Ultimately, Dr. Prybyla and I used trial and error to figure out the
where and the how much. For a total knee, is 40 cc's enough? How
about 60 cc's? It turns out that 120 cc's is the right volume for a total
knee. We use 20 cc's of Exparel, 20 cc's of Marcaine 0.25%, and 80 cc's
of saline. Again, you have to make sure the liposomes reach every
area and nerve that has been injured.
These days, when I'm giving talks about opioid-sparing techniques, I
know at least one person in the audience is going to come up after-
ward clutching an article that says liposomal bupivacaine doesn't
work — and that's why they don't use it. I say, great, let's read the arti-
cle together, really get into the nuts and bolts of it, and I guarantee I'll
be able to show you exactly why it didn't work the way it was sup-
posed to.
The protocol
Of course, as I mentioned, there's more to opioid-sparing surgery than
just liposomal bupivacaine. Pre-operatively, we work with anesthesia
providers and administer a multimodal cocktail that includes a stan-
dard dose of IV Tylenol (Ofirmev) and 200 mg of Celebrex.
Post-operatively, I write a prescription for Tylenol 1000 mg po q8.
Writing the prescription is important, because we don't want patients
to think it's just an elective. We also use the NSAID Meloxicam 15 mg
po qd, because it doesn't require pre-authorization, and Gabapentin
300 mg po qhs, which is to be taken only at night. The reason: It helps
with sleep, and it manages pain in a different pathway. Patients take
each medication for 5 days.
Clear understanding of the protocol is essential, of course, so we go
over it post-operatively with patients so many times that by the time
they're ready to leave, they can tell the next patient what the protocol
is. And of course, if needed, we use interpreters or explain everything
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