Perineural local anesthesia infusion pumps, also known as pain pumps, represent a major step forward for post-operative pain management. These ambulatory pumps and their intrawound catheters show great promise in fast-tracking patient recovery and discharge times, smoothing out post-narcotic pain control and helping patients return to physical activity and avoid chronic pain.

Pumps have met a hesitant reception in some facilities, however, due to financial and functional factors. Here are some key points you'll want to consider in order to maximize their benefits if you're thinking of adding them to your pain management options.

Pain and the pocketbook
There may come a time when we say, "How did we ever live without pain pumps?" We're not there yet, though, and neither are many insurance companies. Several major insurers have recently announced that they're not planning to cover post-op pumps, citing insufficient clinical evidence for their effectiveness. These decisions were made in spite of the American Society of Anesthesiologists' guidelines supporting post-incisional infiltration for pain control and a number of wildly successful, albeit small-scale, clinical trials. So, first and foremost, consult with your payers to see what, if anything, they'll reimburse you for.

"Who's paying?" turns out to be a formidable question and potentially limiting factor in the maintenance of post-operative pain. It's still a fairly expensive technology: Is a patient willing to pay out of pocket for it? While $100 for three days of pain management at home may seem reasonable, $500 may not.

Granted, pain pumps are to a certain extent gilding the lily. After such procedures as open inguinal hernia repair or laparoscopic cholecystectomy, patients are going home very comfortable, since we've used nerve blocks and opioids. They're not in agony when they leave. But given the unpredictability of pain from patient to patient, they might be in agony the next day. That's one of the big advantages of a pump in the days after surgery.

Consider also the fact that, along with nausea and vomiting, pain is the main reason patients are admitted to hospitals after their surgery. Setting aside the question of why insurers would rather pay for a hospital visit than a pump, ask yourself what your bottom line is in terms of benefit versus reimbursement. Are you willing to pass on the cost of pain control?

User friendliness
When you're trialing pain pumps, remember where and how they'll be used: in the patient's home, without direct clinical supervision. So simplicity is important. A pump that's easy for the patient, and the patient's family, to use will spare them the anxiety of operating difficult equipment and spare your staff a lot of frustrated or confused telephone calls.

Size is a big issue in ease of use. You'll want a pump to be small enough to be portable and allow patient activity - mobility is, of course, the aim of outpatient surgery - but not so small that the patient can't read the pump's screen or operate its buttons. Keep in mind that elderly patients may not have the dexterity of someone who's 20 years old. Additionally, a pump that has no moving parts means that malfunctions are that much less likely.

In general, disposable pumps are less expensive than reusable ones but they're no less effective. Likewise, there's not much difference in efficacy between pumps that use a spring-loaded device to infuse the medication and elastomeric models in which the pressure of an inflated bladder delivers the drug.

One small but useful feature you might want to look out for is something that lets the patient know that the pump is operating correctly. With an IV bag and tubing, you see the fluid drip, but most pumps work so slowly and quietly that you can't perceptibly see or hear the job getting done. For that reason, a blinking icon on the screen, a window through which fluid can be seen moving or some other signal can prove useful. For the patient, an assurance that the pump is in fact working is almost like a placebo effect.

Aspects of control
There aren't too many pieces of medical equipment that you'd allow patients to handle by themselves. In addition to the continuous infusion that pumps provide, though, some also offer patient-controlled analgesia settings, giving patients the ability to self-administer an extra dose of medication if they're not comfortable and feel they need more.

It's valuable for patients to have that ability, for the pump to empower them to help themselves as opposed to letting them passively wait for something to happen. Given the local anesthetic that's used in these ambulatory pumps and safety features that prevent patients from going beyond a set parameter, they can't hurt themselves with this.

Similarly, patients should be able to easily discontinue infusion in the event of an adverse reaction or a device malfunction, whether that's by pressing a "stop" button, disconnecting the pump or tying a knot in the tube to prevent medication from being administered. The beauty of the disposable pump is that the patient can be talked through the removal process if necessary and that the pump itself is easy to get rid of.

The capacity of the pump's drug reservoir also makes a difference in pain control. A larger reservoir may be more labor intensive for clinicians to preload and may result in a larger item for patients to carry around. But if a longer recovery and pain control period is expected, a reservoir with greater capacity could provide more effective pain relief. If it contains enough medication for the length of the treatment, it will sidestep the need for a visiting nurse or a return to the provider's office for a refill.