With many major orthopedic surgeries shifting to the outpatient setting, ASCs and hospital outpatient departments are grappling with how to help patients heal at home and achieve high levels of patient satisfaction while limiting opioid use. Anesthesia providers can achieve this with new postop pain management solutions like regional anesthesia and new pain pump technologies that safely extend the duration of pain relief for orthopedic surgery patients out to five days.
Becker’s Healthcare recently spoke with two anesthesiologists about the benefits of innovative pain pump solutions compared to legacy elastomeric pain pumps:
- Leslie Thomas, MD, director, regional anesthesia and acute pain, Ochsner Health in New Orleans
- Scott E. Thomas, MD, regional anesthesia fellowship director, Andrews Institute ASC in Gulf Breeze, Fla.
The following article is based on those conversations and additional statements made by Dr. Leslie Thomas during a March webinar.
Regional anesthesia enables ASCs to perform major orthopedic surgeries on an outpatient basis
Having a pain management strategy for orthopedic surgery patients, especially those undergoing total joint replacements, is critically important. “Patients that have a positive perioperative experience can be an incredibly powerful tool in recruiting new business by word-of-mouth marketing,” Dr. Scott Thomas said.
Continuous catheters not only improve patient satisfaction, but they also improve surgical outcomes. Rehab and therapy are huge components of successful surgeries and the whole perioperative process. According to Dr. Scott Thomas, “When patients aren’t limited by pain, they can work harder in rehab postoperatively. That helps prevent formation of scar tissue and other complications. On total knee cases, when patients have good therapy sessions for the first few days after surgery, that sets their recovery course and gets them moving in the right direction.”
Unlike opioids, the medications used with nerve catheters for regional anesthesia don’t alter the patient’s balance, motor function or ability to stand on crutches after surgery. “Our patients need to start PT about an hour after they get out of the operating room,” Dr. Leslie Thomas said. “With multimodal analgesia, a peripheral nerve catheter and therapy, patients can safely go home after their surgeries.”
Dr. Scott Thomas emphasized that “in the modern era of social media and online reviews, patient satisfaction can be paramount to the success of an ASC.”
“A single positive patient experience can be worth its weight in gold for attracting not only new patient business, but new surgeons too,” he said. “No marketing technique is more powerful, or more cost-efficient, than a personal recommendation from a trusted friend or family member.”
Electronic postop pain pumps ensure patient safety and satisfaction during the in-home healing process
Next-generation, electronic postop pain pumps are much more configurable, more precise and more reliable than legacy elastomeric pumps. “If we are doing a shoulder surgery versus a knee surgery, we can use different pain pump infusion settings,” Dr. Scott Thomas said. “This ensures the best outcome for the patient, while minimizing the total amount of medication they receive and reducing potential drug side effects. We can also track how much medication the patient has received. This is a huge advantage compared to elastomeric pumps.”
Dr. Leslie Thomas agreed: “When we used elastomeric pumps, we would call patients and sometimes the drug reservoir would be empty after 24 hours. I don’t feel comfortable sending people home with those anymore, due to concerns about local anesthetic toxicity. Surgeons also saw more neuropathic pain in some patients, especially total knees. We thought it could be because patients were getting so much local anesthetic on specific nerves in such a short period of time. Since we started using electronic pumps, we haven’t seen that.”
Intermittent Bolus infusion mode uses less medication, enhances anesthetic spread and provides five days pain relief
Electronic pain pumps support a new infusion mode called intermittent bolus which has several benefits. With continuous infusion, the anesthetic may not achieve the spread needed within the nerve space. When anesthesia providers program an electronic pain pump to infuse an automated bolus every few hours, that forceful delivery gives the spread required to manage pain without draining the anesthetic reservoir too rapidly.
“One of the most common reasons a patient seeks unplanned care after surgery is due to poorly managed pain,” Dr. Scott Thomas said. “A well-placed catheter and a smart pain pump infusing automated boluses can help them avoid costly and time-consuming trips to the ER and reduces the strain on limited emergency resources so they can be used for sicker patients.”
