THE USE OF EXPAREL IN PECTORAL FIELD BLOCKS FOR

BREAST PROCEDURES

EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Please see Important Safety Information throughout and refer to accompanying full Prescribing Information.

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Important Safety InformationEXPAREL is contraindicated in obstetrical paracervical block anesthesia.

Adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.

Field block infiltration, or fascial plane infiltration, can be an effective technique in a multimodal analgesic strategy1,2

• A PECS (ultrasound-guided medial and lateral pectoralis nerve) block is a less invasive technique for providing analgesia after breast surgery compared with standard approaches, such as thoracic epidural, paravertebral, intercostal nerve, and intrapleural blocks2,3

• In PECS I and PECS II field infiltration, ultrasound guidance can be used to identify the appropriate fascial plane(s) and deposit local anesthetic to provide regional analgesia2

— PECS blocks are applied in the pectoral and axillary regions, with the muscles in both regions innervated by the brachial plexus3

• A PECS block can be administered by the anesthesiologist or surgeon; direct injection during open surgery is also possible2

• These techniques provide effective analgesia after breast surgery and, unlike thoracic paravertebral and epidural blocks, are not associated with sympathetic block2

External anterior view of areas covered by PECS I and PECS II nerve blocks3

PECS I block • Devised to anesthetize the medial and

lateral pectoral nerves, which innervate the pectoralis muscles

PECS II block • Extends the block to provide blockade

of the upper intercostal nerves

Areas covered by a PECS I or PECS II block

Lateral pectoral nerveMedial pectoral nerve

Dorsal nerve

Musculocutaneous nerve

Anterior scalene muscle

Brachial plexusAxillary artery

Thoracodorsal nerve

Latissimus dorsi muscleLong thoracic nerve

Please refer to accompanying full Prescribing Information.

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Important Safety Information (continued)If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.

EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients.

Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Internal view of nerves to target with a PECS block2

PECS I block • The lateral and medial pectoral

nerves lie in the fascial plane between the pectoralis major and minor muscles

PECS II block• Spinal nerves T2 to T4 lie in

the fascial plane between the pectoralis minor and serratus anterior muscles

Internal sagittal view of where to inject local anesthetic2

PECS I block • Injection between the pectoralis

major and minor muscles

PECS II block• Injection between the pectoralis

muscles and a second injection between the serratus anterior and pectoralis minor muscles

Consider the neuroanatomy to target the appropriate nerves for a PECS block

Image used with permission from Blanco et al.3 NYSORA website. www.nysora.com.

1 2

Major

Minor

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Important Safety Information (continued)Warnings and Precautions Specific to EXPARELAvoid additional use of local anesthetics within 96 hours following administration of EXPAREL.

EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.

The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and durationdepending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Image 1 used with permission from Afonso AM, Newman MI, Seeley N, et al. Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use. Plast Reconstr Surg Glob Open. 2017;5(9):e1480.

Image 2 courtesy of Jacob Hutchins, MD.

1. Linear probe is placed over the third rib on the anterior chest wall.

2. Image shows the pectoralis major and minor muscles, the third rib, and the intercostal muscle between the ribs, overlying the pleura. Needle is inserted into the plane between the pectoralis major and minor muscles, where 10 mL of local anesthetic is injected.

Performing a PECS I block for pectoral and breast procedures

Common applications/procedures for a PECS I block• Surgeries involving the pectoralis

major muscle • Breast expanders• Traumatic chest injuries• Portacath• Pacemaker insertion

Administering EXPAREL in a PECS I block• For a bilateral PECS I block, a minimum

of 20 mL of volume (10 mL per side) is generally used in clinical practice

PECS I block• Involves hydrodissection of the plane between the pectoral

muscles with local anesthetic3

• Main landmarks for point of injection under ultrasound guidance are3

— Pectoralis major muscle — Pectoralis minor muscle• A PECS I block does not reliably block pain at the serratus muscle2

Nerves involved3:• Medial pectoral nerve (C8, T1)• Lateral pectoral nerve (C5, C6, C7)

— Pectoral branch of thoracoacromial artery

Watch Dr Mark Brzezienski perform a plane block for mastectomy pain control.

Watch this video, which demonstrates the technique for PECS I and II infiltration blocks.

2

Major

Minor

SA, inject

1

5

Please refer to accompanying full Prescribing Information.

