bupivacaine liposome

bupivacaine liposome (injection)

(byoo-pi-vi-kane lye-poe-some) bupivacaineliposomeinjection,

Exparel

(trade name)

Classification

Therapeutic: anesthetics topical local
Pharmacologic: amides
Pregnancy Category: C

Indications

Postoperative single-use infiltration of surgical sites.

Action

Local anesthetics inhibit initiation and conduction of sensory nerve impulses by altering the influx of sodium and efflux of potassium in neurons, slowing or stopping pain transmission. Liposome formulation prolongs the duration of action.

Therapeutic effects

Lessened postoperative pain.

Pharmacokinetics

Absorption: Depends on amount injected and vascularity of administration site. Some systemic absorption occurs; however action is primarily local.Distribution: Widely distributed following release from liposomes, high concentrations in highly perfused organs (heart, lungs, liver, brain). Crosses the placenta.Protein Binding: 95%.Metabolism and Excretion: Mostly metabolized by the liver, metabolites are primarily renally excreted; 6% excreted unchanged in urine.Half-life: Following bunionectomy—34.1 hr; following hemorrhoidectomy—23.8 hr.

Time/action profile (blood levels)

ROUTE	ONSET	PEAK	DURATION
infiltration	unknown	0.5–2 hr	96 hr†

† Pain relief lasted for 24 hr.

Contraindications/Precautions

Contraindicated in: Hypersensitivity; cross-sensitivity with other amide local anesthetics (ropivacaine, lidocaine, mepivacaine, prilocaine) may occur; Obstetric: Obstetrical paracervical block anesthesia (may cause fetal bradycardia/death).Use Cautiously in: Impaired cardiovascular function;Hepatic disease (blood levels ↑ in severe hepatic impairment);Renal impairment (risk of toxic reactions may be ↑); Obstetric / Lactation / Pediatric: Pregnancy, lactation, and children<18 yr (safety has not been established)

Adverse Reactions/Side Effects

Central nervous system

central nervous system toxicity (life-threatening)
dizziness
drowsiness
headache
insomnia

Cardiovascular

peripheral edema
prolonged AV conduction
tachycardia

Gastrointestinal

constipation (most frequent)
nausea (most frequent)
vomiting (most frequent)

Dermatologic

pruritus

Hematologic

anemia

Musculoskeletal

back pain
muscle spasm

Miscellaneous

hypersensitivity reactions including anaphylactoid-like reactions and laryngeal edema (life-threatening)
fever
procedural pain

Interactions

Drug-Drug interaction

Should not be administered concurrently with local lidocaine, wait at least 20 minutes before infiltration with bupivacaine liposome.Should not be admixed with other local anesthetics.Should not be used within 96 hr of other formulations of bupivacaine ; overall exposure and risk of toxicity/adverse reactions will be ↑.

Route/Dosage

Infiltration: (Adults) Bunionectomy—106 mg (8 mL) given as 7 mL into osteotomy and 1 mL into subcutaneous tissue; Hemorrhoidectomy—266 mg (20 mL) diluted to a volume of 30 mL and given as six 5 mL aliquots.

Availability

Liposome injectable suspension (for infiltration only): 1.3% in 10- and 20-mL single use vials

Nursing implications

Nursing assessment

Assess infiltrated area for pain following administration and periodically during therapy.
Monitor cardiovascular and respiratory status (vital signs, level of consciousness) constantly following infiltration. Notify health care professional immediately if signs of cardiac toxicity (atrioventricular block, ventricular arrhythmias, cardiac arrest) occur.
Monitor for central nervous system toxicity. Notify health care professional promptly if they occur. Early signs of central nervous system toxicity include (restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, twitching, depression or drowsiness.
Monitor for signs and symptoms of allergic reactions (urticaria, pruritus, erythema, angioneurotic edema, laryngeal edema, tachycardia, sneezing, nausea, vomiting, syncope, excessive sweating, elevated temperature, severe hypotension). Have resuscitative equipment available.

Potential Nursing Diagnoses

Acute pain (Indications)

Implementation

Do not confuse with propofol. In a syringe suspension is milky white and may be mistaken for other medications. Label syringe to ensure dose is not administered IV.
Infiltration: May be administered undiluted or diluted with preservative–free 0.9% NaCl up to 0.89 mg/mL. Invert vial multiple times to re-suspend particles immediately prior to withdrawal from vial. Injected with a 25 gauge or larger bore needle slowly into soft tissues of surgical site with frequent aspiration to check for blood and minimize risk of intravascular injection. Use diluted suspension within 4 hrs of preparation in a syringe. Vials are for single dose; discard unused portions. May be stored in refrigerator for up to 1 month prior to opening. Do not use if solution is discolored or has been frozen; freeze indicator turns from green to white if exposed to freezing temperatures.
Do not administer in an area with povidone iodine until dry. If administered with other non-bupivacaine local anesthetics, administer other agents first and wait at least 20 min before infiltrating with bupivacaine liposome. Do not administer other forms of bupivacaine within 96 hr of bupivacaine liposome.

Patient/Family Teaching

Inform patient that infiltration may cause temporary loss of sensation or motor activity in infiltrated area.
Instruct patient to notify health care professional of pregnancy is known or suspected or if breast feeding.

Evaluation/Desired Outcomes

Prolongation of postoperative analgesia.