Thanks Mac. In fact, flying and practicing anesthesia have much in common. Some folks describe it as going to sleep and waking up is like taking off and landing in flying terms.
@@DRBLUESNYC I was fortunate to help out at a Avian hospital in another country. I was taught to among other tasks, to administer anesthesia to large raptors using Isoflurane , under direct supervision. This lit a candle that has never gone out.
Some possible important distinction/speculation between interscalene and other blocks, beyond just the fact that there may simply not be enough data yet: Interscalene block is a relatively low block volume, particularly when compared with truncal blocks like TAP or rectus sheath, or other plane blocks like FIB. Speculation: If the release profile is not tightly controlled it may be hard to simultaneously have a concentration sufficient for prolonged release without risking toxicity. Block of the lower extremity can increase fall risk. Speculation: if the tail of the distribution is long, there could be prolonged partial block which may inadvertently increase this risk.
Hi Ben HC! That is really great. Thank you for sharing. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
Hi Paulsdrc! Indeed. Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Liposomal bupivacaine does make a huge difference in terms of pain control for rotator cuff surgery under Inter scalene nerve block for post op pain control. At my practice, we follow our patients for a few days and have noticed major reductions in pain medications for rotator cuff surgery versus straight bupivacaine. I know it’s anecdotal evidence but really strong results as per my follow ups. Our surgeons are very happy with this new technique and request it near 100 %.
There is no question that it does make a difference. However, it requires higher degree of skills and knowledge for successful application - as your note attests to. Best regards and thanks for watching the NYSORA chanel!
Our surgeons? Surgeons want anything that keeps them from getting calls. Thats why so many people are using this drug in unapproved blocks. Its that simple.
I just got this for acl surgery. It has been almost 24 hours since my surgery and I have literally had no pain besides for my hamstring where the took the graft from. They said it will last 2-4 days :)
@@No-xh2cs Indeed. It was first introduced in the surgical would infiltration. This was a mistake - as if the pharma did this through anesthesiologists - we could have provided better guidance on how to use this drug. Because the liposomal formulation has only a small amount of free drug in the suspension, the immediate effect is much weaker than that of bupivacaine (Marcaine), which is what surgeons are used to using. For that reason, it created some disappointment. If anesthesiologists were involved in educating, we would have advised a mixture of marcaine (bupi) and liposomal formulation for an immediate effect (marcaine) and sustained analgesia (liposomes). As for the price - drug development is expensive, therefore, all new, branded medications are severalfold more expensive than the older, generic preparation. This will be the fate with liposomal bupivacaine just the same - eventually - it will become generic and inexpensive. However, our discussion should focus on what is the best mode of application for the best indications, and this can be expanded into other applications when it becomes generic. Greetings and thank you for your contribution to the discussion.
Hello Dr. Hatzic. I agree with you completely on Exparel. I was extremely excited when it came out and was patiently waiting for it to be approved for all nerve blocks. If you were to use it off label, in which blocks do you feel comfortable using it?
Hi Samy. Indeed, but the prices will come down when the drug formulation becomes generic. In the meantime, perineural catheters are the only alternative - it would be interesting to know what the cost/patient of the catheter is in your institution. I suspect it is higher when you factor in the 1) equipment 2) pump 3) time to insert and manage them 4) pharmacy fees, etc. Best regards
its prohibitive because hospitals will not reduce their markups on the drug in hospital settings. Ridiculous. Its fairly reasonable OTC with RX at Walmart. Hospitals refuse to cooperate
@@02hreblue30 Would love to hear more about this. However, when you compare the price of a single injection versus Catheters (Eqiopment + skill + time + troubleshooting and management + infusion pumps + pharmacy cost + follow up), it is obvious that whatever the cost, single injection is cheaper and simpler. Best regards
The wide use of exparel, which is superior, adds a lot of expense for hospitals. I suspect this is related what’s going on with FDA, the questionable articles about efficacy, etc.
Hi Brett. Exparel is really a uniquely fascinating and unusual story. Everyone's talking about its expense being prohibitive. However, the cost of an infusion pump for perineural catheter alone is greater. Therefore, there must be additional agenda as to why this drug formulation is not being adopted at a higher rate. An extended-release formulation is what the field of regional anesthesia has needed to keep its relevance and improve acute pain management. Now when it is available, the regional community is being uber critical, while it keeps embracing ever increasing number of clinically unproven new techniques with old, short-acting available local anesthetics. This is what the video tried to convey. Greetings.
@@DRBLUESNYC an infusion pump is an institutional investment that will serve hundreds of patients over it's lifetime, and the duration of block from perineural catheters is both more reliable and longer than exparel. It's no surprise that institutions would rather invest in the more reliable proven technology.
