A Novel Technique for Split-Thickness Skin Donor Site Pain Control: Subcutaneous Catheters for Continuous Local Anesthetic Infusion
ARMY INST OF SURGICAL RESEARCH FORT SAM HOUSTON TX
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Pain after split-thickness skin grafting can be severe. The current management of donor site pain is limited to oral and parenteral narcotics and nonnarcotic adjuncts, topical analgesics, and regional and axial anesthesia.1 The ON-Q Postop Pain Relief System I-Flow Corporation, Lake Forest, CA consists of an ON-Q pump and Soaker catheter designed to deliver a continuous infusion of local anesthetic to a surgical site. The device is Food and Drug Administration approved for postoperativepostinjury pain control and has been described after laparotomy, thoracotomy, inguinal hernia repair, and rib fractures.2 4 We describe our experience at the U.S. Army Institute of Surgical Research USAISR with the use of subcutaneous catheter placement for continuous infusion of local anesthetic placed deep to lower extremity split-thickness skin graft donor sites. Standard excisional preparation of a skin or soft tissue wound is carried out. A split-thickness donor site is chosen, typically from the upper lateral thigh, and skin is harvested at a depth of 0.010 inches. Autografting is completed and the grafted wounds are dressed. The local anesthetic infusion catheters are then inserted in the subcutaneous space deep to the skin donor site via palpation as the included introducer and needle are advanced. Of note, when using the sharp as opposed to the blunt tip introducer, 2 to 3 cm of the distal end of the Soaker catheter must be trimmed to allow it to pass through the introducer and remain with its perforated portion entirely within the subcutaneous space deep to the donor site. The insertion site is placed 2 to 5 cm cephalad to the most proximal portion of the donor site. Two optionally, only one 10-cm catheters are passed in parallel, one medially and one laterally, to cover the entire field of a 200- cm2 donor site Figure 1. The catheters are primed with 2 ml of 1 4 bupivacaine and attached to the ON-Q Pain Pump device, which infuses at a rate of 4 mlhr.
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