Exparel with a Peripheral Nerve Block

Case Report

Austin J Anesthesia and Aalgesia. 2014;2(6): 1034.

Exparel with a Peripheral Nerve Block

Jean Daniel Eloy*, Heidi Boules, James Doran, Kathleen Beebe, Anthony Sifonios and Vanny Le

Department of Anesthesiology, Rutgers/New Jersey Medical School, USA

*Corresponding author: Daniel Eloy, Department of Anesthesiology, Rutgers/New Jersey Medical School, 185 South Orenge Ave, MSB E538, Newark, NJ 07103, USA

Received: July 15, 2014; Accepted: August 15, 2014; Published: August 18, 2014


Acute postoperative pain is primarily managed with opioids. In this case, we present the successful postoperative pain management of a patient post left upper extremity sarcoma resection with the use of Exparel via an Infra clavicular nerve block. This case also highlights an alternative to continuous peripheral nerve blocks with their associated risks and complications and illustrates a multimodal approach to acute postoperative pain management in which non-opioid adjuvants are used to achieve an opioid sparing and even opioid free regiment. The case also suggests that an opioid free approach in the treatment of post surgical pain is feasible and should be considered especially when incorporating regional anesthesia as part of a multimodal approach.

Case Presentation

A 27-year-old 78 kg male presented for a radical resection of a left forearm sarcoma. The patient completed chemotherapy for the sarcoma three months prior to the scheduled surgery without complications. His medical history was pertinent for bipolar disorder and depression and a past history of alcohol and illicit substance abuse, which he had been rehabilitated for four years prior to surgery. The patient's surgical history was limited to mediport insertion and left forearm biopsy, which were performed under general anesthesia without complications. MRI of his left upper extremity revealed a 7 cm x 5.6 cm x 3.5cmmulti-loculated, necrotic tumor originating 4 mm proximal to the radial carpal joint. The mass was lying on the cortex of both the radial and ulnar shafts along the interosseous membrane. The lesion was noted to be deep to the flexor digitorum profundus, the flexor carpi ulnaris and the flexor pollicus longus. The median, ulna, and radial nerves along with the radial artery were not encased by tumor but adjacent to the mass (See MRI 1&2).

The patient met with the anesthesia care team prior to surgery in order to explore non-opioid options in the perioperative period. Given the patient's social history, he had expressed to the surgical and anesthetic teams his desire to undergo this procedure and the period of recovery without the use of opioids, except when absolutely necessary. Our plan was to perform a preoperative left brachial plexus block with a catheter using ultrasound guidance to provide both intra operative as well as postoperative analgesia.

On the day of surgery, the patient was brought to the operating room, placed on standard monitors and given supplemental oxygen in preparation for the nerve block. He was sedated with 2 mg midazolam intravenously. An infra clavicular Nerve block was performed with successful blockade of the brachial plexus [1]. A total of 20 ml of 1.3 % Exparel®, 266 mg, was delivered to the site in a single dose. Additionally, a perineural catheter was inserted; however, no additional local anesthetic was injected via this catheter. The catheter was placed to provide a route for rescue medication to be injected, should he require additional local anesthetic.

General anesthesia was induced and the sarcoma was subsequently resected uneventfully. The use of opioid was limited to 100 mcg of fentanyl for the purpose of tracheal intubation. The patient also received 30 mg of Ketorolac and a continuous Ketamine infusion of 20 mg/hr for the duration of the case [2]. Anesthesia was maintained with a 50% mixture O2/Air and Isofluorane. The patient was extubated without complications and received no additional opioids during the immediate postoperative period.

The patient was admitted to a surgical floor to complete his recovery where he was followed by the acute pain management service. He was placed prophylactically on acetaminophen 1000 mg PO Q8 hours, ketorolac 30mg IV Q6 hours and gabapentin 300mg PO Q8 hours. For the first 24 hours after surgery, he reported a score of zero out of ten pain score on the Visual Analog Scale (VAS). He reported an inability to flex or extend his fingers, which reflected a degree of motor blockade. This motor blockade completely resolved over 24 hours. At 48 hours post-op, the patient reported a maximum score of two out of ten VAS pain scoreand no residualmotor blockade. Finally, by 72 hours post-op, the patient reported a maximum score of five out of ten VAS pain score and stated that there was no residual numbness in the blocked arm. The indwelling infra clavicular catheter was removed and the patient was discharged home. Within the immediate 72 hours post-op, the patient did not require any opioid supplementation nor was the infra clavicular catheter bol used with additional local anesthetic.

Citation: Eloy JD, Boules H, Doran J, Beebe K, Sifonios A and Le V. Exparel with a Peripheral Nerve Block. Austin J Anesthesia and Analgesia. 2014;2(6): 1034. ISSN: 2381-893X