I had this for a surgery and didn't have a good reaction to it. It's probably dependent on your body. I had it in for 3 days and it caused me ALOT of pain.
A better study will be to compare liposomal bupivacaine vs. bupivacaine with epi or other drug additives especially if we’re jumping to the conclusion that liposomal bupivacaine is safer and better than bupivacaine. It’s misleading to conduct a study solely against placebo and then apply the results of that study against standard of care. Also, let’s not forget that liposomal bupivacaine is not cheap, whereas I can get the same analgesic response and duration of analgesia by using bupivacaine 0.5% with epi mixed with dexmedetomidine.
HI Chris! Thank you for the comment. This first video on Exparel was not about the efficacy versus bupivacaine.; we will get to that soon. The video only presented the evidence of efficacy that led to its approval for use in interscalene block (FDA), and interscalene and femoral blocks (EMA). These efficacy results versus placebo can not be challenged. And efficacy versus placebo is what the regulatory agencies use as a standard for approval of new drugs and formulations. The video rather pointed out how it makes no sense to approve the drug formulation for interscalene but not for other, simpler blocks. The next video will build on this info and discuss many common misconceptions in clinical practice and research trials. Jumping a bit ahead of the upcoming videos, however, this formulation should not be compared to bupivacaine, as these are two different things. Whatever the allowed language for the marketing, liposomal bupivacaine is a depo formulation of bupivacaine - a formulation of a medication that releases slowly over time to avoid repetitive administration of local anesthetic or need for catheters. As such, this formulation does not have the potency of bupivacaine at the onset (upon administration), but it exceeds the duration of bupivacaine as the free bupivacaine is released from liposomes. This is not debatable as it is documented at every pharmacokinetic study on the liposome bupivacaine. To get the most out of the formulation, a mixture with bupivacaine for a more free drug at the onset is the key. These planned videos series are packed with information from someone who has been involved in studies of the drug, and clinical observations for a decade, and even first-hand experience as a patient. But, the videos are coming soon and will be very interesting and revealing as there are many misconceptions and even colleagues who have not even heard of these developments. Therefore, educational. Best regards.
Preservative free dexamethasone as well. My understanding of the evidence isn't particularly supportive of epi for nerve blocks (in terms of having any significant prolongation to the block with large volume or major nerve blocks) but I would be happy to review any new publications in the topic. Regarding additives in general however, I'm hesitant to use some newer additives discussed in the literature as I worry the volume of data may not be sufficient to capture local neurotoxicity or other patient harms. Regarding prolonged blocks in general, I find it important to discuss patient expectations especially for any block with a notable motor component as some find a prolonged motor block very distressing. This would be a benefit of catheter infusions as they can more easily be "turned off". Disclaimer - don't have a fellowship in regional, and work in rural/remote parts of Canada... Regional is still a highlight of any list for me though
Расскажи пожалуйста в какой пропорции ты мешаешь анестетик и дексметомидин?) Я из России и у меня есть все тоже самое, но никто из наших докторов ничего не добавляет. Я иногда дексометазон, но и то сильной разницы не увидел..
@@aydinrustamov6583 Hi Aydin: Your Question: Please tell me in what proportion do you interfere with the anesthetic and dexmethomidine?) I am from Russia and I have everything the same, but none of our doctors adds anything. I sometimes dexometasone, but even then I did not see a strong difference" Anser: The reason you do not see much benefit of adding dexamethasone is because there is none or minimal in comparison to dexamethason IV.Best regards
A study has been done for this drug for use in chronic fatigue syndrome no results yet. But why not for pain in fibromyalgia, pain thru out the entire body that is unresolved? And has no origin just musculoskeletal pain.
Dr Hadzic, your educational videos are brilliant, but please get off the Exparel payroll, as quite clearly it’s going to be difficult to be impartial when you’ve got that kind of conflict of interest.
