Heller, L., Kowalski, A.M., Wei, C., & Butler, C.E. (2008). Prospective, randomized, double-blind trial of local anesthetic infusion and intravenous narcotic patient-controlled anesthesia pump for pain management after free TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 122(4), 1010–1018.

To assess the efficacy of continuous infusion pump delivery of bupivacaine at TRAM flap donor site; to assess the safety of continuous infusion pump delivery of bupivacaine at TRAM flap donor site

Patients received 0.375% bupivacaine or isotonic saline through a continuous infusion pump in the suprapubic area and caudal to the donor site incision. All patients received narcotic via PCA programmed for demand-only mode, with no basal rate. Patients could receive oral narcotics. Pain at rest was evaluated four times per day while patients were awake. Overall satisfaction was assessed every four hours for the first three days.

• The sample was composed of 48 patients, 23 in the intervention group and 25 in the control group.
• In the intervention group, mean patient age was 50.3 years; in the control group, 47.6 years.
• All participants were female.
• All participants were undergoing unilateral mastectomy with TRAM flap reconstruction.

• Single site
• Inpatient
• M.D. Anderson Cancer Center, Houston, Texas

Prospective randomized, double-blinded trial

• Amount of PCA narcotic used
• Type and amount of oral narcotic used
• Pain score, on a 10-point visual analog scale (VAS), measured four times daily when patient was at rest
• Patient satisfaction as measured every four hours for three days

• During the first two postoperative days, total PCA use was lower in the continuous infusion group than in the control group. (In both groups, measures of the intensity of abdominal pain at rest reflected significantly lower pain with each postoperative day. Measures were not significantly different between groups.)
• Patient satisfaction was higher in the continuous infusion versus the control group (P = 0.032).

Continuously infused bupivacaine reduced patients' need for PCA opioids early in the postoperative period.

• Pain from the mastectomy site may have been a confounding factor.
• The study had a small sample size, with fewer than 100 patients.
• Limitations may include individual differences regarding pain perception, pain threshold, and the appropriateness of requests for pain medication.

Postoperative mastectomy-TRAM patients may benefit from continuous infusion of anesthetic to an operative site. Ongoing research to determine the most effective dosage and the most effective anesthetics is warranted.