immediate CP bypass is not available...until it is proven that IV lidocaine will not free the bupivicaine from IV exparel...is wreckless and irresponsible at best. Overly cautious? Maybe, but if I'm face to face with a snake that I can't identify, I'm going to assume its poisonous and back out.
      This seems really extreme to me. Yes, I would not give IV (or epidural) lido to a patient who had exparel on board, but why not just skip the lido , and keep the exparel? I've worked at several places using exparel and we aren't having issues. Seems like a great drug to me (although expensive).
  • APEX Anesthesia Review

  • Top SRNA Review Book!

  • Latest files

    17/04/18

    16/04/18

    15/04/18

    15/04/18

    19/11/17

  • Upcoming Events

  • Site Sponsors