title: Postoperative Pain Management in DIEP Flap Breast Reconstruction: Identification of Patients With Poor Pain Control.
abstract: OBJECTIVE
  Adequate control of postoperative pain directly improves patient satisfaction and outcomes, and timely identification of patients with poorly controlled pain is essential. Pain management protocols are best studied in patients recovering from the same operation. In our institution, the postoperative pain regimen for patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction is standardized using patient-controlled analgesia (PCA) followed by conversion to oral narcotics. From this uniform population, we were able to identify a subgroup of patients with poor pain control.
  
  
  METHODS
  Over a 44-month period, 179 consecutive patients underwent DIEP flap breast reconstruction with 242 flaps performed. A retrospective chart review recorded PCA usage, visual analog scale pain scores, and length of stay.
  
  
  RESULTS
  Pain management with PCA after DIEP flap breast reconstruction was uniformly controlled. Most patients (74.9%) required PCA usage in the first 2 days with conversion to oral analgesics. A subgroup of patients (25.1%) continued to require PCA usage on the third postoperative day. These "nonresponder" patients had a higher visual analog scale score on the first postoperative day, higher total intravenous morphine use, and a longer length of stay (all, P < .05). A multivariate analysis revealed more nonresponders among patients undergoing immediate breast reconstruction (P < .05); however, all other factors analyzed had no correlation.
  
  
  CONCLUSIONS
  We report a subgroup of patients with poor pain control after DIEP flap breast reconstruction. This group of patients required a longer course of pain management and subsequently a longer hospital stay. Pain management protocols that identify these patients promptly can allow for appropriate modifications.
authors.forename: Eran D
authors.initials: ED
authors.lastname: Bar-Meir
authors.forename: Janet H
authors.initials: JH
authors.lastname: Yueh
authors.forename: Philip E
authors.initials: PE
authors.lastname: Hess
authors.forename: Christoph E A
authors.initials: CE
authors.lastname: Hartmann
authors.forename: Munique
authors.initials: M
authors.lastname: Maia
authors.forename: Adam M
authors.initials: AM
authors.lastname: Tobias
authors.forename: Bernard T
authors.initials: BT
authors.lastname: Lee