Becker's ASC Review

9 ASC MANAGEMENT • In patients undergoing hemorrhoidectomy, a total of 266 mg (20 mL ) of EXPAREL was diluted with 10 mL of saline, for a total of 30 mL, divided into six 5 mL aliquots, injected by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers to produce a field block. Local Analgesia via Infiltration Dosing in Pediatric Patients The recommended dose of EXPAREL for single-dose infiltration in pediatric patients, aged 6 to less than 17 years, is 4 mg/kg (up to a maximum of 266 mg), and is based upon two studies of pediatric patients undergoing either spine surgery or cardiac surgery. Regional Analgesia via Interscalene Brachial Plexus Nerve Block Dosing in Adults The recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults is 133 mg (10 mL), and is based upon one study of patients undergoing either total shoulder arthroplasty or rotator cuff repair. Compatibility Considerations Admixing EXPAREL with drugs other than bupivacaine HCl prior to administration is not recommended. • Non-bupivacaine based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. • Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. • When a topical antiseptic such as povidone iodine (e.g., Betadine ® ) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution. Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL. Non-Interchangeability with Other Formulations of Bupivacaine Different formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa. Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug's functional properties relative to those of the unencapsulated or nonlipid-associated drug. In addition, different liposomal or lipid-complexed products with a common active ingredient may vary from one another in the chemical composition and physical form of the lipid component. Such differences may affect functional properties of these drug products. Do not substitute. CLINICAL PHARMACOLOGY Pharmacokinetics Administration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours after local infiltration and 120 hours after interscalene brachial plexus nerve block. In general, peripheral nerve blocks have shown systemic plasma levels of bupivacaine for extended duration when compared to local infiltration. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy. PATIENT COUNSELING Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue. Pacira Pharmaceuticals, Inc. San Diego, CA 92121 USA Patent Numbers: 6,132,766 5,891,467 5,766,627 8,182,835 Trademark of Pacira Pharmaceuticals, Inc. For additional information call 1-855-RX-EXPAREL (1-855-793-9727) Rx only March 2021 USPI vs. SCA vs. Surgery Partners: How big 3 stack up By Laura Dyrda The largest ASC chains keep getting bigger, and three of the top com- panies have hundreds of ASCs and thousands of physicians. Here is how they stack up. United Surgical Partners International (Dallas) ASCs and surgical facilities: 430+ Physicians: 11,000+ Employees: 20,000+ Patients served annually: 1.5 million Surgical Care Affiliates (Deerfield, Ill.) ASCs and surgical facilities: 250+ Physicians: 8,500 Employees: 10,000+ Patients served annually: 1 million Surgery Partners (Brentwood, Tenn.) ASCs and surgical facilities: 180+ Physicians: 4,000+ Employees: 7,000+ Patients served annually: 600,000 n Bad news for Optum By Laura Dyrda A mid lingering antitrust issues, Optum's $13 billion acquisition of data analyt- ics firm Change Healthcare is facing more hurdles. Optum owns one of the biggest ASC chains in the U.S., Surgical Care Affiliates, and the company's plans to grow its data capabilities could be in jeopardy aer the Justice Department sued to stop the acquisition. e Justice Department originally considered suing to halt the acquisition last August. e acquisition is opposed by the American Hospital Association. While Change has considered selling assets to close the deal, it hasn't proposed accept- able divestitures to alleviate antitrust issues. Optum's revenue increased 14.1 percent, hitting $155.6 billion in 2021, and the company had an operating margin of 8.3 percent. Optum Insight's revenue back- log increased $2.2 billion to $22.4 billion last year driven by new health system partners, among other factors. OptumHealth served 100 million people last year and boosted revenue per consumer by 33 percent by transitioning cases to value- based payments. Optum plans to bring more than 500,000 new patients into value-based arrangements this year. n

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