S. Kampe a, *, M. Warm b, S.-M. Kasper a, C. Diefenbach a

Transcription

1 The British Association of Plastic Surgeons (2003) 56, Concept for postoperative analgesia after pedicled TRAM flaps: continuous wound instillation with 0.2% ropivacaine via multilumen catheters. A report of two cases S. Kampe a, *, M. Warm b, S.-M. Kasper a, C. Diefenbach a a Department of Anaesthesia, University of Cologne, Jospeh-Stelzmann-Str., Cologne 50931, Germany b Department of Gynaecology and Obstetrics, University of Cologne, Cologne 50924, Germany Received 27 July 2002; accepted 9 May 2003 KEYWORDS Postoperative analgesia; Continuous wound instillation; Multilumen wound catheters; Ropivacaine; TRAM flap Summary 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. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. 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. 1 A review of the literature of the past few years shows that little attention has been given to postoperative pain assessment and management *Corresponding author. Tel.: þ ; fax: þ address: sandra.kampe@medizin.uni-koeln.de 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. 2 Recent data report that thoracic epidural analgesia is more effective in pain control after TRAM flaps than IV morphine patientcontrolled analgesia (PCA). 3 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 S /03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /s (03)

2 Concept for postoperative analgesia after pedicled TRAM flaps 479 via two multilumen catheters placed in the wound site that provide even distribution of local anaesthetics over a wide area. Case reports 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. 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. Placement of the catheters Before wound closure was finished the multilumen catheters (PainBuster Soakere, Pain Management System, manufactured by I-Flow Corporation, Lake Forest, CA 92630, USA; distributed by Willy Rüsch GmbH, P.O. Box 1180, 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. Each catheter has a distribution length for local anaesthetics of 12.5 cm. The Soaker Cathetere (20 GA, 75 cm long, the filter included) is designed to provide even distribution over a wide area. 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 w, 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 ¼ no signs of sedation, 1 ¼ mild sedation, 2 ¼ moderate sedation, 3 ¼ 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 ¼ poor, 2 ¼ fair, 3 ¼ good, 4 ¼ excellent), and the quality of recovery score, developed by Myles et al. after general anaesthesia and surgery in adults (Table 1), was assessed. 4 Results Our patients had no need for medication for breakthrough pain throughout the recovery period. The VAS scores at rest were mm 4 h and 16 h postoperatively, the VAS scores on coughing were

3 480 Fig. 1 S. Kampe et al. Anatomical drawing with schematic description of the placement of the pain catheters and wound drains 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 Fig. 2 Top view of the PainBuster Soakere Catheter. Fig. 3 Side view of the draped patient. Placement of the PainBuster Soakere Catheter subcutaneously into the abdominal wound through the umbilicus.

4 Concept for postoperative analgesia after pedicled TRAM flaps 481 Discussion Fig. 4 Side view of the draped patient. Placement of the PainBuster Soakere Catheter with the split introducer needle under the autologous flap into the reconstructed breast. 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 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. 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. 5,6 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. 3 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%. 7 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 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 Table 1 The quality of recovery score (QoR) from Myles et al. (Anesthesia and Analgesia 1999; 88: p. 86) Not at all Some of the time Most of the time 1. Had a feeling of general well-being Had support from others (especially doctors and nurses) Been able to understand instructions and advice. Not being confused 4. Been able to look after personal toilet and hygiene unaided Been able to pass urine ( waterworks ) and having no trouble with bowel function 6. Been able to breathe easily Been free from headache, backache or muscle pain Been free from nausea, dry-retching or vomiting Been free from experiencing severe pain, or constant moderate pain Summary score: 0 18.

5 482 S. Kampe et al. on postoperative day one to 15 on postoperative day two. 3 Although thoracic epidural analgesia has been shown to be more effective in reducing pain in patients after TRAM flap procedures than opioid PCA, 3 the potential of neurologic complications is a well-known risk of thoracic epidurals. 8 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 pk a and low lipid solubility which blocks nerve fibres involved in pain transmission to a greater degree than those controlling motor function. 9 Ropivacaine appears to be less toxic than equal concentrations of racemic bupivacaine because of its faster dissociation from cardiac Na þ channels. 10 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. 11 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, C max 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 undergoes extensive hepatic metabolism after IV administration, with only 1% of the drug eliminated unchanged in the urine. 16 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 mg. The outcome of all six patients to these reactions was good. 16 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). 17 We, therefore, felt it to be very unlikely that cardiovascular or CNS side effects would occur in our patients. Single dose wound infiltration with local anaesthetics is an established technique for pain relief after inguinal herniotomy. 18 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. 19 To our knowledge no data are available on the continuous administration of ropivacaine for several days via multilumen 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 1. Clough CB, O Donoghue JM, Fitoussi AD, Vlastos G, Falcou MC. Prospective evaluation of late cosmetic results following breast reconstruction: II. TRAM flap reconstruction. Plast Reconstr Surg 2001;107(7): Kroll SS, Sharma S, Koutz C, et al. Postoperative morphine requirements of free TRAM and DIEP flaps. Plast Reconstr Surg 2001;107(2): Correll DJ, Viscusi ER, Grunwald Z, Moore JH. Epidural analgesia compared with intravenous morphine patientcontrolled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med 2001;26(5): Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999; 88: Elliot LF, Eskenazi L, Beegle Jr. PH, Podres PE, Drazan L. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg 1993;92: Hwang TG, Wilkins EG, Lowery JC, Gentile J. Implementation and evaluation of a clinical pathway for TRAM breast reconstruction. Plast Reconstr Surg 2000;105: Park G, Fulton B, Senthuran S. The management of acute pain, 2nd ed. New York: Oxford University Press; 2000.

6 Concept for postoperative analgesia after pedicled TRAM flaps Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization. Anesthesiology 1997;86: Rosenberg PH, Heinonen E. Differntial sensitivity of A and C nerve fibres to long-acting local anaesthetics. Br J Anaesth 1983;55: Cuignet O, Dony P, Gautier P, et al. Comparative toxicity of ropivacaine and bupivacaine ar equipotent dose in rats. Eur J Anaesthesiol 2000;19(Suppl.):A Knudson K, Beckman SM, Blomberg S. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997; 78: Kopacz DJ, Emanuelsson BM, Thompson GE, et al. Pharmacokinetics of ropivacaine and bupivaacaine for bilateral intercostals blockade in healthy male volunteers. Anesthesiology 1994;81(5): Hickey R, Blanchard J, Hoffman J, et al. Plasma concentrations of ropivacaine given with or without epinephrine for brachial plexus block. Can J Anesth 1990;37(8): Mulroy MF, Burgess FW, Emanuelsson BM. 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. Reg Anesth Pain Med 1999;24: Horn EP, Schroeder F, Wilhelm S, et al. Wound infiltration and drain lavage with ropivacine after major shoulder surgery. Anesth Analg 1999;89: McClellan K, Faulds D. Ropivacaine. An update of its use in regional anaesthesia. Drugs 2000;60(5): AstraZeneca. Ropivacine global prescribing information. Available from: URL: Erichsen CJ, Vibits H, Dahl JB, Kehlet H. Wound infiltration with ropivacaine and bupivacaine for pain after inguinal herniotomy. Acta Anaesthesiol Scand 1995;39: Gupta A, Thörn SE, Axelsson K, et al. Postoeprative pain relief using intermittent injections of 0.5% ropivacaine following laparoscopic cholecystectomy. Reg Anesth Pain Med 2002;26(2):126.