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Concept for postoperative analgesia after pedicled TRAM flaps: continuous wound instillation with 0.2% ropivacaine via multilumen catheters. A report of two cases
Pedicled TRAM flap surgery is a complex procedure characterised by an extensive wound site. We present two patients with efficient postoperative pain relief by continuous wound instillation of ropivacaine 0.2% via two multilumen catheters. The catheters were placed subcutaneously before the wound closure through the umbilicus into the abdominal wound, and under the autologous flap into the breast. Each multilumen catheter provides even distribution for local anaesthetics over 12.5 cm. At the end of surgery, patients received a single shot dose of local anaesthetic via the pain catheters. After surgery the continuous infusion of ropivacaine 0.2% was commenced at a rate of 10 ml/h per catheter. Pain scores at rest and on coughing were low on the first postoperative day, and later zero. No medication for breakthrough pain was required throughout the recovery period, and the patients experienced no adverse events linked to the analgesia scene. Patient satisfaction was excellent, and quality of recovery score was superior.
The transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction has increased in popularity for autologous breast reconstruction because of the perceived superior aesthetic results that can be obtained compared with implant reconstruction.
A review of the literature of the past few years shows that little attention has been given to postoperative pain assessment and management after TRAM flap reconstructions. Available literature suggests that TRAM flaps are very painful procedures, which require approximately 110 mg of IV postoperative patient-controlled morphine over a five day hospital stay.
Recent data report that thoracic epidural analgesia is more effective in pain control after TRAM flaps than IV morphine patient-controlled analgesia (PCA).
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
To our knowledge no data are available on continuous wound instillation of local anaesthetics for postoperative analgesia after TRAM flaps. We present the concept of continuous wound instillation with 0.2% ropivacaine via two multilumen catheters placed in the wound site that provide even distribution of local anaesthetics over a wide area.
1. Case reports
1.1 Patients' demographic data and anaesthesia
Both patients gave their individual informed written consent for the postoperative analgesic regimen and allowed their data to be published. The first patient (ASA II, 42 years old, weight 76 kg, height 172 cm) had breast cancer and underwent a mastectomy, sampling of axillary lymph nodes, and the pedicle TRAM flap reconstruction in one 5-h procedure. The second patient (ASA II, 63 years old, weight 62 kg, height 165 cm) had a family history of breast cancer. She had undergone prophylactical mastectomy years ago and suffered now from capsular fibrosis of her right breast. Her TRAM flap reconstruction took 6 h. Neither patient had cardiopulmonary disease, an allergy history, or routinely used analgesics.
Oral premedication of 7.5 mg midazolam was given 1 h preoperatively. General anaesthesia was induced and maintained with propofol/remifentanil infusions, intubation of the trachea and intraoperative relaxation was provided by administration of mivacurium. Ventilation was controlled artificially, the lungs being ventilated with oxygen in nitrous oxygen.
1.2 Surgical technique and placement of wound drains
The rectus sheath was closed directly in both patients without use of inlay mesh. Contralateral plication of the rectus sheath was performed to minimise fascial resection and to restore symmetry to the umbilicus. Three silicone drains, 12 Ch/4.0 mm (Pfm, Cologne, Germany) were placed into the wound site, one drain over the pectoralis major muscle under the flap, and two drains over the fascial sheath into the abdominal wound (Fig. 1) . The first patient had an additional fourth drain in the axilla. All wound drains were without suction.
Fig. 1Anatomical drawing with schematic description of the placement of the pain catheters and wound drains.
Before wound closure was finished the multilumen catheters (PainBuster Soaker™, Pain Management System, manufactured by I-Flow Corporation, Lake Forest, CA 92630, USA; distributed by Willy Rüsch GmbH, P.O. Box 1180, 71385 Kernen, Germany, (Fig. 2) were placed with the split introducer needles: one catheter was sited subcutaneously into the abdominal wound through the umbilicus, ‘abdominal catheter’,(Fig. 3) . This ‘abdominal catheter’ was placed in a loop over the fascial sheath to reach not only the abdominal wound, but also the intercostal nerves (Fig. 1). The second catheter was placed in a loop over the pectoralis major muscle under the autologous flap, ‘flap catheter’ (Fig. 4) , extending into the axilla in our first patient. The exact position of the catheters is shown in Fig. 1.
