Patients who are given regional nerve blocks wake up faster, are more alert and have less pain. They need fewer opioids, so they're less likely to have respiratory distress or nausea. Which means they can usually be discharged sooner and start physical therapy sooner. The only problem? Blocks wear off.

That's where continuous peripheral nerve catheters and pain pumps can take over. Yes, continuous nerve blocks add a whole new level of complexity for patients, but they can control and dramatically reduce post-surgical pain for several days. When you send patients home with a pump and a little education, they're usually able to get through the toughest post-surgical stretch without relying heavily on opioids. And by recovering comfortably at home, they reduce the burden on providers and the healthcare system in general.

"For those interested in making outpatient surgery as affordable and feasible as possible, the role for peripheral nerve catheters is a significant one," says Christopher Canlas, MD, an assistant professor of clinical anesthesiology in the division of ambulatory anesthesiology at Vanderbilt University Medical Center in Nashville, Tenn. "They play an important role in reducing hospital days and increasing patient comfort."

There are a wide variety of block and pump features to consider. Here are the factors you should weigh to choose the best options for your facility.

1. The pump manufacturer

But one of first things to consider isn't the pump itself. It's the pump manufacturer, says Brandon Winchester, MD, an anesthesiologist at the Andrews Institute for Orthopaedics and Sports Medicine in Gulf Breeze, Fla. "Be sure to consider how stable the company is and how much confidence you'll have implementing a program and knowing that the pump is still going to be around in 6 months or 6 years," says Dr. Winchester, the co-founder of the educational regional anesthesia website, blockjocks.com.

"At another institution, we got burned after about a year-long trial of 5 different pumps," he recalls. "We'd in-serviced the whole hospital and trained about a thousand nurses and 50 anesthesiologists. Then, several weeks later, the company whose pump we'd chosen announced they were no longer in the pump business." That was an important lesson, he says. "Since then I've had a lot of appreciation for the established company, as opposed to the new guy on the block who's flying in hot, flying in cheap and may be flying out the next day."

Manufacturer support is a crucial consideration, he adds. "Is there an 800 number the patient can call if something goes wrong? If so, how many people are staffing that number? If the patient is having issues that are more pump-related than clinical, what are their options?"

2. Electronic or elastomeric?

Next up, you'll need to consider the 2 basic types of pumps: simple, self-contained balloon-like elastomeric pumps and non-disposable electronic pumps, which provide a greater range of features and alarms.

Electronic pumps have worked out well for David Cohen, MD, an anesthesiologist at the William Beaumont Hospital in Royal Oak, Mich. He says they're easier to customize than elastomeric pumps.

"We can easily adjust the baseline infusion rate and the amount of bolus, if we choose to use a bolus, and the lockout time (between boluses)," he says. "It's less one-size-fits-all, so we're more able to be responsive to the needs of particular patients.

"If a patient has chronic pain issues and needs a higher flow, we can increase the rate or set a higher bolus amount with a shorter lockout interval," he adds. "Or, if we have a frail patient who doesn't need much medication, we can dial the settings down and extend the duration of the pump. Instead of 2 or 3 days, they might be able to get to 5 or 6 days, if they use it judiciously."

And since the local anesthetic is contained in an IV bag that's attached to the electronic pump and inserted into a fanny pack, there are no preset limitations on the amount of anesthetic solution provided. "We can provide 100 ccs or a 1-liter bag, or anything in between," he says.

Electronic pumps can also claim a higher accuracy rate in terms of flows, says Dr. Cohen. "If you set a pump for 4 ccs an hour, they say you'll be getting 4 or very close to it, as opposed to the tolerances on elastomeric pumps, which are wider. Instead of 4, you might be getting 3 or 6, or anywhere in between. You want tight tolerances on medical devices."

Some patients may get better relief with a lower basal rate with a higher bolus rate that has lockout capabilities.

Electronic pumps have a smaller carbon footprint, which appeals to Dr. Cohen. "The IV bag will end up in a landfill, but the actual pump can be reprocessed and reused," he says. "With elastomeric pumps, you get one use and you're done. If you can use a pump multiple times, it seems likely to be more environmentally friendly." His patients take a cardboard UPS mailer home with them, says Dr. Cohen. "And they're told they'll be responsible for a fairly significant fee if the pump doesn't get returned," he says. "But the vendor doesn't want their money. They just want the pump, and close to 100% are returned."

3. Ease of use

But keep in mind there's an important tradeoff when it comes to choosing between simpler and more complex pumps.

