Multilumen Catheters Research Articles

Selection of the vascular catheter: can it minimise the risk of infection?

Data regarding the prevention of catheter-related bloodstream infection (CRBSI) by making the correct decisions about when to place a central line, the appropriate selection of catheter composition and the size and number of lumens, a suitable choice of insertion site and the technique used are not well reported in recent medical literature. There is no clear evidence that the composition of the catheters presently on the market makes a significant difference to the risk of infection. Several prospective studies suggest that femoral vein location represents the highest risk of infection, followed by jugular vein and subclavian vein positioning, however, most articles do not correct for basic confounding variables. Several papers have reported that arterial catheters have a similar risk of infection as central venous catheters (CVCs). The slight increase in infection risk when using multi-lumen catheters is probably offset by their improved convenience. Current evidence does not support routine tunnelling of short-term catheters until its efficacy is evaluated at different placement sites, using specific catheters and situations and in relation to other preventive interventions. Cuffing is usually applied only to long-term tunnelled catheters. The available evidence suggests that chlorhexidine–silver sulfadiazine, minocycline–rifampicin CVCs and antifungal-coated catheters are useful in decreasing the incidence of CRBSI when other measures are not effective.

Polyscope: A New Era in Flexible Ureterorenoscopy

Despite improvements in instrumentation and technology in flexible ureteroscopy, the issue of procedural and off-procedural damage remains a problem. The aim of our study was to highlight our initial experience in flexible ureteroscopy using polyscope, a new advancement in the era of flexible ureterorenoscopy. In this study, we used an 8F modular flexible, steerable polyscope for diagnostic purposes and Dormia basket removal for small renal stones. Three outer disposable catheters were used with proper sterilization in 22 cases. The polyscope was used in six cases of undiagnosed hematuria, and biopsy was taken from pelvic growth in one patient, which turned out to be transitional-cell carcinoma. Polyscope was used for removal of residual stones or small stones (< 1 cm) using Dormia basket in 16 cases (from August 2008 to July 2009). The mean stone size was 7.5 mm. The vision achieved was excellent in all the cases. Minimally invasive techniques are preferred for treatment of renal stones. The problem of lower caliceal stone access has been solved with the primary and secondary deflection of modern flexible ureteroscopes. The modular design of polyscope makes it a more cost-effective option. Relatively cheap and disposable multilumen catheters preclude the need for sterilization of optic cable, thus decreasing the chances of handling-related damages. The chance of instrument-related infection is minimal. Besides, it can be used as a semirigid ureteroscope should the need arises.

Pressure-created communication between lumens of a multilumen venous catheter

To describe the inadvertent creation of a connection between lumens of a multilumen catheter by use of an in-line intravenous hand pressure pump. Case report. Operating theater. All lumens of a 4F triple lumen catheter were verified patent by irrigation with saline before insertion into an internal jugular vein of an 18-mo-old child undergoing cardiac surgery. During surgery, the flushing of saline into one lumen of the catheter by means of an in-line hand pressure pump caused registration of >300 mm Hg pressure recorded from another lumen. The connections to these two lumens were then reversed. Repeated flushing also caused registration of pressure >300 mm Hg. On removal of the catheter at the end of surgery, flushing of one lumen caused fluid to emerge from the wrong exit hole as the appropriate exit hole was blocked with blood clot. None. Pressure measurement in intravenous catheter lumens. Greater than 300 mm Hg was recorded during flushing with an inline hand pressure pump. High pressure created by use of an in-line intravenous hand pressure pump may cause creation of a communication between lumens of multilumen catheters.

