Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction - continuous wound instillation with ropivacaine 0.2%. A pilot study.

Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8h at rest (P=0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P=0.003). No differences were seen in the flap perfusion. Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A does of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.

The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization.

We report three recent cases in which there was intravascular loss of the entire guide wire. In one case, this loss was discovered more than three months after the patient's procedure. In another case, the loss was detected one month later, and in the third case, four days was the interval of the loss. We discuss the problems of human error and failure of diagnosis, both of which were responsible for serious sequelae.

The continuous epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil provides effective postoperative analgesia after total hip replacement: a pilot study.

PURPOSE: To assess the analgesic efficacy and functional outcome of postoperative epidural infusion of ropivacaine combined with sufentanil in a randomized, controlled trial. METHODS: Thirty-two ASA I-III patients undergoing elective total hip replacement (THR) were included. Lumbar epidural block using 0.75% ropivacaine was combined with either propofol sedation or general anesthesia for surgery. On arrival in the recovery room, the epidural infusion was commenced at a rate in mL calculated as follows: (height in cm - 100) x 0.1. Eleven patients received an epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil (Group R+S0.5), ten patients ropivacaine 0.1% with 0.75 microg x mL(-1) sufentanil (Group R+S0.75), and 11 patients ropivacaine 0.1% with 1 microg x mL(-1) sufentanil (Group R+S1) over a postoperative study period of 44 hr. All patients had access to iv piritramide via a patient-controlled analgesia (PCA) device. Postel-Merle-d'Aubigné scoring system (PMA score) was assessed preoperatively, three weeks after surgery, and three months after surgery by an orthopedic surgeon blinded to study group. RESULTS: Motor block was negligible in all three groups. After eight hours of epidural infusion, sensory block had regressed completely in all patients. There was no significant difference with regard to visual analogue scale (VAS) scores (at rest: P = 0.55, on movement: P = 0.63), consumption of rescue medication (P = 0.99), patient satisfaction (P = 0.22), and the incidence of adverse events. All treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. There was no difference between groups regarding orthopedic PMA score (pain: P = 0.24, mobility: P = 0.65, and ability to walk: P = 0.44). CONCLUSION: Ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil for postoperative analgesia after THR provides efficient pain relief and, compared with 0.75 and 1 microg x mL(-1) sufentanil, reduces sufentanil consumption without compromise in patient satisfaction, VAS scores, and functional outcome.