Use a continuous-infusion anesthetic pump to manage patients’ pain during recovery from abdominoplasty

Postoperative pain is a primary concern for all patients who undergo aesthetic plastic surgery. Even though this surgery is elective, and patients may be willing to endure the recovery to achieve the results they desire, limiting their postoperative pain is—or should be—a key goal for the surgeon.

Of all of the procedures in the aesthetic surgeon’s repertoire, abdominoplasty is often one of the more anxiety-provoking because of the difficulty of the recovery. Over the past year, I have incorporated continuous-infusion “pain pumps” into my abdominoplasties and have found them to be invaluable for the postoperative recovery of my patients.

Technique

The pain pump consists of one or two catheters and a pumping device that delivers a local anesthetic. When the pump is filled with the anesthetic, the tension in the pump material increases. As the tension dissipates gradually, the anesthetic is infused continuously at an even rate.

Several companies manufacture these continuous-infusion systems. Whereas all systems maintain a basal rate, some of them also allow a bolus to be infused. With the ability to bolus a local anesthetic, the patient can control the pain should he or she experience excessive discomfort. A lockout that prevents patients from rebolusing within a prescribed period of time negates the risk of overdosing.

The surgery proceeds as usual, and after the skin is elevated away from the anterior rectus fascia and the excess lower abdominal skin is resected, a tunneling sheath and introducer are placed in the midline (Figure 1). The rectus diastasis is plicated over the tunneling catheter above and below the umbilicus.

The catheters are introduced through the skin and into the abdominal wound. They are placed next to each other on the lateral aspect of the wound to make them easy to manage and distant from the midline site where the drains are placed. The tips of the catheters are then threaded through the tunneling sheath (Figure 2), and the tunneling sheath is removed (Figure 3).

The catheters are primed and bolused with 10 mL each of 0.375% bupivicaine,  connected to the pain pump, and secured to the skin at the entrance site with ad­hesive tapes. The ex­cess catheter length is coiled and placed under an occlusive dressing. Drains are placed and a traditional closure of the incision is performed, with care taken not to catch the catheters or drains during the closure.

A 270-mL pain-pump reservoir is intentionally overfilled with 300 mL of anesthetic. Each catheter infuses at a rate of 2 mL/hour, for a total of 4 mL of 0.375% bupivicaine infused per hour. The anesthetic in the pain pump lasts for a little more than 3 days. At the end of the infusion, the bulb is flat and obviously empty. The patient is given written instructions for how to remove the catheters, and to date every patient has successfully removed the catheters at home.

Many systems are available that permit longer or shorter infusion durations and a range of basal-infusion rates. Ultimately, it is up to the individual practitioner to determine the specific system to be used.

Observations

During my initial use of the continuous-infusion pain pumps, I was not connecting the catheters to the pain pump until after the closure had been completed. Patients would then awaken from anesthesia with discomfort that would abate after about 1 hour. As a result, I began bolusing and connecting the pain pump immediately after placing the catheter, and I have since noticed significant improvement in patient comfort.

While in recovery, patients are comfortable and can easily shift themselves in the gurney. Most patients are able to ambulate to the restroom prior to discharge. Because of the decreased pain and discomfort, I can discharge patients to home sooner, increasing the efficiency of the operating facility.

In the days immediately following surgery, patients state that they can ambulate with greater ease. Those who have had previous caesarean deliveries indicate that there is less pain associated with the abdominoplasty as a result of the pain-pump placement. A typical comment from patients is, “I wish I had had one of these after my C-section.”

Benefits Beyond Pain Relief

Whereas diminished pain is an obvious benefit of the continuous-infusion pain pump, secondary benefits must be acknowledged as well. With greater local pain relief, the need for oral narcotics is diminished. This leads to a de­creased risk of constipation, which can be difficult for the pa­tients who are afraid to bear down during the immediate postoperative period because of the pain this generates.

Decreased pain also enables the patient to ambulate with greater ease and therefore with greater frequency. Ambulation decreases the risk of pulmonary embolus. The diminished pain permits the patient to take deeper breaths, which helps to clear the postoperative atelectasis, a common cause of postoperative fevers and a contributor to postoperative pneumonia.

In casual conversation with other aesthetic surgeons, I have found that some offer the pain pumps as an “extra,” charging an additional fee for the device and its placement. But I have found that the device alleviates a significant portion of the postoperative pain, so I have elected to simply incorporate the cost of the pump into our pricing scheme. The increase in price has not affected patients’ decisions to book surgery, and abdominoplasty remains one of the more popular procedures that I perform.

Last Thoughts

Patients who have used the pain pump have been extremely satisfied. This satisfaction results in a positive experience that they share with their friends. Alleviating fears of pain is always good for a plastic surgery practice.

To paraphrase a well-known commercial, “I’m not only the president of the company, I am also one its members.” After my own recent caesarean delivery, I had a continuous pain pump placed. The morning afterward, I was ambulating with minimal difficulty, and I was able to host a welcome party for my son 3 nights after his birth! PSP

Linda Li, MD, FACS, is a plastic surgeon in private practice at Aesthetic Perfection Plastic and Reconstructive Surgery in Beverly Hills, Calif. She can be reached at [email protected]