Hi Doug. I appreciate your comment. I am a public persona, and I do appreciate hearing honest and open feedback like yours. The modern-day regulations make it easy to get info on whether someone is a hired gun for pharma. Exparel's manufacturer, Pacira, has indeed sponsored some of our studies and educational programs, which we have always disclosed in our programs and publications. Harvard University, Duke University, Columbia University, UCSD, UPEN, to name a few, have also been beneficiaries of Exparel's research and educational support. Organized societies have also benefitted from Pacira's support of their annual meetings, exhibit floor fees, etc. I do not think you could say that they were on Exparel payroll by this association. I featured a disclosure even in this very video, although we did not have to disclose anything by UA-cam regulations. Instead, we have done so staying true to our own code of ethics. In fact, I would LOVE to be on Exparel payroll as a marketer. With NYSORA's community of 5 million readers, we would be wildly successful in making the planet become more familiar with the best uses of Exparel; UA-cam is a minuscule portion of NYSORA's community. I am a fervent pioneer of modern regional anesthesia and have a track record to back this statement that goes beyond a portfolio of a salesman. Had it not been for the ultrasound revolution in the field of nerve blocks, the regional anesthesia subspecialty would have been obsolete by now. Just the same, if we do not embrace the pharmacological advances that extend the relevance of the immense efforts that the regional anesthesia community has invested into building the subspecialty, we will not have a future. That is why the video was mostly all about. Thank you for watching, and for being open about your thoughts on this. I am aware of the risk of the association with the conflict of interest, but then - sticking my neck out in saying what I believe is what makes me who I am. Regards and respect, AH
Thanks for the honest reply. Please keep up the great educational work, I recommend your app to pretty much every trainee I work with, it’s absolutely game changing.. All the very best, Doug
Thank you dear dr.Hadzic One I have read in Board Revie somthing that may can help; Use only Dexamethasone do not use the susspension form from Corticosteroids like Solomedrol and Traimsinolone or Betametason... In the neck facet joint pain on the aim not to cause a strok bei a Susspension medicine caused embolism in the Vertebral Artery Can it hier with liposomal Bubevacaine be somthing similar to that condition? Grettings from Syria🌺🌺🌺
DO NOT MISS OUT OUR NEW VIDEOS, SUBSCRIBE HERE: ua-cam.com/users/nysoravideo
Love this channel, I’m a helicopter pilot but find anesthesia such an interesting field
Thanks Mac. In fact, flying and practicing anesthesia have much in common. Some folks describe it as going to sleep and waking up is like taking off and landing in flying terms.
@@DRBLUESNYCTotally agree, I use the same analogy to explain my patients the procedure
@@DRBLUESNYC I was fortunate to help out at a Avian hospital in another country. I was taught to among other tasks, to administer anesthesia to large raptors using Isoflurane , under direct supervision. This lit a candle that has never gone out.
Some possible important distinction/speculation between interscalene and other blocks, beyond just the fact that there may simply not be enough data yet:
Interscalene block is a relatively low block volume, particularly when compared with truncal blocks like TAP or rectus sheath, or other plane blocks like FIB. Speculation: If the release profile is not tightly controlled it may be hard to simultaneously have a concentration sufficient for prolonged release without risking toxicity.
Block of the lower extremity can increase fall risk. Speculation: if the tail of the distribution is long, there could be prolonged partial block which may inadvertently increase this risk.
Hi Ben HC! That is really great. Thank you for sharing. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
This stuff is awesome, no numbness, or anything odd, just no pain.
Hi Paulsdrc! Indeed. Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Liposomal bupivacaine does make a huge difference in terms of pain control for rotator cuff surgery under Inter scalene nerve block for post op pain control. At my practice, we follow our patients for a few days and have noticed major reductions in pain medications for rotator cuff surgery versus straight bupivacaine. I know it’s anecdotal evidence but really strong results as per my follow ups. Our surgeons are very happy with this new technique and request it near 100 %.
There is no question that it does make a difference. However, it requires higher degree of skills and knowledge for successful application - as your note attests to. Best regards and thanks for watching the NYSORA chanel!
Our surgeons? Surgeons want anything that keeps them from getting calls. Thats why so many people are using this drug in unapproved blocks. Its that simple.
I just got this for acl surgery. It has been almost 24 hours since my surgery and I have literally had no pain besides for my hamstring where the took the graft from. They said it will last 2-4 days :)
Would liposomal bupivacaine be viable for use in IPACK and adductor canal block for total knee arthroplasty?
Perserved mobility due to nature of both blocks but decreased pain...
Interesting, this is the FIRST time I hear about liposomal bupivacaine, even though I practice anesthesia!
It's expensive maybe that's why 😂 also they used it in widely in surgery before anesthesia took it up too
@@No-xh2cs Indeed. It was first introduced in the surgical would infiltration. This was a mistake - as if the pharma did this through anesthesiologists - we could have provided better guidance on how to use this drug. Because the liposomal formulation has only a small amount of free drug in the suspension, the immediate effect is much weaker than that of bupivacaine (Marcaine), which is what surgeons are used to using. For that reason, it created some disappointment. If anesthesiologists were involved in educating, we would have advised a mixture of marcaine (bupi) and liposomal formulation for an immediate effect (marcaine) and sustained analgesia (liposomes). As for the price - drug development is expensive, therefore, all new, branded medications are severalfold more expensive than the older, generic preparation. This will be the fate with liposomal bupivacaine just the same - eventually - it will become generic and inexpensive. However, our discussion should focus on what is the best mode of application for the best indications, and this can be expanded into other applications when it becomes generic. Greetings and thank you for your contribution to the discussion.
