A Smarter Way to Improve Patient Care

Patient Experience Pain Management Anesthesia

By: Joe Paone | Senior Editor

Published: 3/22/2022

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Innovative pain pumps deliver precise medication doses that extend analgesic activity well beyond the PACU.


Postoperative pain pumps have become “smarter” over the years, enabling providers to better ensure patients get the right dosages of anesthetic medicine at the right times — and even allowing individuals in recovery to give themselves an extra boost when they really need it. Some newer pumps even allow providers to monitor their patients’ usage of analgesics in real time or analyze collected data for improving how pain is managed.

The devices allow anesthesia providers to extend high-quality pain control beyond the OR while reducing use of opioids, according to Jeff Gadsden, MD, an anesthesiologist and division chief for orthopedics, plastics and regional anesthesiology at Duke University Medical Center in Durham, N.C. “The local anesthetics we use might be able to provide 24 hours of relief at best,” he says. “Placing a continuous catheter and hooking it up to a reservoir of local anesthetic that pumps to the nerve site over the course of several days works well.”

Many surgical facilities use older elastomeric pain pumps. “These are rubbery balls filled with liquid local anesthetic to the point where they are very taut, and the elastic recoil of the ball pushes local anesthetic through the tubing to the patient,” says Dr. Gadsden. The problem with elastomeric pumps is accuracy. “They notoriously have a plus-minus on their ranges, so you might be underdosing or in some cases overdosing the patient,” he adds.

That has led to interest in more precise technology for delivering local anesthetics — usually meds with good safety profiles such as ropivacaine or bupivacaine. Many providers also would like to empower patients to administer additional small doses of medication or even reduce the amount of medication if they feel too numb. These issues have led to increased adoption of electronic pumps.

Tailored treatments

DUAL CONTROL The latest pain pumps allow patients to give themselves a boost of medication to treat breakthrough pain, while clinicians gain the ability to set dosage limits, monitor usage and collect valuable data for process improvement.

The newest models enable providers to pre-program administration rates and timing, while the patient can retain the ability to self-administer within a set limit. Instead of the medicine continuously running at a set volume as with an elastomeric pump, electronic pumps offer providers and patients greater control over how much medicine is delivered, and when.

“It gives clinicians a lot of flexibility,” says Dr. Gadsden. “You can program a background rate, and then program a patient bolus so the patient can give themselves a booster dose. You can set it so that every hour or two hours, the pump automatically delivers a dose, so even when the patient is sleeping, they get that additional effect.”

Dr. Gadsden says the concept of the electronic pain pump is usually introduced to the patient by their surgeon during a preoperative visit. The surgeon explains that, as part of the recovery process, an anesthesia provider will place a catheter in the surgical area that will provide several days’ worth of numbness and pain control.

The pump comes with a carrying case as well as instructions and precautions (“what to do, what to expect, what you should call us about if you experience it,”says Dr. Gadsden). When the reservoir of medication is empty, the patient simply peels the bandage off the catheter, which slides out and can be thrown away.

Cost comparisons between elastomeric pumps and electronic pumps are difficult to quantify. “There are a couple different sources of that cost,” says Dr. Gadsden. “One is the acquisition cost; the other is the cost for the pharmacist to fill the pump up.” He says pharmacists typically needs to mix medications and manually fill elastomeric pumps themselves, which consumes person-hours, whereas electronic pumps tend to use prefilled IV bags purchased from a compounding pharmacy. “In terms of the actual device, they’re converging somewhat in the same price zone,” he adds.

There’s also opportunity cost savings related to patient outcomes, according to Dr. Gadsden. For example, patients who are given pumps that administer local anesthetics for three days might go to the ER for treatment of uncontrolled pain more often or take more opioids than patients who are given pumps that deliver medications for five days. Dr. Gadsden says those factors are challenging to put a dollar figure on, but they impact the overall costs of care.

John J. Finneran IV, MD, an associate clinical professor of anesthesiology at University of California, San Diego, agrees that the cost difference between elastomeric and electronic pumps isn’t much, with disposable versions of both types running in the $150 range. Reusable electronic pumps, while more costly, can be used for dozens of patients, but the cost savings are heavily dependent on how reliable your patient population is in getting those pumps back to you, he notes.

 

Automation and control

Dr. Finneran uses pain pumps to place about 1,000 continuous peripheral nerve blocks a year. “We can provide really good pain relief after surgery,” he says. “The longest-acting numbing medicine we have is bupivacaine, which only lasts 12 to 24 hours, depending on where you put it. Surgical pain lasts much longer than that.”

Electronic pumps let Dr. Finneran combine automated boluses with patient-controlled boluses, a feature he says is key. “Giving patients boluses of local anesthetic is nice, but if you only have patients controlling their boluses, and they forget to do it or fall asleep, it can lead to a lot of pain that’s difficult to get back under control,” he says. “With automated boluses, you can take advantage of that extra spread of local anesthetic while not relying on the patient to self-administer the medication.”

He says electronic pumps are not challenging for most patients to use. “The pumps administer the medication automatically, either as a continuous infusion or as automated boluses, and patients can push a button if they want to give themselves an extra dose,” says Dr. Finneran.

Patients’ main concern about the devices is removing the catheter. “Most patients assume they need to schedule a follow-up appointment to have it removed,” he says. “Really, it’s just secured in with a tape-like dressing, and when you peel it off, it just falls out.” In terms of potential complications, Dr. Finneran says connections can become kinked or tubing can catch on something and become disconnected. On rare occasions, pumps will malfunction and need to be reset — ideally by a nurse who can walk patients through the resetting process.

Dr. Finneran and colleagues recently conducted a study about pain pumps that is under final review. “We compared automated boluses to continuous infusion for popliteal sciatic catheters for pain control after foot and ankle surgery,” he says. They found that patients with preprogrammed automated boluses needed fewer total doses of local anesthetic, which was provided in a 500-mililiter reservoir — the largest amount he and his colleagues usually give patients. “We thought that by giving patients doses of long-lasting numbing medicine spread out in such a way that the basal dosing was less, we could potentially extend their pain relief by prolonging the infusion,” he says. “Interestingly, we found those patients also had better pain control. Their pain scores were lower, their opioid consumption was lower and the drug lasted longer.”

Providers who are tempted to provide more than 500 milliliters of anesthetic should keep the weight of the reservoir in mind. “Patients are connected to it, and they need to be able to move around,” says Dr. Finneran. “Any more than 500 milliliters is quite cumbersome to carry in a fanny pack, especially when you factor in the weight of the pump and the tubing.”

Infusion dosages and timing depend on the procedure. “Femoral nerve catheters, which an ASC might provide after an ACL repair, have a very low dosing requirement,” says Dr. Finneran. “We set the pump to administer four milliliters per hour, with a four-milliliter patient-controlled bolus available every 30 minutes. Brachial plexus catheters require more local anesthetic, so we set the pump to deliver eight milliliters per hour.”

Some electronic pumps can collect user data, which can be viewed in real time or collected and analyzed for process improvement purposes. “Many manufacturers now offer electronic dashboards where you can monitor the recoveries of individual patients and get their feedback,” says Dr. Gadsden. “You can see that a patient has been pressing their button a lot to give themselves a bolus, which means they’re probably hurting more than you want. That’s a time to give them a call to see if you can effectively tweak their treatment over the phone.” OSM

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