Ambulatory Continuous Peripheral Nerve Infusions (ON-Q® pumps)

Overview

• Patient can be discharged home with a peripheral nerve catheter. The ongoing continuous administration of local anesthetic will be done with a disposable, elastomeric pump the patient will leave the hospital with.
• The elastomeric pump used at UCSF (ON-Q) provides a regular flow of regional anesthesia to specific anatomic locations to reduce pain after a surgical intervention
• The ON-Q pump is set to infuse a regular flow of the local anesthetic ropivacaine (0.2%) 
• ON-Q pumps are initiated the day of discharge. They are either started after surgery in the PACU or replace the CADD pumps that have been used in the inpatient. 
• Once the pump is empty and deflated, the patient can remove the catheter and dispose the complete system in the trash.

Clinical Use

Indications: 

Ambulatory peripheral nerve infusions are exclusively used for outpatient pain management, most commonly following orthopedic surgery. 

Contraindications: 

Cannot be used in patients who are not able to recognize and report adverse side effects

Dosing:

• The 750ml elastomeric pumps are prepared and labeled by pharmacy
• Rates of continuous infusions are ordered in even increments (min: 2m/hr., max: 14ml/hr.)
• The chosen flow rate determines the duration of infusion (up to 5 days as part of a multimodal pain plan of care)
• “Select-a-Flow” rate regulators (connected to the pump) are programmed by RNs with provider order
• Neither range orders nor patient boluses are permitted
• Patients with ON-Q pumps are not permitted to alter infusion rates at home (the flow rate dial (“key”) is discarded by the nurse prior to patient discharge). 

Special Considerations

• Supplemental pain medications may be required in addition to the peripheral nerve infusion. The outpatient/discharge prescriptions are ordered by the surgical team.
• Leaking is common at the insertion site, typically managed with reinforced dressings/tape
• Local anesthetic systemic toxicity (LAST) is a life-threatening condition. The patient and  home caregiver need instructions to identify the signs of LAST: 
  • Early signs:  perioral numbness and tingling, tinnitus, metallic taste in mouth, ringing in ears, and blurred vision
  • Late signs: sedation, altered mental status, seizures, coma, dyspnea, hypotension, hypertension, bradycardia, tachycardia, ventricular tachycardia, ventricular fibrillation, and asystole
• Patients/caregivers are told to clamp the tubing in the event of adverse effects
• In addition to LAST, instructions include: importance of caregiver presence, pressure sore and falls prevention, and mobility assistance
• ON-Q pumps are not intended to deliver medicine intravascularly