Lexington, Ky. — A pain pump for controlled delivery of the long-acting local anesthetic bupivicaine directly into the surgical wound site appears to be a reasonably safe and effective method for managing pain after cosmetic or reconstructive surgical procedures.
"Existing data are favorable, but there remains a need for prospective, randomized, double-blind studies to evaluate the efficacy and safety of the pain pump for optimizing pain management after plastic surgery procedures," Dr. Pu notes.Dr. Pu, associate professor of surgery, division of plastic surgery, University of Kentucky, Lexington, is the author of a safety and efficacy report, "The Use of a Pain Pump for Optimal Postoperative Pain Management," published recently in Plastic and Reconstructive Surgery (Plast Reconstr Surg 2006;117:2066-2069). He conducted a literature review of this topic as a member of the Plastic Surgery Educational Foundation DATA Committee. Prior to publication, his paper underwent rigorous review by other members of that committee and subsequently by the American Society of Plastic Surgeons' Executive Committee and the peer-reviewers of the journal.
Continuous infusion of bupivicaine postoperatively is intended to provide ongoing preemptive analgesia by blocking the establishment of central sensitization from painful stimuli, and the resultant amplification of postoperative pain.
It typically involves continuous infusion of 0.25 percent bupivicaine with or without epinephrine delivered at a rate of 2 cc per hour per surgical site for a 48-hour postoperative period.
"The recommended maximum dose of bupivicaine is 400 mg per 24 hours, and so this protocol administers a dose that is well below the threshold for safety," Dr. Pu says.
The longest standing experience with use of a pain pump postoperatively is in orthopedic surgery, and there have been several published studies evaluating it in patients who have undergone a variety of orthopedic procedures. There have also been several randomized, controlled studies evaluating use of a pain pump after inguinal hernia repair and in cardiothoracic procedures. In addition, gynecologists have been using the pain pump to improve patient comfort after delivery by Caesarean section.
"Overall, the results of the studies from these different surgical specialties demonstrate statistically and clinically significant benefits of the pain pump in a variety of endpoints, including reduction of pain scores, lessening of narcotic use and associated adverse events, improved pulmonary function, and greater patient satisfaction relative to placebo-treated controls," Dr. Pu notes.
Moving from anecdote to proof
Anecdotally, pain pumps have been used by cosmetic and reconstructive surgeons as a method for controlling postoperative pain after certain procedures.
However, there are few published studies in the plastic surgery literature on this modality and none with a prospective, randomized, double-blind, placebo-controlled design, Dr. Pu says.
The available papers describe use of pain pumps in patients who had undergone augmentation mammaplasty, abdominoplasty and breast reconstruction. Based on comparisons with historical controls, the authors of those reports concluded the pain pump was effective and had benefits, which included decreased use of oral/intravenous pain medications, lower pain scores and enabling earlier ambulation. In addition, those papers indicated favorable safety, with no reports of catheter- or pain pump-related complications. However, experience in other studies indicates the potential for some problems to occur.
"Safety of the pain pump seems acceptable overall. However, the catheter may kink, clog or leak, and there is also a question whether the infused fluid can accumulate and increase the risk of seroma," Dr. Pu says.
There is also an economics issue to consider as use of a pain pump may add several hundred dollars to the cost of the procedure.