Hello Dr. Hatzic. I agree with you completely on Exparel. I was extremely excited when it came out and was patiently waiting for it to be approved for all nerve blocks. If you were to use it off label, in which blocks do you feel comfortable using it?
Have I missed Part 2 of this?
Sorry, but how is possible a randomized, double blind study between a white drug and a transparent one?
2 - 3 Years ago I asked our pharmacy to source Liposomal Bupivacaine but the cost was prohibitive
Hi Samy. Indeed, but the prices will come down when the drug formulation becomes generic. In the meantime, perineural catheters are the only alternative - it would be interesting to know what the cost/patient of the catheter is in your institution. I suspect it is higher when you factor in the 1) equipment 2) pump 3) time to insert and manage them 4) pharmacy fees, etc. Best regards
@@DRBLUESNYC
Thank you Admir
I will look at it again
its prohibitive because hospitals will not reduce their markups on the drug in hospital settings. Ridiculous. Its fairly reasonable OTC with RX at Walmart. Hospitals refuse to cooperate
@@02hreblue30 Would love to hear more about this. However, when you compare the price of a single injection versus Catheters (Eqiopment + skill + time + troubleshooting and management + infusion pumps + pharmacy cost + follow up), it is obvious that whatever the cost, single injection is cheaper and simpler. Best regards
The wide use of exparel, which is superior, adds a lot of expense for hospitals. I suspect this is related what’s going on with FDA, the questionable articles about efficacy, etc.
Hi Brett. Exparel is really a uniquely fascinating and unusual story. Everyone's talking about its expense being prohibitive. However, the cost of an infusion pump for perineural catheter alone is greater. Therefore, there must be additional agenda as to why this drug formulation is not being adopted at a higher rate. An extended-release formulation is what the field of regional anesthesia has needed to keep its relevance and improve acute pain management. Now when it is available, the regional community is being uber critical, while it keeps embracing ever increasing number of clinically unproven new techniques with old, short-acting available local anesthetics. This is what the video tried to convey. Greetings.
@@DRBLUESNYC really enjoy your videos, as do my colleagues. Thank you!
@@Slippery-Stan-Miracle-Man Thank you Brett. Best regards.
@@DRBLUESNYC an infusion pump is an institutional investment that will serve hundreds of patients over it's lifetime, and the duration of block from perineural catheters is both more reliable and longer than exparel.
It's no surprise that institutions would rather invest in the more reliable proven technology.
I had this for a surgery and didn't have a good reaction to it. It's probably dependent on your body. I had it in for 3 days and it caused me ALOT of pain.
A better study will be to compare liposomal bupivacaine vs. bupivacaine with epi or other drug additives especially if we’re jumping to the conclusion that liposomal bupivacaine is safer and better than bupivacaine. It’s misleading to conduct a study solely against placebo and then apply the results of that study against standard of care.
Also, let’s not forget that liposomal bupivacaine is not cheap, whereas I can get the same analgesic response and duration of analgesia by using bupivacaine 0.5% with epi mixed with dexmedetomidine.
HI Chris! Thank you for the comment. This first video on Exparel was not about the efficacy versus bupivacaine.; we will get to that soon. The video only presented the evidence of efficacy that led to its approval for use in interscalene block (FDA), and interscalene and femoral blocks (EMA). These efficacy results versus placebo can not be challenged. And efficacy versus placebo is what the regulatory agencies use as a standard for approval of new drugs and formulations. The video rather pointed out how it makes no sense to approve the drug formulation for interscalene but not for other, simpler blocks. The next video will build on this info and discuss many common misconceptions in clinical practice and research trials. Jumping a bit ahead of the upcoming videos, however, this formulation should not be compared to bupivacaine, as these are two different things. Whatever the allowed language for the marketing, liposomal bupivacaine is a depo formulation of bupivacaine - a formulation of a medication that releases slowly over time to avoid repetitive administration of local anesthetic or need for catheters. As such, this formulation does not have the potency of bupivacaine at the onset (upon administration), but it exceeds the duration of bupivacaine as the free bupivacaine is released from liposomes. This is not debatable as it is documented at every pharmacokinetic study on the liposome bupivacaine. To get the most out of the formulation, a mixture with bupivacaine for a more free drug at the onset is the key. These planned videos series are packed with information from someone who has been involved in studies of the drug, and clinical observations for a decade, and even first-hand experience as a patient. But, the videos are coming soon and will be very interesting and revealing as there are many misconceptions and even colleagues who have not even heard of these developments. Therefore, educational. Best regards.
