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
References: 

The American Society of Regional Anesthesia and Pain Medicine. (2018). The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Regional Anesthesia and Pain Medicine, 43(2), 150–153. Retrieved from: https://www.asra.com/content/documents/asra_last_checklist_2018.pdf

Dave, S., Shriyan, D., & Gujjar, P. (2017). Newer drug delivery systems in anesthesia. Journal of anaesthesiology, clinic Dave, S., Shriyan, D., & Gujjar, P. (2017). Newer drug delivery systems in anesthesia. Journal of Anaesthesiology, Clinical Pharmacology, 33(2), 157–163. https://doi.org/10.4103/joacp.JOACP_63_16al pharmacology, 33(2).

Jafra, A., & Mitra, S. (2018). Pain relief after ambulatory surgery: Progress over the last decade. Saudi journal of Anaesthesia, 12(4), 618–625. https://doi.org/10.4103/sja.SJA_232_18

Kriel, H. H., & Yngve, D. (2019). Elastomeric Pain Pumps for Scoliosis Surgery. Cureus, 11(2), e4042. https://doi.org/10.7759/cureus.4042

ON-Q pump website: www.myON-Q.com. 24/7 Product Support Hotline: 1-800-444-2728

Author: 
Marilyn A Bazinski