Introduction

Delivery of local anesthetic solutions through percutanoeus catheters is currently used to relieve operative site pain following free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Disposable, portable infusion pumps allow continuous delivery of local anesthetics through the catheters. The outcomes of this strategy have not been directly compared with traditional narcotic analgesia for flap donor sites. Therefore, the purpose of this study was to prospectively evaluate the efficacy of local anesthesia infusion pumps for postoperative TRAM donor site pain management.

Materials and Methods

Patients undergoing unilateral free TRAM breast reconstruction over an 8-month period at a major cancer center were included in the study. All patients had two percutaneous local anesthetic delivery catheters placed in the TRAM donor site: one above and one below the fascial closure. Patients received a 20 ml bolus followed by a 4 ml/h infusion solution delivered with an elastomeric bulb pump (On-Q, I-flow Corp., Lake Forest, CA) for 5 days. Patients were randomized to receive either 0.375% bupivacaine solution (study group) or isotonic saline solution (control group). Patients, nurses, and physicians were blinded to the type of solution infused. All patients received PRN-only intravenous narcotic through a patient controlled anesthesia pump. Pain intensity and satisfaction scores (range, 0-4), side effects of narcotic and local analgesics, and objective milestones of postoperative recovery were assessed with a written patient questionnaire that was administered 4 times per day during hospitalization. The quantity of narcotics used and surgical/anesthetic complications were evaluated by the healthcare team. Results of study and control patients were compared.

Results

There were no anesthetic- or catheter/pump-related complications in any of the 23 study or 25 control patients. Total narcotic use (IV and oral) during hospitalization was 75.6 mg and 102.9 mg for study and control patients, respectively. Study patients used less IV narcotics (45.6 vs. 85.6 mg, p=0.04) on the first postoperative day and transitioned to oral narcotics sooner than control patients. The mean pain satisfaction score was higher in the study group (3.7) than in the control group (3.3) (p=0.03). There were no differences in overall pain intensity scores, length of hospitalization, incidence of anesthetic side effects, or milestones of surgical recovery.

Conclusion

Continuous infiltration of local anesthetic with percutaneous catheters and a portable infusion pump resulted in greater patient satisfaction with donor site pain management than narcotics alone, without increased complications. This strategy should be considered for postoperative pain management in surgical flap reconstructive procedures.