Standardization of infusion solutions to reduce the risk of incompatibility

Although critically ill patients usually have various central intravenous (i.v.) lines, numerous drugs have to be infused simultaneously through the same lines. This can result in potentially harmful in-line incompatibility that can cause decreased drug effectiveness or increased microparticle load. To minimize the risk of these medication errors at an anesthesia intensive care unit (ICU), the preparation and administration of continuously infused drugs were standardized and the practicability in daily clinical routine was evaluated. The concentration and diluent of continuously administered i.v. drugs were standardized. The drugs were grouped according to pH, medical indication, and chemical structure. The ICU staff decided to use multilumen central venous catheters, and each group of drugs was assigned to one lumen. Only drugs that belonged to the same group were infused simultaneously through the same lumen; therefore, intragroup incompatibilities had to be excluded before establishing the new drug administration plan at the ICU. The visual compatibility of 115 clinically reasonable intragroup drug mixtures was investigated. All drug combinations were compatible for six hours except mixtures containing thiopental, which was reassigned to a single-line use. In the following year, the practicability of this drug administration plan was evaluated. No deviations were found in the compliance of the staff prescribing and preparing only standardized concentrations and diluents. Further research to investigate the chemical compatibility of the drugs in these multiple mixtures will follow. A project intended to avoid incompatibility among i.v. drugs infused in the intensive care setting included steps to standardize solutions and determine which could be given together.

Tyrosine: A Possible Marker of Severe Intestinal Injury During Ischemia

Long periods of ischemia can cause organ injury and dysfunction. The protein degradation occurring in the muscular layer and in the mucosa of the intestinal wall during ischemia may release amino acids into the intestinal lumen or into the circulation. The small intestine, like skeletal muscle, cannot synthesize or degrade tyrosine. Thus, the tyrosine concentration released from the gut mucosa reflects the balance between protein synthesis and degradation. We aimed to determine whether tyrosine can be used as a marker of intestinal injury during ischemia. In 19 anesthetized rabbits, an ultrasonic flow probe was placed around the superior mesenteric artery to estimate blood flow. A segment from the ileum was isolated using two multilumen catheters with inflated balloons to create a closed segment for perfusion. Animals were allocated into three groups: a sham group without intervention (group I); a group submitted to superior mesenteric artery ligation only (group II); and a group submitted to 1 h of SMA clamping followed by 1 h of reperfusion (group III). Concentrations of lactate and tyrosine (fluorometry) were determined in the serum and the gut luminal perfusate. Gut luminal perfusate tyrosine concentrations increased significantly in group II (from 10 +/- 8 to 93 +/- 63 mm/mL at 2 h) and were significantly higher than in group I (26 +/- 24 mm/mL) and group III (11 +/- 13 mm/mL) (P < 0.05 for all). Tyrosine is released from cells into the lumen during severe intestinal ischemia. Regional measurements of tyrosine levels may be a useful indicator of severe intestinal villus compromise.

A Prospective Comparison of Continuous Wound Infiltration with Ropivacaine Versus Single-Injection Paravertebral Block After Modified Radical Mastectomy

The efficacy of continuous wound infiltration with local anesthetic has not been compared with that of thoracic paravertebral block (PVB) after breast surgery. In this study, we evaluated the analgesic efficacy and morphine consumption of the two techniques after mastectomy. Forty-eight patients undergoing modified radical mastectomy with axillary dissection were randomly assigned to either a preoperative PVB with 20 mL of ropivacaine 0.5% (group PVB) or a continuous ropivacaine 0.5% infusion (CRI) at a 2 mL/h rate for each of two multilumen catheters placed subcutaneously at the end of the procedure (group CRI). The catheters were left in place for 24 h postoperatively. A standardized general anesthetic was administered to all patients. Postoperative morphine consumption, pain scores and painful restricted movement of the shoulder for 24 h postoperatively as well as incidence of adverse events, including postoperative nausea and vomiting, were recorded. Morphine consumption was similar between groups (PVB: 42.6 +/- 11 vs CRI: 38.7 +/- 11 mg in 24 h, P = 0.225). Absolute pain scores were low in both groups. Four hours after surgery, group PVB showed a significant reduction in postoperative pain (PVB: 0 [0-10] vs CRI: 0 [0-30], P = 0.002) and reduced painful restricted movement (P = 0.004), whereas the CRI group had lower pain scores (PVB: 10 [0-30] vs CRI: 0 [0-20], P = 0.034) and painful restricted movement (P = 0.043) 16 and 24 h (PVB: 10 [0-30] vs CRI: 0 [0-30], P = 0.012) after surgery. Postoperative nausea and vomiting was significantly more frequent in the CRI group (P = 0.017). Continuous wound infiltration of local anesthetics is an effective alternative to paravertebral analgesia after mastectomy with axillary dissection.