"The more features and capabilities a pump has, the more things a patient has to learn, and the practitioner has to learn, and nurses have to learn," says Dr. Winchester, "and the more things that everybody can get confused by. If a pump can do 50 different things, the patient can potentially get confused by 50 different things. Whereas if a pump only does something really simple, there's not going to be a lot of confusion about it."

But, Dr. Winchester adds, when you gain simplicity, "what you potentially lose is several-fold." For example, the least complex pumps don't have bolus options, and aren't as precise. "They might run higher than they need to and run out quicker," he says.

Still, he says, "all things considered, I think for a pump being used for a wide variety of patients in an ambulatory setting, with a wide range of intellectual capabilities and medical understanding, simple tends to be better." Dr. Canlas agrees. "Ergonomics and simplicity of use are the biggest factors as to why we chose one pump over another," he says. "The simpler the pump, the fewer potential malfunctions and the less confusing to patients. The fancier pumps may allow you to do some other things, but it really depends on your patient population. We don't want to overcomplicate things for our patients."

4. Do you need a bolus?

As noted, the most-basic models provide a steady flow of anesthetic, and nothing else — not even a bolus. But the experts we talked to strongly favor having a bolus option, at least in the vast majority of cases.

"It gives patients a little bit of control," says Steven Butz, MD, an anesthesiologist at the Children's Hospital of Wisconsin Surgicenter in Milwaukee. "It also gives me an idea of how the pain control is by telling me how often patients are hitting the button, when I follow up with post-op phone calls. It tells me how well the pump is working and whether I need to go up or down on the rate."

Dr. Canlas initially worried that giving patients a bolus option could lead to episodes of local anesthetic toxicity, but says his facility recently decided to allow patients more control. "Some patients may actually get better relief with a lower basal rate with a higher bolus rate that has lockout capabilities," he says. "I've seen success both ways."

The type and necessity of the bolus feature may be dependent on the procedure, says Dr. Winchester, who adds that interscalenes and femorals don't seem to need a bolus because "the nerve is so easily covered by the catheter trickle infusion." While this would allow the simplest of all settings — "Just set the pump at a certain rate, leave it running, and don't let it go up or down," says Dr. Winchester — the potential downside is that if the local isn't spreading well enough, you don't have the ability to turn it up, he says. And if you leave it at a higher rate, the anesthetic could spread to the phrenic nerve, which causes shortness of breath, he adds.

Some other blocks, on the other hand, strongly indicate the need for a pre-scheduled bolus, delivered at specific intervals, says Dr. Winchester. That feature is available only with electronic pumps. One such block is the fascia iliaca, because the tip of catheter isn't close enough to the nerves; another is the TAP (transversus abdominis plane), because volume spread delivered by a bolus may be needed to get to multiple dermatomal levels.

The manual bolus feature of an elastomeric pump is more cumbersome, says Dr. Winchester. "It's closer to a manual flush, compared to a digital bolus, which is slick and easier to apply. Basically, you just press a button, like you would with a remote control. No wrist strength or application pressure is needed." A patient-controlled bolus tends to be sufficient with an infraclavicular or adductor canal block, he says.

5. What's the price?

Cost is another area where you'll have to think about tradeoffs.

"We had success with some of the pumps we used previously, but the costs were escalating, and we didn't think they were worth it," says Dr. Canlas. "There are a bunch of products that are competitive out there that for us do the job just fine. For us, it came down to simplicity for patients as well as cost to our institution." Dr. Winchester says he's seen the same price inflation. "Unfortunately, some of the more established elastomeric companies have gotten expensive. You can have confidence that they're not going out of business in 2 weeks, and that they have a strong sales and support network, but their pumps cost a lot more," he says. "With hospitals, the name of the game is to save money, and there are other pumps coming in a lot cheaper. That's a major consideration."

So it's important to compare prices, he says. "One might be a Rolls-Royce or a Ferrari. I'd love to drive a Ferrari, but I don't, because they're too expensive. You might find the features of a Ferrari favorable, but still have to settle for a mini-van."

Prices, he says, range from around $100 to more than $400 per pump. How you use them also affects the bottom line. In certain scenarios, electronic pumps are more economical, because they can be equipped with larger bags.

"If you want to leave the catheter in for a week — like we do for our shoulders that are getting aggressive physical therapy — instead of paying twice as much for a larger elastomeric pump, you can pay the same amount for an electronic pump and simply fill a bigger bag," says Dr. Winchester. "You may even want a pump to last 10 to 14 days for a patient with complex regional pain syndrome. For that, you'd have to use 2 elastomeric pumps, even if you used the larger size. But with an electronic pump, you'd be able to do it with very little additional cost — just the cost of the additional anesthetic." OSM