Preservative free dexamethasone as well.
My understanding of the evidence isn't particularly supportive of epi for nerve blocks (in terms of having any significant prolongation to the block with large volume or major nerve blocks) but I would be happy to review any new publications in the topic.
Regarding additives in general however, I'm hesitant to use some newer additives discussed in the literature as I worry the volume of data may not be sufficient to capture local neurotoxicity or other patient harms.
Regarding prolonged blocks in general, I find it important to discuss patient expectations especially for any block with a notable motor component as some find a prolonged motor block very distressing. This would be a benefit of catheter infusions as they can more easily be "turned off".
Disclaimer - don't have a fellowship in regional, and work in rural/remote parts of Canada... Regional is still a highlight of any list for me though
@@BenHC That's great Ben. Thanks for sharing. Don't need a fellowship to be a top gun regionalist for the patients benefit. ;) Greetings!
Расскажи пожалуйста в какой пропорции ты мешаешь анестетик и дексметомидин?) Я из России и у меня есть все тоже самое, но никто из наших докторов ничего не добавляет. Я иногда дексометазон, но и то сильной разницы не увидел..
@@aydinrustamov6583 Hi Aydin: Your Question: Please tell me in what proportion do you interfere with the anesthetic and dexmethomidine?) I am from Russia and I have everything the same, but none of our doctors adds anything. I sometimes dexometasone, but even then I did not see a strong difference" Anser: The reason you do not see much benefit of adding dexamethasone is because there is none or minimal in comparison to dexamethason IV.Best regards
sorry, but 0.50 % 100 ml bupivacaine costs 18 usd, 20 ml of exparel 300 usd
A study has been done for this drug for use in chronic fatigue syndrome no results yet. But why not for pain in fibromyalgia, pain thru out the entire body that is unresolved? And has no origin just musculoskeletal pain.
Dr Hadzic, your educational videos are brilliant, but please get off the Exparel payroll, as quite clearly it’s going to be difficult to be impartial when you’ve got that kind of conflict of interest.
Hi Doug. I appreciate your comment. I am a public persona, and I do appreciate hearing honest and open feedback like yours. The modern-day regulations make it easy to get info on whether someone is a hired gun for pharma. Exparel's manufacturer, Pacira, has indeed sponsored some of our studies and educational programs, which we have always disclosed in our programs and publications. Harvard University, Duke University, Columbia University, UCSD, UPEN, to name a few, have also been beneficiaries of Exparel's research and educational support. Organized societies have also benefitted from Pacira's support of their annual meetings, exhibit floor fees, etc. I do not think you could say that they were on Exparel payroll by this association. I featured a disclosure even in this very video, although we did not have to disclose anything by UA-cam regulations. Instead, we have done so staying true to our own code of ethics. In fact, I would LOVE to be on Exparel payroll as a marketer. With NYSORA's community of 5 million readers, we would be wildly successful in making the planet become more familiar with the best uses of Exparel; UA-cam is a minuscule portion of NYSORA's community. I am a fervent pioneer of modern regional anesthesia and have a track record to back this statement that goes beyond a portfolio of a salesman. Had it not been for the ultrasound revolution in the field of nerve blocks, the regional anesthesia subspecialty would have been obsolete by now. Just the same, if we do not embrace the pharmacological advances that extend the relevance of the immense efforts that the regional anesthesia community has invested into building the subspecialty, we will not have a future. That is why the video was mostly all about. Thank you for watching, and for being open about your thoughts on this. I am aware of the risk of the association with the conflict of interest, but then - sticking my neck out in saying what I believe is what makes me who I am. Regards and respect, AH
Thanks for the honest reply. Please keep up the great educational work, I recommend your app to pretty much every trainee I work with, it’s absolutely game changing.. All the very best, Doug
@@dougmorgan1322 Thank you. Best regards.
Thank you dear dr.Hadzic
One I have read in Board Revie somthing that may can help;
Use only Dexamethasone do not use the susspension form from Corticosteroids like Solomedrol and Traimsinolone or Betametason...
In the neck facet joint pain on the aim not to cause a strok bei a Susspension medicine caused embolism in the Vertebral Artery
Can it hier with liposomal Bubevacaine be somthing similar to that condition?
Grettings from Syria🌺🌺🌺
Sorry, Dr Hadzic, I misspelled your name.:(
Hi Anya, No problem-Keep watching our upcoming videos.
Those are the most serial killer glasses I've ever seen...🤯
Because the FDA is crap