Taking Great Pains:
EXPAREL® helps improve postop pain after breast reconstruction
Published on September
23, 2014, Plastic Surgery Practice
By Charles K.
Lee, MD, FACS
The past decade has brought major treatment advances in
breast reconstruction surgery. Most notably, autologous flap procedures have
vastly improved the patient experience. But despite significant strides on the
surgical front, one constant that continues to diminish the quality of life of
patients undergoing breast surgery is postsurgical pain. Inadequate pain
control after surgery has been correlated with long-term chronic pain,1 which
affects between 27% and 48% of patients following breast surgery.2,3
While pain management is integral to an optimal recovery for
all surgery patients, given the tremendous psychological and physical disease
burden breast cancer patients endure prior to undergoing reconstruction, the
need for exceptional postsurgical analgesia is especially critical for this
population.
The current standard of care for postsurgical pain
management following breast reconstruction consists of a combination of
continuous nerve blocks, catheters (anywhere between two and four, in addition
to two drains), opioids, and NSAIDs. While effective, the standard regimen has
its share of downsides ranging from opioid-related adverse events, which
prolong recovery and increase cost of care, to catheter-related issues such as
infections at insertion sites, pump errors, and delayed ambulation due to
continuous tethering to pain pumps. Despite the well-recognized drawbacks and
due to a lack of comparably effective, yet more tolerable alternatives, blocks
and pumps have become a fixture in the postsurgical pain-management toolbox.
Enter EXPAREL
A lot changed in 2011 with the US Food and Drug
Administration approval of a novel formulation of bupivacaine, called EXPAREL®
(bupivacaine liposome injectable suspension). EXPAREL can provide up to 72
hours of local analgesia and reduced opioid requirements via infiltration at
the surgical site. Unlike standard bupivacaine, which produces a 6- to 8-hour
analgesic effect, the bupivacaine in EXPAREL is encased in liposomes which
break down over time to extend the release of the active drug over a 3-day
period.
I was initially skeptical about the promise of a
non-narcotic local anesthetic that produced prolonged pain relief without
catheters, pumps, or IVs, and significantly reduced opioid burden. However,
after a few initial cases, it was clear that EXPAREL could greatly enhance the
recovery experience of all my patients, especially those undergoing breast
cancer surgery and reconstruction.
Evidence Builds
As part of a broader effort to gain formulary acceptance, I
conducted a small study with 25 patients to demonstrate the clinical value of
EXPAREL in comparison to previous cases using a standard pain regimen
(bupivacaine HCl block supplemented by opioid-based rescue, administered via
patient-controlled analgesia [PCA]). Patients treated with EXPAREL, half of
whom underwent breast reconstruction while the other half underwent aesthetic
procedures, reported an average pain score of 3 (using a NRS scale of 1 to 10),
compared to 7 for patients who received the standard pain regimen. In addition,
patients who received EXPAREL reported being “highly satisfied” with their pain
relief.
While the measurable reduction in pain was a key driver of
pharmacy acceptance, the cost savings and reduced infection risk associated
with the elimination of catheter-based pain control modalities also helped move
the needle. Since we added EXPAREL to our pharmacy, I have almost entirely
eliminated the use of PCAs, and patients report being more comfortable, able to
ambulate sooner, and highly satisfied with their quality of care.
During the past 2 years, I have used EXPAREL in more than
300 cases, including hand and leg surgery, breast surgery, and facelifts, and
observed consistent results in terms of pain reduction, opioid reduction, and
satisfaction. By controlling pain during the critical few days after surgery
without requiring invasive ports, and eliminating high opioid requirements,
EXPAREL allows reconstructive surgery patients to focus on the vitally
important psychological and practical aspects of healing from a life-changing
procedure. Based on my experience, EXPAREL promises to redefine our approach to
intraoperative and postoperative pain control.
Tips and Techniques
As a surgeon, I considered myself experienced in local
infiltration techniques. However, EXPAREL ® behaves differently from
traditional anesthetics, including bupivacaine HCl, in a few important ways.
For starters, the liposomal composition makes EXPAREL more viscous than
standard bupivacaine, so once placed, EXPAREL remains local and does not
disperse.
Unlike Marcaine, which can be liberally applied around the
site and massaged into the targeted region, EXPAREL needs precise placement
into soft tissues in the region of the sensory nerves, as well as the muscle
and fascia, to produce the desired effect. A 20-mL vial of EXPAREL (266 mg) can
be expanded with up to 280 mL of preservative-free normal sterile saline for a
total volume of 300 mL.
In most of my cases, I will expand the volume to
approximately 60 to 100 mL, depending on the surface area to cover. For a DIEP
flap, I expand the volume of EXPAREL up to 200 mL and infiltrate the tissues
and muscle around the breast and abdomen, as well as the fascial planes (versus
the subcutaneous area), and in the region where sensory fibers may be.
References
1. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical
pain: risk factors and prevention. Lancet. 2006;367(9522):1618-1625.
2. Carpenter JS, Sloan P, Andrykowski MA, et al. Risk
factors for pain after mastectomy/lumpectomy. Cancer Pract. 1999;7(2):66-70.
3. Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for
chronic pain following breast cancer surgery: a prospective study. J Pain.
2006;7(9):626-634.
- See more at:
http://www.plasticsurgerypractice.com/2014/09/taking-great-pains-exparel-helps-improve-postop-pain-breast-reconstruction/#sthash.esDmyv6B.dpuf