Fig. 2Top view of the PainBuster Soaker™ Catheter.
Fig. 4Side view of the draped patient. Placement of the PainBuster Soaker™ Catheter with the split introducer needle under the autologous flap into the reconstructed breast.
Each catheter has a distribution length for local anaesthetics of 12.5 cm. The Soaker Catheter™ (20 GA, 75 cm long, the filter included) is designed to provide even distribution over a wide area.
1.4 Postoperative pain therapy
Twenty minutes before the end of surgery 20 ml 0.2% ropivacaine were administered via the ‘abdominal catheter’ and 10 ml 0.2% ropivacaine via the ‘flap catheter’.
On arrival in the recovery area the continuous wound instillation was commenced. The catheters were connected to two continuous infusion devices (Multifuse®, B. Braun Melsungen, 3508 Melsungen, Germany) and ropivacaine 0.2% 10 ml/h were administered via each catheter. After 48 h of continuous infusion the infusion rate was reduced to 7.5 ml/h 0.2% ropivacaine per catheter.
Wound pain at rest and on coughing was assessed using a 100 mm visual analogue scale (VAS) ranging from 0 (no pain) to 100 (worst pain imaginable) at 4, 16, 24, 32 and 48 h postoperatively. Sedation was evaluated on a 4-point scale (0=no signs of sedation, 1=mild sedation, 2=moderate sedation, 3=severe sedation). The catheters were removed on the fourth postoperative day. The quality of pain treatment was judged by the patients at the fourth postoperative day on a 4-point scale (1=poor, 2=fair, 3=good, 4=excellent), and the quality of recovery score, developed by Myles et al. after general anaesthesia and surgery in adults (Table 1) , was assessed.
Our patients had no need for medication for breakthrough pain throughout the recovery period. The VAS scores at rest were 10–20 mm 4 h and 16 h postoperatively, the VAS scores on coughing were 20–30 mm at the first two assessment points. From the third assessment point onwards the VAS scores at rest and on coughing were 0 mm in both women. The patients reported that mobilisation and attending to personal hygiene had been possible, easy and pain-free. Even after the decrease of the infusion rate to 7.5 ml/h per catheter 0.2% ropivacaine, the patients had VAS scores of 0 mm at rest and on coughing. Mild sedation in both patients was noted at the first examination point. Neither women experienced adverse events like nausea, vomiting or pruritus. No signs of systemic local anaesthetic toxicity were seen. The quality of pain treatment was judged as excellent, and the two patients reached the highest quality of recovery score of 18 points.
Wound drains were removed on the third postoperative day. The abdominal wound drains had each produced 80–100 ml hemorrhagic drainage, the flap drain 50 ml. The fourth drain in our first patient with the lymph node sampling was removed on the fifth postoperative day and had produced 200 ml drainage.
Bowel function returned without pharmacological support. Both patients had bowel function return on the third day. Our patients were discharged home on the seventh postoperative day after an uneventful recovery.
To complete our observations, the clinical impressions of the surgeon (gynaecologist) and the anaesthetist were that the perfusion of the flaps was improved by the local anaesthetic, especially during the first postoperative hours.
3. Discussion
With regard to the increasing population of patients with breast cancer and superior aesthetic results of the TRAM flap, an increase in women undergoing the complex TRAM flap procedure can be expected. The procedure is characterised by an extensive wound site as the breast mound is created from skin and fat between the umbilicus and suprapubic area. The flap, which is based on the rectus abdominis muscle, is brought up in a tunnel under the skin as a pedicle flap.
Several morbidities including severe postoperative pain, respiratory, and cardiovascular complications require an optimal anaesthetic and analgesic management.
Postoperative analgesic regimens like IV opioid PCA and thoracic epidural analgesia are effective techniques after major surgery. It is supposed that IV morphine PCA is an inadequate method of pain control for the level of pain experienced after TRAM flap surgery as some patients are unable to titrate themselves to a comfortable, pain-free level.