Comparison of oligon central venous catheters with standard multilumen central venous catheters in cardiac surgery ICU patients

Catheter-related infections account for a large part of all nosocomial infections, and clinical studies have suggested that impregnation of catheters with antiseptics or antibiotics could decrease the rates of colonization. The purpose of this study was to assess the efficacy of oligon catheters to reduce bacterial colonization.

Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients*

To evaluate a new silver-impregnated multi-lumen central venous catheter for reducing catheter-related colonization in intensive care patients. Multicenter, prospective, randomized, controlled clinical study. Ten adult intensive care units (multidisciplinary, medical and surgical, university and nonuniversity hospitals) in eight institutions. A total of 577 patients who required 617 multi-lumen central venous catheters between November 2002 and April 2004 were studied. Intensive care adult patients requiring multi-lumen central venous catheters expected to remain in place for >or=3 days were randomly assigned to undergo insertion of silver-impregnated catheters (silver group) or standard catheters (standard group). Catheter colonization was defined as the growth of >or=1,000 colony-forming units in culture of the intravascular tip of the catheter by the vortexing method. Diagnosis of catheter-related infection was performed by an independent and blinded expert committee. A total of 320 catheters were studied in the silver group and 297 in the standard group. Characteristics of the patients, insertion site, duration of catheterization (median, 11 vs. 10 days), and other risk factors for infection were similar in the two groups. Colonization of the catheter occurred in 47 (14.7%) vs. 36 (12.1%) catheters in the silver and the standard groups (p = .35), for an incidence of 11.2 and 9.4 per 1,000 catheter days, respectively. Catheter-related bloodstream infection was recorded in eight (2.5%) vs. eight (2.7%) catheters in the silver and the standard groups (p = .88), for an incidence of 1.9 and 2.1 per 1,000 catheter days, respectively. The use of silver-impregnated multi-lumen catheters in adult intensive care patients is not associated with a lower rate of colonization than the use of standard multi-lumen catheters.

Influence of infusion flow rates on central venous pressure measurements through multi-lumen central venous catheters in intensive care

To study the influence on central venous pressure (CVP), measured at the distal port, of crystalloid infusions administered through the proximal port(s) of a central venous multi-lumen catheter. Thirty-one intensive care patients. CVP was measured at the distal port of a multi-lumen catheter inserted in the subclavian or internal jugular vein. Using the proximal port(s), saline (0.9%) was infused at rates varying from 2 ml/h to 14,340 ml/h. CVP measured before the infusion and during infusion (after 30 s to 1 min) were not significantly different. Positive pressure ventilation with PEEP (5.6 +/- 2.5 cmH(2)O) and/or norepinephrine infusion (0.25 +/- 0.21 microg kg(-1) min(-1)) did not produce any significant change in CVP during infusion. The administration of crystalloids at different flow rates through the proximal port(s) of a multi-lumen catheter placed in the superior vena cava does not affect CVP measurement at the distal port, even in mechanically ventilated patients or patients receiving vasopressors.

Complications and survival of multilumen central venous catheters used for total parenteral nutrition.

