With the proper use, and the proper patient, pain pumps used with continuous nerve block catheters can be extremely effective pain management tools. Use these tips to help your patients handle post-op pain more easily, safely and successfully.

1. Outline expectations
This process can begin in the surgeon's office, during the pre-op visit. The surgeon can discuss with patients that they'll be receiving a nerve block catheter as part of their post-operative pain management. Patients have told us that they appreciate getting this information from the surgeon during their pre-op visit, rather than hearing it for the first time from the anesthesiologist on the day of surgery. Of course, you should repeat this information during the pre-operative anesthesia visit and on the day of the procedure as well. Pre-op nurses should remind patients that they'll be taking the pump home, and outline the patient's responsibilities for managing the device. Nurses should address the patient's and family's questions in recovery, and should provide a brief demonstration of how the catheter operates once connected. The success of a continuous nerve block catheter program depends on teamwork between the anesthesiologist, surgeon, nurses and patient.

Encourage patients to continue taking pain medication if necessary. Some patients may not realize that they can use a nerve block catheter as well as prescribed medications. Explain that even though the catheter is working, the level of numbness may diminish with time, and won't remain as strong as when the pump is initially connected, which may cause their pain to increase. Urge them to take pain medication on the day of surgery until they get used to the level of numbness that the nerve block catheter will cause.

Upon discharge, slip an information sheet into the fanny pack that the patient's pump is typically stored in. The sheet should include a phone number to call with questions or concerns about taking medications while the pump is connected, as well as general care instructions for the catheter, with directions on how to remove it once it's empty, or how to reinforce dressing with gauze if leakage occurs.

Outline in the literature the common side effects associated with continuous nerve block catheters. For example, point out that with an interscalene nerve catheter, taking deep breaths may be more difficult than usual. Reassure the patient that these issues are normal and typically nothing to worry about.

Other reactions are a much larger cause for concern. Even when administered properly, local anesthetics can be toxic. Share the signs of local anesthetic toxicity — lightheadedness, dizziness, metallic taste, confusion and drowsiness — with patients, and direct them to call their anesthesiologist if they experience any of these symptoms.

2. Know your pumps
For your patients' sake as well as your own, you want to use pumps that are safe as well as easy to fill, program and operate. Both disposable elastomeric pumps and reusable electronic pumps have benefits and drawbacks. Typically a cheaper option, elastomeric pumps come in both continuous rate and variable rate versions, and some include a patient-controlled bolus as well.

Elastomeric pumps are easy to use, but factors like temperature may affect their accuracy in administering local anesthetic. Some elastomeric pumps that get too cold or too hot can change the viscosity of the local anesthetic agent, which can speed up or slow down the rate of anesthesia delivery. You should ask pump manufacturers for studies indicating how close to the actual rate of delivery their elastomeric pumps can get.

Battery-powered electronic pumps infuse medication through a mechanical system, which makes their delivery rate more consistent and accurate in comparison to elastomeric pumps. Electronic pumps also allow greater individualization of anesthesia delivery to a particular patient. You can change the maximum deliverable anesthesia rate, and can alter the continuous rate by as little as 0.5ml. But while this variability is certainly appealing, most patients don't require that level of customization. Electronic pumps are usually more expensive, take more time to program — some patients may find them more difficult to understand and operate — and may be prone to mechanical or electronic failure.

3. Know when not to use them
Pain pumps are generally effective for most patients, but there are situations when you shouldn't send patients home with a continuous nerve block catheter and pain pump.

A patient's ability to communicate is always a concern. Patients must be able to speak and understand English at a level that lets them understand the pump's instructions and converse clearly with the anesthesiologist and nurses throughout the post-op follow-up process. Patients also need a reasonable support system at home to help them operate the pump or to make a phone call if serious problems like local anesthetic toxicity arise.

Clinically speaking, some patients aren't viable candidates for continuous nerve block catheters. Nerve damage or neuropathy doesn't necessarily preclude a patient from receiving a continuous nerve block, but consider where he is in the recovery process. A total joint replacement patient with stable neuropathy associated with a disease like diabetes may be a suitable candidate for a continuous nerve block. But the nerve function of a patient with an injury stemming from an accident or trauma may continue to worsen or improve. The recovery process for nerve injuries is dynamic; be wary of using continuous nerve block catheters for patients with nerve injuries.

Infections at the site of the nerve block are another possible contraindication. A conservative approach with these patients, such as using a single-shot nerve block as opposed to introducing an additional foreign body to the site via a continuous nerve block catheter, may be appropriate.

4. Modify post-op protocols
The anesthesiologist should be patients' key contact once they're sent home with their pump. Make daily follow-up calls to ambulatory pain pump patients to head off potential problems and evaluate the continuous catheter's effectiveness in providing analgesia.

Adding a pain pump will mean modifying your post-op protocols. You must adapt if a patient begins to experience pain. In the ACL repair patient, for example, the continuous femoral block is used to cover the anterior knee. Frequently, a single-injection sciatic nerve block is administered to cover the posterior knee, and the block should last between 12 and 18 hours. Nurses and patients must understand that pain in the posterior knee is simply a result of the single-injection sciatic nerve block wearing off, not an issue with the femoral catheter. If posterior knee pain occurs, administer supplemental analgesics to minimize the discomfort.

When using a pain pump for inpatients, having an order for PCA narcotics available if needed, but not hooked up to the patient, may be useful. Don't waste your nurse's time, or your facility's money and resources, hooking up the pump when it may not be necessary. Many patients will do fine with only supplemental oral analgesics while benefiting from a continuous nerve block catheter.

5. Make pain pumps pay
While government payors (Medicare and Medicaid) and some private insurers don't reimburse the cost of pain pumps, the placement of continuous nerve block catheters can generate increased revenue for an anesthesia practice. A brachial plexus catheter placed for post-op pain control generates 13 units versus 8 units for a single-injection nerve block. You'll collect another 3 units if you use ultrasound for placement. In 2011, government reimbursement rates for physician-administered nerve block catheters were $82.56 (sciatic catheters), $81.20 (brachial plexus catheters), $73.39 (femoral catheters) and $33.64 for ultrasound guidance. Private carriers typically reimburse significantly higher than government rates, but that's dependent on the individual contracts.

Any nerve block placed for post-op pain control (either single injection or continuous catheter) must be properly documented as such, and not simply part of the primary anesthetic. There are several things you should do to identify the block as a post-op pain technique. First, document the nerve block separately from the anesthesia record and document that the surgeon requested the nerve block. Also, the use of CPT codes for common upper and lower extremity peripheral nerve blocks with the "distinct procedural service" modifier (59) will further identify the block as a post-operative pain technique and not part of the primary anesthetic. Common CPT codes for continuous catheters include 64416 (brachial plexus), 64448 (femoral) and 64446 (sciatic).

If your carrier doesn't currently reimburse you for continuous nerve block catheters, that's an important point to discuss come contract renegotiation time. When that time comes, be sure to stress that these techniques are critical in reducing patients' recovery times, giving them a degree of control over their post-op pain, and decreasing medical costs.