Common applications/procedures for a PECS II block• More extensive breast surgery involving

the serratus anterior and the axilla• Tumor resection• Sentinel node excision• Axillary clearance• Tissue expanders

Administering EXPAREL in a PECS II block• For a bilateral PECS II block, a minimum

of 40 mL of volume (20 mL per side) is generally used in clinical practice

PECS II blockThe goal is to infiltrate 2 fascial compartments by dividing the dose and injecting3 • Between the pectoral nerves (the pectoral fascia and clavipectoral fascia) • Under the pectoralis minor muscle (between the clavipectoral fascia and the

superficial border of the serratus muscle)

Nerves involved include4

• Long thoracic nerve (nerve to serratus anterior)• Thoracic intercostal nerves from T2 to T6• Thoracodorsal nerve (nerve to latissimus dorsi)

1. Linear probe is placed over the fourth rib on the anterior chest wall.

2. Image shows the pectoralis major and minor muscles, the pleura, and the serratus anterior muscle overlying the fourth rib. Needle is advanced toward the fourth rib until the tip lies in the plane between the pectoralis minor and serratus muscles, where 20 mL of local anesthetic is injected. Image 1 used with permission from Afonso AM, Newman MI,

Seeley N, et al. Multimodal analgesia in breast surgical procedures: technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg Glob Open. 2017;5(9):e1480.

Image 2 courtesy of Jacob Hutchins, MD.

Important Safety Information (continued)Warnings and Precautions for Bupivacaine-Containing ProductsCentral Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.

Performing a PECS II block for more extensive pectoral and breast procedures

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Determine the right volume to cover the surgical site• Consider the size of the surgical site and the neuroanatomy

• Expand the volume to disperse liposomes throughout the surgical site

• Enough multivesicular liposomes must be available at the pain receptors to continuously release bupivacaine, ensuring long-lasting analgesia

• For large surgical sites, the 266 mg (20 mL) vial of EXPAREL can be expanded with normal (0.9%) saline or lactated Ringer’s solution up to a total volume of 300 mL

Important Safety Information (continued)Warnings and Precautions for Bupivacaine-Containing Products (continued)Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias, sometimes leading to death.

Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.

Dosing considerations • Size of the surgical site

• Volume needed to cover the width and depth of site

• Patient factors that could impact safety of an amide local anesthetic

• Maximum dose should not exceed 266 mg (20 mL)

• Intended for single–dose administration only

Dosing and administration information for EXPAREL

EXPAREL expandedEXPAREL unexpanded

7

Important Safety Information (continued)Warnings and Precautions for Bupivacaine-Containing Products (continued)

Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.

Methemoglobinemia: Cases of methemoglobinemia have been reportedwith local anesthetic use.

Please refer to accompanying full Prescribing Information.

OR

EXPAREL266 mg(20 mL)

+ Up to 30 mL of 0.5% bupivacaine HCl

150 mg total

30mL

Bupivacaine HCl 0.5%

+ Up to 60 mL of 0.25% bupivacaine HCl

150 mg total

60mL

Bupivacaine HCl 0.25%

For early analgesic coverage, administer with bupivacaine HCl• Bupivacaine HCl may be administered immediately before EXPAREL or admixed in the same syringe

• Keep a 1:2 ratio of the milligram dose of bupivacaine HCl to EXPAREL. In determining the ratio, consider — One 20 mL vial of EXPAREL contains 266 mg of free-base bupivacaine, which is molar equivalent to

300 mg of bupivacaine HCl — One 30 mL vial of 0.5% bupivacaine contains 150 mg of bupivacaine HCl

• Admixing may impact the pharmacokinetic/pharmacodynamic properties of EXPAREL; the effect is concentration dependent

Example of admixing

©2019 Pacira BioSciences, Inc.Parsippany, NJ 07054 PP-EX-US-4904 11/19

Please refer to accompanying full Prescribing Information.For more information, please visit www.EXPAREL.com or call 1-855-RX-EXPAREL (793-9727).

References: 1. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66(9):847-848. 2. Afonso AM, Newman MI, Seeley N, et al. Multimodal analgesia in breast surgical procedures: technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg Glob Open. 2017;5(9):e1480. doi:10.1097/GOX.0000000000001480. 3. Blanco R, Barrington MJ. Pectoralis and serratus plane blocks. NYSORA website. http://www.nysora.com/pectoralis-serratus-plane-blocks. Accessed October 29, 2019. 4. Gonzales J. PECS versus PVBS for perioperative analgesic management in breast surgery. American Society of Regional Anesthesia and Pain Medicine website. https://members.asra.com/pain-resource/regional-anesthesia/truncal-blocks/pecs-versus-pvbs-for-perioperative-analgesic-management-in-breast-surgery. Accessed October 29, 2019. 5. Data on fi le. 5903. Parsippany, NJ: Pacira BioSciences, Inc.; October 2019.

Visit www.EXPAREL.com to discover more

IndicationEXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information EXPAREL is contraindicated in obstetrical paracervical block anesthesia.

Adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.

If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.

EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients.

Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPARELAvoid additional use of local anesthetics within 96 hours following administration of EXPAREL.

EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.

The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing ProductsCentral Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.

Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias, sometimes leading to death.

Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.

Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.

Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

6 millionpatients have received non-opioid EXPAREL

since 20125