In a prospective study of 879 triple-lumen catheters, 219 pulmonary artery catheters, 31 double-lumen and six single-lumen catheters used for the administration of total parenteral nutrition over a 1-year period, the overall complication rate was 12.5 per cent (14.7 complications per 1000 catheter-days) and the catheter-related sepsis rate 4.4 per cent (5.2 per 1000 catheter-days). The probability of development of catheter-related sepsis did not increase with the duration of catheterization. There were no differences in the rate of complications associated with 427 catheters changed by replacement at a new site compared with 159 lines changed over a guidewire. These data support the use of multilumen central venous catheters for the administration of total parenteral nutrition. They suggest that a routine weekly change of line is unnecessary; catheters should be changed only on the development of a complication. When it is required, a catheter should be changed by replacement over a guidewire.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism

Venous thromboembolism comprises deep vein thrombosis (DVT) and pulmonary embolism (PE) and strikes more than 1 in 1000 adults per year, causing discomfort, suffering, and occasionally death. DVT is defined as blood clots in the pelvic, leg, or major upper-extremity veins. These clots can break off from the veins, travel through the heart, and lodge in the lung arteries, causing potentially deadly PE. Although about 300 000 new cases are diagnosed yearly in the United States, probably 3 to 4 times as many cases occur without obvious symptoms and are never detected. This illness is often “silent” and can mimic other common conditions such as heart attack, pneumonia, and anxiety. Its aftermath spans a wide spectrum, from inconsequential to fatal. Awareness of DVT and PE is the best way to prevent this condition. Medical professionals have recognized DVT for almost 2 centuries, but until recently, only about half of Americans were informed about the disease. Without knowledge of DVT as a medical problem, the public could not engage healthcare providers to discuss lifestyle changes and more intensive measures that usually succeed in preventing this illness. Historically, many prominent public figures have been afflicted with DVT but received little attention. However, …

Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.

Factors influencing early failure of central venous catheters in children with cancer

Background The authors report the results of a prospective, multicenter, multidisciplinary study of central venous catheters (CVCs) in pediatric oncology patients analyzing factors involved in early failure. Methods Information was collected from parent-held records on the fate of 824 devices inserted over a 20-month period, 415 of which were no longer in situ. Results Within the first 7 weeks after insertion, there were 66 failures, all occurring in external lines. Accidental dislodgement was the principal reason for CVC failure (44 of 66, 67%). Detailed analysis of the reason for failure of this large subgroup showed 11 factors individually associated with early dislodgement, of which, 4 were independently associated with failure by multivariate analysis. These 4 variables were the use of multilumen catheters, the absence of a skin exit site suture, platelet transfusion at the time of insertion, and patient age less than 2 years. Conclusions This study confirms the multiple influences on successful CVC usage. Our analysis supports the principle of only using multilumen lines when clinically essential. The findings also support the inception of randomized studies of fixation, particularly in infants.

Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial

Objective The aim of this study was to assess the efficacy of a disinfectable, needle-free connector in the prophylaxis of catheter-related bloodstream infection. Methods A randomized controlled trial was performed in a polyvalent intensive care unit. Patients who needed multilumen central venous catheters were randomly assigned to a study or a control group. All catheters were inserted and manipulated according to the Centers for Disease Control and Prevention (CDC) recommendations. Study group patients were equipped with catheters with disinfectable, needle-free connectors whereas control group patients were equipped with catheters with 3-way stopcocks. Two peripheral blood cultures and a semiquantitative culture of the catheter tip were performed on removal of the catheter. Results The study included 243 patients, with a total of 278 central venous catheters. The catheters' mean insertion duration was 9.9 days. Both groups were comparable regarding patient and catheter characteristics. Incidence rate of catheter-related bloodstream infection was 0.7 per 1000 days of catheter use in the study group, compared with 5.0 per 1000 days of catheter use in the control group ( P = .03). Conclusions To add a disinfectable, needle-free connector to the CDC recommendations reduces the incidence of catheter-related bloodstream infection in critically ill patients with central venous catheters.

Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: a quantitative systematic review.