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
Besides the risk of severe respiratory depression in 0.4%, the incidence of nausea, whilst on PCA has been estimated to be around 60%, whilst for vomiting, the estimates vary between 30 and 40%.
Moreover, IV opioid PCA is associated with the risk of delayed return of bowel function. Our patients resumed normal bowel function spontaneously on the third and fourth postoperative day. Correll et al. reported on first bowel movements in the IV opioid PCA group on postoperative day 5–6.
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
It was reported recently that patients with thoracic epidurals had pain scores of zero throughout the postoperative recovery period whereas patients with IV PCA had pain scores between 35 on postoperative day one to 15 on postoperative day two.
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
Comparing our pain scores with Corrells' study, the continuous wound instillation with ropivacaine 0.2% in our patients was more effective than IV opioid PCA and from postoperative day one onwards as effective as thoracic epidural analgesia. This is most likely due to the fact that the local anaesthetic is administered directly to the site of surgical trauma. Postoperative pain after pedicled TRAM flaps is often caused by damage of intercostal nerves, irritation of the peritoneum, and by the wound pain caused by the electrical preparation close to the pectoralis major muscle. Because of the placement of our pain catheters the administered ropivacaine reaches directly the site of trauma. As the wound drains are sited in the same anatomical layer as the pain catheters, it is possible that some ropivacaine might have been drained into the wound drains. However, pain therapy was effective and the amount of secretion drained by the wound drains did not exceed normal values.
We present a very simple treatment regimen for postoperative pain control: the continuous wound instillation with ropivacaine 0.2% via multilumen catheters. Ropivacaine is a new long-acting, enantiomerically pure (S-enantiomer) amide local anaesthetic with a high pKa and low lipid solubility which blocks nerve fibres involved in pain transmission to a greater degree than those controlling motor function.
In healthy volunteers, ropivacaine had a significantly higher threshold for CNS toxicity than bupivacaine, with mean maximum tolerated unbound arterial plasma concentrations of 0.56 and 0.3 mg/l, respectively.
The drug undergoes a degree of systemic absorption after intercostal, subclavian perivascular, peribulbar, intraarticular or local administration. However, because ropivacaine is extensively (90–94%) bound to plasma proteins after systemic absorption, Cmax for unbound drug remains well below the threshold for CNS toxicity reported in volunteers (approx. 0.6 mg/l) regardless the route of administration.
Ropivacaine 0.25% and bupivacaine 0.5%, but not 0.125% provide effective wound infiltration analgesia after outpatient hernia repair, but with sustained plasma drug levels.
The clinical experience from 60 studies involving 3000 patients showed that accidental intravascular administration of ropivacaine occurred in six patients. Only one patient convulsed and none showed signs of cardiotoxicity at doses of 75–200 mg. The outcome of all six patients to these reactions was good.
Our patients had no history of hepatic disorder and we took notice of the recommended maximum dose for continuous wound instillation (40 mg/h corresponding to 20 ml/h).
Intermittent injections intraperitoneally of 0.5% ropivacaine following laparoscopic cholecystectomy via a catheter placed in the bed of the gall bladder reduced pain intensity in the first 4 h postoperatively.
To our knowledge no data are available on the continuous administration of ropivacaine for several days via multi-lumen catheters placed in the wound site after complex TRAM flap surgery.
However, our observations suggest that continuous wound instillation with 0.2% ropivacaine should be considered for postoperative pain treatment after TRAM flap surgery. We have been using this concept successfully over the last 8 months and will start a prospective, double-blinded study to determine plasma pharmacokinetics of ropivacaine when administered via continuous wound instillation for several days, and to evaluate if the blood flow of the flap is even improved by 0.2% ropivacaine.
References
Clough C.B.
O'Donoghue J.M.
Fitoussi A.D.
Vlastos G.
Falcou M.C.
Prospective evaluation of late cosmetic results following breast reconstruction: II. TRAM flap reconstruction.
Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction.
Ropivacaine 0.25% and bupivacaine 0.5%, but not 0.125% provide effective wound infiltration analgesia after outpatient hernia repair, but with sustained plasma drug levels.
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