|LETTERS TO EDITOR
|Year : 2020 | Volume
| Issue : 6 | Page : 540-541
Continuous local infiltration using suction drain: A cheap and innovative alternative in epidural contraindicated patients
Rachel C Koshy1, Hally Thankamony1, Jayasree Vijay1, Cherian Kurian2
1 Department of Anaesthesiology, RCC, Trivandrum, Kerala, India
2 Department of Surgical Oncology, RCC, Trivandrum, Kerala, India
|Date of Submission||17-Jan-2020|
|Date of Decision||15-Feb-2020|
|Date of Acceptance||22-Apr-2020|
|Date of Web Publication||01-Jun-2020|
Dr. Hally Thankamony
Department of Anaesthesiology, RCC, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Koshy RC, Thankamony H, Vijay J, Kurian C. Continuous local infiltration using suction drain: A cheap and innovative alternative in epidural contraindicated patients. Indian J Anaesth 2020;64:540-1
|How to cite this URL:|
Koshy RC, Thankamony H, Vijay J, Kurian C. Continuous local infiltration using suction drain: A cheap and innovative alternative in epidural contraindicated patients. Indian J Anaesth [serial online] 2020 [cited 2020 Jul 11];64:540-1. Available from: http://www.ijaweb.org/text.asp?2020/64/6/540/285529
Epidural analgesia and nerve blocks are superior to any other methods in managing acute postoperative pain and related postoperative pulmonary complications. Managing acute postoperative pain without a working epidural is a difficult task for the anesthesiologist. In this article, we are describing postoperative wound infiltration with continuous infusion of 0.2% ropivacaine (Continuous Local Infiltration Analgesia [CLIA] technique) in two epidural contraindicated patients.
Case 1: A 43-year-old gentleman was diagnosed with extra abdominal fibromatosis, Behcet's syndrome, and fatty liver. He had raised transaminases levels.
Case 2: A 54-year-old gentleman, a diagnosed case of adenocarcinoma colon with alcoholic liver disease (CHILD Pugh score B and MELD score 11). His INR was 1.56 even with multiple fresh frozen plasma (FFP) transfusions and inj. vitamin K. We had decided to do the procedures under general anesthesia with CLIA technique with improvised suction drain as epidural analgesia was contra indicated in both cases.
After clearance for anesthesia and written informed consent, both of them were induced with general anesthesia as per hospital protocol. Before closure, suction drain catheters of 14FG were fixed in the subcutaneous plane for wound infiltration in first case in the right para spinal area extending from L4 –S1 [Figure 1] and same size suction drain catheters were placed in to the preperitoneal space in the second case (midline laparotomy incision). 30 mL 0.2% ropivacaine was given in the intraoperative period and for the postoperative period 0.2% ropivacaine infusion was continued at a rate of 10 mL per hour using elastomeric pump along with intravenous patient-controlled analgesia (PCA) fentanyl (10 mcg per hour basal infusion rate on first postoperative day and no basal infusions on subsequent days with demand bolus of 20 mcg and lock out interval of 30 min). In both cases, postoperative numerical rating scores were assessed and found to be less than or equal to 3 throughout. CLIA catheters were removed on the third day in both cases.
Continuous wound infiltration is a relatively new technique with the advent of multiporous catheters and elastomeric pumps. Catheters placed in the subcutaneous plane act as a channel for continuous infiltration of local anesthetics, which provides analgesia with added advantage of ease of insertion compared to epidural analgesia. Continuous wound infiltration by local anesthetic causes direct inhibition of noxious afferent nerve endings and it also reduces local inflammatory mediators following injury. There are specially developed multi porous soaking catheters which are used for local anesthetic infiltration which are very costly.
We used two suction drain catheters with about 50 holes each, which are connected to an infusion pump using a three way [Figure 2], which is a cheaper alternative to conventional local infiltration analgesia (LIA) catheters. The hole provided in the suction drain gives uniform spread of local anesthetics to a larger area like our conventional CLIA catheters. We used this technique along with fentanyl patient controlled analgesia with less demand doses and basal infusion rate compared to fentanyl PCA alone. This analgesic technique decreases acute postoperative pain and pulmonary complications, reduces hospital stay and postoperative morbidity. Effects of different types of drugs have been studied in various concentrations. 0.5% bupivacaine 5 mL/h has got adequate analgesia. Patient-controlled wound infiltration with 0.2% bupivacaine was less effective. Rare complications associated with CLIA technique are prolonged wound healing, hematoma, chondrotoxicity, and even myotoxicity. The overall infection rate was calculated as 0.34%. Delayed wound healing and hematoma can be prevented by correct placement of catheters under strict asepsis and antibiotic prophylaxis 30 min before making the skin incision.
Even though epidural analgesia and peripheral nerve blocks remains superior in the postoperative pain control, continuous wound infiltration is an alternative for the same purpose in epidural contraindicated patients. Individual risk benefit ratio has to be assessed before choosing the methods of analgesia. Suction drain catheters are cheaper alternatives to the specially designed wound infiltration catheters.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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