There is a controversy as to whether the number of lumens in the central venous catheters may impact the incidence of catheter-related bloodstream infection. We performed a systematic search (MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies, any language, to April, 2003) for full reports on randomized comparisons of single-lumen and multi-lumen catheters. Trials had to report on dichotomous data of catheter colonization or bloodstream infection. Meta-analyses were performed using a fixed effect model. Data were expressed as odds ratio (OR) and number-needed-to-treat (NNT) with 95% confidence interval (CI). Five randomized trials (1987-1995) with data on 255 single-lumen and 275 multi-lumen catheters were analyzed. Average insertion times were 8 to 21 days with multi-lumen catheters and 9 to 24 days with single-lumen catheters. In 4 trials, 23 of 176 (13.1%) multi-lumen and 26 of 177 (14.7%) single-lumen catheters were colonized (OR, 0.92; 95% CI, 0.49-1.72). In 5 trials, bloodstream infection occurred with 23 of 275 (8.4%) multi-lumen and with 8 of 255 (3.1%) single-lumen catheters (OR, 2.58; 95% CI, 1.24-5.37; NNT, 19; 95% CI, 11-75). For every 20 single-lumen catheters inserted, one bloodstream infection will be avoided that would have occurred had multi-lumen catheters been used. The risk of catheter colonization is not decreased. Although these conclusions are based on limited data, single-lumen catheters should be used whenever feasible.

Central venous catheter—related blood stream infections: incidence, risk factors, outcome, and associated pathogens

Objective: To determine the incidence, risk factors, outcome, and pathogens of central venous catheter—related bloodstream infections (CVC-BSIs). Design: Prospective study. Setting: Escorts Heart Institute and Research Centre, New Delhi, India. Participants: One thousand three hundred fourteen consecutive patients undergoing cardiac operations who were admitted to the intensive care unit with CVC. Interventions: All patients were assigned into CVC-BSI (n = 35) and non—CVC-BSI (n = 1,279) groups. Measurement and main results: Of the 1,314 patients in the study, 35 (2.6%) had CVC-BSI. On univariate analysis, significant risk factors were use of multilumen catheters, coexistent infections, intra-aortic balloon counterpulsation (IABC), total ventilation hours, emergency surgery, acute physiology, age, chronic health evaluation score (APACHE II), and steroids. On multivariate analysis, duration of catheterization (24.5 ± 10.9 v 6.1 ± 3.2; p < 0.001), coexistent infections (57.11% v 2.61%; p < 0.001), IABC (77.1% v 4.1%; p = 0.005), and temperature (38.2 ± 0.6 v 37.4 ± 0.3; p < 0.001) were independent predictors of CVC-BSI. Pathogens isolated were Escherichia coli (47%), Acinetobacter species (11.7%), Enterobacter species (5.8%), Proteus species (5.8%), methicillin-resistant Staphylococcus species (11.7%), coagulase-negative Staphylococcus species (5.8%), and Candida (11.7%). The mortality rate in CVC-BSI was 22.9% as compared with 0.2% in non—CVC-BSI cases ( p < 0.001). Conclusion: By univariate analysis, the risk factors for CVC-BSI were use of multilumen catheters, duration of catheterization, total ventilation hours, IABC, emergency surgery, APACHE II score, coexistent infections, and steroids. On multivariate analysis, duration of catheterization, IABC, coexistent infections, and temperature were independent predictors of CVC-BSI. The mortality was increased with CVC-BSI.