Another useful feature of the Nimbus PainPRO postop pain pump is the patient-controlled analgesia function. Patients can hit a button on the pump and give themselves an additional dose of medicine, as needed. As Dr. Leslie Thomas observed, “Patients like having that Demand Bolus. I think we get a lot less calls because it’s available. After the patient presses the bolus button and knows they will get relief, they get a lot more comfortable going home to recover after seeing that. That capability allows us to use lower doses than we ever thought would’ve worked.”
Nerve blocks and continuous catheters minimize or eliminate the use of opioids for postoperative pain
Previously, the gold standard after surgery was to give patients substantial prescriptions for narcotic pain medicine, despite the risks and side effects. Now physicians are rethinking that approach in favor of more regional anesthesia.
Intermittent bolus pumps like the Nimbus PainPRO have dramatically reduced patient use of opioids following outpatient orthopedic procedures. This is a positive step toward preventing drug diversion and improving the patient experience, since opioids affect appetite, sleep patterns and digestive processes.
“We call our patients on postop day one and four,” Dr. Leslie Thomas said. “Our shoulder patients rarely, if ever, take any opioids postop with these intermittent bolus pumps. Our surgeons absolutely love the new electronic pain pumps. It’s incredible. Basically, all upper extremity cases are almost opioid free now. Some total knees and ACLs are still using some opioids, but it’s a lot less.”
Dr. Scott Thomas echoed those results, “Prior to the adoption of regional anesthesia, the preferred method for treating severe pain following surgery was to administer high doses of opioid medications. A successful outpatient regional anesthesia program that utilizes these feature-rich pain pumps can oftentimes be the difference maker between competing facilities.”
Before deploying an electronic pain pump program, engage key stakeholders like Nursing, Pharmacy, and Supply Chain
Post-anesthesia care unit nurses can be important advocates for electronic pain pumps. But if setting up the device for the patient requires extra steps, that can make them less attractive. “We have all of our specific infusion programs set up in our Nimbus pumps,” Dr. Leslie Thomas said. “So, it’s super easy for the nurses to set them up. I also think that’s a safety aspect, which is why I prefer electronic pain pumps.”
Legacy elastomeric pain pumps must be filled with local anesthetic by the HOPD Pharmacy or by an outsourced pre-filling service for an ASC. For a busy postop acute pain service, that can require significant Pharmacy resources, or trigger greater expense by outsourcing every pump pre-fill.
One advantage of newer electronic pain pumps like Nimbus® II PainPRO is that they infuse from a standard IV bag of medication — 500mL, 1000mL or a custom size for the procedure. Compared to labor-intensive elastomeric pump filling, preparing a bag in pharmacy can be a simpler task. And, if outsourced to a 503B compounder, a bag of local anesthetic typically costs less versus purchasing a prefilled pump.
Electronic pumps like Nimbus are also recyclable, which can help facilities reduce supply chain waste and achieve sustainability. Each Nimbus pump comes with a box to return it for recycling purposes, but there is no penalty if patients don’t return the pump. Other pump companies can require you to return equipment via FedEx or UPS. That obligation can be a challenge in large healthcare facilities. And, from a patient advocacy perspective, most ASCs don’t want their patients to get a bill or be sent to collections for not returning a pump.
Conclusion
Electronic pain pumps and continuous catheters represent a positive evolution in pain management. “Often, patients are more anxious about their postoperative course, and anticipated pain specifically, than the actual surgery or anesthesia,” Dr. Scott Thomas said. “Offering state-of-the-art regional anesthesia techniques with auto bolus pain pumps helps alleviate many patient concerns regarding pain management.”
Dr. Leslie Thomas summed up her thoughts: “When we went from elastomeric pumps to the electronic pumps with an intermittent bolus every three hours and the ability for patients to give themselves an on-demand dose every 30 minutes, that changed the ballgame.”