TAKE-HOME INSTRUCTIONS Anesthesiologist Nathan Schwartz, MD, explains to a patient how to use a pain pump.

For many providers, continuous local anesthetic infusion pumps, or "pain pumps," have become a staple of post-op pain management, especially for orthopedic cases and especially when they're ambulatory. These devices, however, often seem overshadowed by flashier technology in the surgical suite, even when they're improved to benefit your patients as well as your process. We asked some regional anesthesia experts about pumps' latest perks.

Latest in Portable Pain Pumps

Ambu's ACTion Block Pain Pump features a latex-free, silicone-free, disposable elastomeric reservoir in 200ml, 400ml and 650ml sizes.

The B. Braun Symbios Go Block Pump features a flow rate controller that lets you set the infusion rate within a predetermined range (2-10ml/hr).

The LMA AutoFuser (now from Teleflex) has a rounded, low-profile, hard-case housing for stability. A front-fill port makes filling easy. And its on-demand bolus doses don't interrupt the continuous infusion.

Patient control
Any improvement in the way a pain pump dispenses its ropivacaine or other anesthetic agent is a win for post-op patients, particularly when it entails their interaction with their care. "Patient involvement in post-op pain control is key," says Emily DeBusk, BS, RN, a block nurse and PACU nurse at Baptist Health Care in Gulf Breeze, Fla., and founder of BlockNursing.com.

The latest pumps feature variable rate regulators — oftentimes an intuitive dial — that let patients adjust the infusion to meet their specific pain management needs. On-demand bolus dosage for immediate, additional pain relief has long been part of a pump's operation, but 1 manufacturer recently introduced a "true parallel bolus" function, which temporarily ups the dose without affecting the base rate.

If you're in the market for a new pump, though, make sure that the patient control aspects that draw you in are easy for the patient to control. "The most important feature of a pain pump is that it's simple to use, and easy to figure out how it works," says Daniel Nash, CRNA, DNAP, of St. Anthony's Bone and Joint Hospital in Oklahoma City and Maverick Regional Anesthesia Education. "We often send them home with these, so we want them to be able to operate them on their own."

Because the devices are sent home with patients, he notes, they tend to be extremely safe — the anesthesia is a low, dilute concentration and the infusion rate controls are highly accurate — but if they're not understood, they can frustrate patients, or leave them to suffer more pain than is necessary. Dials and buttons that are easy to read and manipulate are a good sign, as is the availability of a manufacturer's customer service hotline with 24-7 access.

Pieces and parts
As long as a pump does its job, it's easy to take the component parts for granted. But the pieces that make up a pump make a difference, and can be improved.

For example, says Ms. DeBusk, "Although it seems that anything you could fill with local anesthetic would be acceptable for the job, ... the shape is important to notice. The shape of the pump will affect where the patient is able to keep the pump and protect it from being damaged in the patient's recovery."

Rounded and streamlined is the shape of continuous infusion for the latest products. And if the amount of anesthesia required allows it, smaller is better, says Mr. Nash. "You don't want a big and bulky shell. Shoulder surgeries, they're discharged fairly quickly, and all of those accoutrements — the pouch and ball and tubing — ?can sit right in the sling." If, instead, the infusion location requires a belt or neck pouch, you wouldn't want to inconvenience patients with large baggage.

Pumps operate via 2 different mechanisms: They're either battery operated, spring-driven, cartridge-loaded devices; or elastomeric bladders that dispense their under-pressure contents through a regulator. Several recently introduced products all use the balloon solution. Is it a superior solution? "I can see where that would be handy," says Mr. Nash. "They're more disposable and probably less expensive." For outpatient surgery providers, sending patients home with a single-use device they can discard once it's empty is a definite advantage, he says.

The same goes for pumps that feature antimicrobial catheters, such as those made from silver-coated materials. Catheter implantation is guided by the utmost sterile technique, says Mr. Nash, but any additional assistance is welcome, especially because it'll be in the patient and clinically unmonitored for 3 days or so. (He cites European studies that have found an uptick in catheter-related infections at the 60-hour mark.)

Filling and billing
Pain pump innovations aren't limited to the patient's experience. Some were developed to make providers' jobs easier, such as vendor-sponsored pump-filling services and third-party billing arrangements.

The primary appeal of purchasing pre-filled pumps is the convenience and operational efficiency it provides when it frees up surgical staffers to other tasks. But a filling service offers a couple of other advantages that may make its extra expense worth it, says Janice Izlar, CRNA, DNAP, anesthesia administrator at the Georgia Institute for Plastic Surgery in Savannah and president of the American Association of Nurse Anesthetists.

"First, access to the medications you need," she says. "Drug shortages have had a severe effect, and the compounding pharmacies that fill your pumps may have access that you don't have." Second, patient safety. "Any time you're preparing precise amounts, there's the potential for error. There's also the issue of sterility." Of course, "not all compounding pharmacies are equal," so be sure to determine that the one you'll depend on for your pumps is high-quality and complies with all safety regulations.

As you know, Medicare doesn't cover post-op pain management as a separately billable service, and other carriers' rules and requirements for justification can make getting paid for pumps a tricky business. Ms. Izlar points out that, among facilities that host a large number of insurance cases, whether pumps are reimbursed is a significant factor in whether they're used.

That's why a vendor's value-added service of billing for its customers' pump uses may be a highly worthwhile incentive. "Pump companies offering third-party billing arrangements let it be a financially beneficial option to give the best pain control, as opposed to one that burdens an anesthesia practice, facility or patient," says Ms. DeBusk.

PUMP IT UP Pre-filled pain pumps from a compounding pharmacy can free up your staff and secure your access to needed medications.

Motivation for analgesia
Pain pumps aren't perfect. Ms. Izlar recently polled a group of anesthesia provider peers and found their current use to be "inconsistent," in large part due to dissatisfaction with catheters kinking, breaking or dislodging in ambulatory patients. "Pain pumps work much better for total knees, for instance, when the patient is staying in the hospital overnight," she says. "We've found they're not as sturdy when the patient goes home, ambulating and walking freely."

As a result, any use of pain pumps should be supported by a facility-wide education and quality assurance program in order to ensure uniformity and assess effectiveness: in short, to know if the pumps are working, says Mr. Nash. "If you want pumps to be successful, everyone has to know what the goal is, what you're trying to accomplish," from the pharmacy and nurses to the patients and their post-discharge physical therapists.