Antimicrobial/Anti-infective Catheters: Comparison of BSI Rates in a Community Hospital

BACKGROUND: Missouri Baptist Medical Center is a 499-bed community hospital with 30 ICU beds and approximately 92,281 patient days per year. Primary bloodstream infection (BSI) rates are monitored in the intensive care unit (ICU) and range from 3.09/1000 to 16.19/1000 central line days (CLD). In 2001 a study was initiated to compare BSI rates among patients with anti-infective (chlorhexidine- and silver-sulfadiazine-coated) catheters versus those with anti-microbial (minocycline and rifampin)-coated catheters. METHODS: The quasi-experimental study included patients from ICU and general patient-care areas (PCA) with multi-lumen catheters. Anti-infective catheters were used during the Phase I of the study from January through June, and anti-microbial catheters were used during the Phase II of the study from July through December. Patients excluded from the study were those with 1 and 4 lumens, those with dialysis catheters, and those with catheters placed by guidewire exchange. BSI rates, line duration, and time to infection were compared by univariate analysis to determine if implementation of antimicrobial catheters decreased infection rates. RESULTS: During the study period, 27 patients developed BSI. Fifteen of the 27 cases were excluded from the study. The BSI rate for the entire study period was 4.79/1000 CLD. BSI rate for Phase I was 4.81, and 4.78 for Phase II. There was no statistically significant difference noted. BSI rates were higher in ICU patients compared to patients in PCA (7.89 and 1.62/1000 CLD, respectively). No statistical difference was found for line duration or time to infection among the catheter types. In all, infected cases the lines were placed in either the subclavian or internal jugular veins. CONCLUSION: There were no statistical differences in BSI rates between Phase I and Phase II. Limitations of the study included sample size bias, which impeded our ability to detect differences in rates due to inadequate power. Although the study was conducted for a full year, the small numbers of infections made it difficult to demonstrate statistical significance. Literature has shown that the use of central venous catheters impregnated with minocycline and rifampin are associated with lower rates of colonization than those coated with chlorhexidine silver sulfadiazine. However these findings were not duplicated in our study.

Cannulation of central veins

Placement of central venous catheters (CVCs) used to be the preserve of surgeons using general anaesthesia but the success rate was only about 75% and the vein was compromised for future use. The introduction of the percutaneous method led to uncontrolled use of CVCs by inadequately trained staff with serious, potentially avoidable, complications that were sometimes fatal. Recent advances in CVC manufacture, better training in insertion techniques, the use of ultrasound, the development of hospital nutrition teams, and the increasing involvement of interventional radiologists in the ICU should ensure that CVC placement becomes safer. Interventional radiologists should be more involved in the management of ICU patients because they are familiar with ultrasound and fluoroscopic techniques, have extensive experience with advanced catheter and guidewire techniques, and are adept at retrieving catheters or parts of catheters inadvertently lost within the vascular system. Figure 1 lists the indications for using CVCs. Originally CVCs were of fine bore, but newer, wide-bore, high-flow, central venous pressure lines and pulmonary artery catheter introducers permit rapid volume replacement. Multi-lumen catheters allow concurrent central venous pressure (CVP) monitoring and multiple drug infusion.

Rates of infection for single-lumen versus multilumen central venous catheters: A meta-analysis

Since the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters. Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents. Two independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality. A total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00-4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92-3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50-3.41). Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

Concept for postoperative analgesia after pedicled TRAM flaps: continuous wound instillation with 0.2% ropivacaine via multilumen catheters. A report of two cases

Pedicled TRAM flap surgery is a complex procedure characterised by an extensive wound site. We present two patients with efficient postoperative pain relief by continuous wound instillation of ropivacaine 0.2% via two multilumen catheters. The catheters were placed subcutaneously before the wound closure through the umbilicus into the abdominal wound, and under the autologous flap into the breast. Each multilumen catheter provides even distribution for local anaesthetics over 12.5 cm. At the end of surgery, patients received a single shot dose of local anaesthetic via the pain catheters. After surgery the continuous infusion of ropivacaine 0.2% was commenced at a rate of 10 ml/h per catheter. Pain scores at rest and on coughing were low on the first postoperative day, and later zero. No medication for breakthrough pain was required throughout the recovery period, and the patients experienced no adverse events linked to the analgesia scene. Patient satisfaction was excellent, and quality of recovery score was superior.