FLEXIBILITY Pre-filled pumps offer flexibility: You can turn them off, turn them down or stop them early.

When you send a patient home with a pain pump, there's a lot that can go right and a lot that can go wrong. Under the best circumstances, the patient's pain will be minimized, and you won't have to spend the next 3 days fielding phone calls, dealing with complaints or troubleshooting.

But the potential for hassles makes some physicians reluctant to use pumps, regardless of the potential benefit to patients. Like most people, anesthesiologists, once they're finished in the OR, would prefer to go home and not have to take any calls. They don't want to have to deal with messages from patients saying, "My catheter's leaking" or "My arm is numb, what can I do?"

It's a challenge for pump manufacturers, who are working to overcome that reluctance (see "5 Pain Pump Options" on page 50). And those manufacturers are also coming face-to-face with a relatively new challenge, in the form of time-release single-shot blocks designed to relieve pain for several days. Those, too, may discourage anesthesiologists and surgeons from using pumps, the rationale being: Why put catheters in and deal with the potential post-op hassles when I can put one block in and be done?

Flexibility of pumps
Even if a nerve block can last for 3 days — and the data isn't convincing yet — that's not always a positive thing. Inevitably, some patients will call and say they hate the sensation of having an arm that feels like a dead fish. They'd rather have the pain. But with a block, once it's in, you've bought the ticket. There's no way to adjust it.

Pumps, on the other hand, offer much more flexibility. You can turn them off, turn them down or stop them early. When patients call our facility saying they don't like the sensation, we can tell them to clamp their pumps. The flow of local anesthetic stops, the numbness wears off a little bit and they start to get some feeling back. Then, if they decide the pain is even less preferable, they can just unclamp the catheter and let the flow of anesthetic resume.

That flexibility is an advantage, but what about those pesky phone calls? Fortunately for facilities, it's a competitive environment for the pump manufacturers. One way they're fighting for your business is by offering pre-emptive post-op calls to patients, reducing the burden for physicians. Some manufacturers will call every day once the patient's back home just to check in and try to answer all of those routine questions — the ones patients ask most often. And of course if anything really serious comes up, they'll either advise the patient to call the physician, or call the physician on the patient's behalf.

Pump manufacturers are also attacking the "hassle issue" on another front. Patient education before they take the pumps home is extremely important. The better educated patients are, the fewer problems they're likely to have and the fewer phone calls they're likely to make.

Look for the companies that have a lot of educational materials to support what you're doing — things like handouts that the surgeon's office can provide, online patient videos and answers to frequently asked questions. Many questions are pretty straightforward and predictable, like What does this little thing do? or Why am I getting some dripping out of here? Most calls don't require an intervention; they just require patient reassurance. Some manufacturers can even report data back to you, based on those phone calls, so you'll have a record of pain scores or other quality-assurance data you might want to collect.

From a teaching standpoint, once you've decided on a given pump, it makes sense to stick with it, rather than having a variety of pumps around. The more types of pumps you have, the more likely you're going to get yourself into trouble.

PRODUCT ROUNDUP
5 Pain Pump Options

Advanced Infusion
Alpha Infusion Pump and Catheter System
advancedinfusion.com
FYI: The design of the pump's micro-bore catheters eliminates the possibility of dumping and kinking, says the company. The latex- and DEHP-free system allows physicians to run 1-5 catheters from a single pump, with each catheter delivering a different flow rate to different parts of the body, if needed.

Ambu
ACTion Block Pain Pump
ambuusa.com
FYI: You can fill this latex-free system to any volume between 50ml and 650ml. With a flow consistency of +/- 5%, it provides a continuous, stable delivery of anesthetic at a tailored rate. Ambu says its 45-day shelf life is the longest of any elastomeric pump on the market.

I-Flow
On-Q Pain Relief System
iflo.com
FYI: With its highly portable elastomeric pump, the single-use system automatically and continuously delivers a regulated flow of local anesthetic. It can be used for up to 2 to 5 days after surgery. In clinical studies, On-Q patients reported up to 69% lower pain scores, says I-Flow.

Summit Medical Products
AmbIT Infusion Pumps
ambit pump.com
FYI: These patient-controlled anesthesia pumps have customizable basal flow rates, bolus volumes, bolus lockout and a volumetric accuracy of +/- 6%. Designed for ease of use, they meet the same national and international safety standards as pumps that cost thousands more, says the company.

Teleflex
Arrow AutoFuser Disposable Pain Pump
teleflex.com/autofuser
FYI: An optional parallel bolus lets patients immediately address breakthrough pain without interrupting the continuous basal infusion. Its front-fill port and design significantly reduce the pressure needed to fill the reservoir. Available in 2 reservoir sizes, with 3 fixed infusion rates.

PROACTIVE The better educated patients are about pain pumps, the less likely they'll call with routine questions.

Filling and billing
Filling pumps can be both expensive and difficult, since it's necessary to maintain the sterility of the medication. It might be tempting to just take a couple of syringes and fill them yourself. But from a patient safety standpoint, it needs to be done under a hood, and you need to make sure there's no exposure to bacteria. It's not something you want to be doing on your own. If you don't have a pharmacy in your facility that can do it, there are pre-fill options available, but they substantially increase the cost.

Naturally, the cost of the pump is a primary consideration, along with the complexities of billing. Some providers now offer help in this area, too. If your billing office doesn't have experience with pain pumps, that kind of assist can be a big plus, both from the facility's standpoint and from the provider's standpoint.

In some cases, outpatient facilities may have to eat the cost of the home pump, because they can't bill for it. But there's a difference between disposable pumps and electronic pumps, according to one company. The electronic pump might be billable to the patient's insurance under the durable medical equipment (DME) line. Of course, if you do that, you're just cost-shifting to the patient, and your orthopedic surgeon might see a substantial increase to the patient's bill as a big negative. On the flip side, the deductible associated with the DME is usually much lower, and a patient who's already used crutches or other equipment may find that the added out-of-pocket expense with the pump isn't terribly significant.

Track record
The history of pain pumps hasn't been without challenges and unforeseen problems. There have been recalls and lawsuits, and some companies have stopped making them. Before you choose a pump, look into the company's safety and track record. Have they had any incidents where the anesthetic has been administered at a rate that was faster than intended? Are the pumps reliably tamper-proof, such that patients can't mess with them in any way?