This article is more than 5 years old. Information may no longer be current.
Pain pumps: Efficacy and usefulness debated for shoulder repair
Advances in less painful arthroscopic approaches and pain management have limited their applications, some argue.
Research on the use of pain pumps began to emerge in the early 1990s, and the first commercial pumps came on the market a few years later. The pumps were touted as a way to minimize pain by delivering continuous doses of local anesthetic to surgical sites while avoiding the use of narcotics and potential side effects, including drowsiness and nausea.
Interest in pain pumps has grown over the last several years. But while the devices have many proponents, others have stopped using them because they say advances in pain management and surgical techniques have limited their applications.
“We lost some of our enthusiasm for the pumps when the techniques evolved into more arthroscopic approaches. We also found that we could get good analgesia with the interscalene block,” said Xavier A. Duralde, MD, of the Peachtree Orthopaedic Clinic in Atlanta.
Jonathan B. Ticker, MD, who is in a community practice in Massapequa, N.Y. and specializes in shoulders, has used pain pumps for five years and will continue using them for many of his shoulder surgeries. “I started using them for arthroscopic subacromial procedures and then added them for rotator cuff repairs and distal clavicle resections. I also find these devices very effective for capsular release for frozen shoulders.”
He finds the pumps easy to use and has never had an infection with one, leading him to wonder why they are not used more. “It may just be one more variable that physicians may not want to consider adding for their patients. But although it may not be right for every surgeon, I do think there are many patients for whom these devices are right,” said Ticker, who is also an assistant clinical professor at the Columbia University College of Physicians and Surgeons.
Self-administered lidocaine
|
| |
|
COURTESY OF JONATHAN B. TICKER |
In 1990, William J. Mallon, MD, was speaking with anesthesiologist Cathy Thomas, MD, who told him that when Mallon’s partner repaired the rotator cuff of one of her anesthetists, she had him put a catheter in so that when she had pain she could self administer lidocaine. Mallon liked the idea and he and Thomas began exploring the use of implantable, injectable pumps; they then began working with infusion companies that produced devices for home chemotherapy.
Thomas established dosages, and Mallon began using them in patients and keeping them overnight to ensure their safety. “The first one I ever did was on a woman who was the office manager for a medical malpractice firm, so I was pretty sure it was going to work,” Mallon told Orthopedics Today.
Mallon and Thomas continued to use the devices, but they never tried to patent them. At about the same time, Thomas Sgarlato, DPM, was exploring the use of pain pumps following reconstructive foot surgery. In 1996, Sgarlato Laboratories’ Pain Control Infusion Pump (PCIP) became the first pain pump on the market. Today, several other companies have pumps on the market, including I-Flow Corp., Stryker, BREG Inc. and Baxter Healthcare.
Pump designs vary. The PCIP is a continuous-infusion pump that uses spring loading to deliver a constant flow of anesthetic. I-Flow’s Pain Buster is also a continuous infusion pump, but it uses a balloon reservoir to deliver anesthetic. BREG’s Pain Care 2000 Pump is a patient-administered flow device that delivers anesthetic into the wound or joint. There are also electronic devices that are considered by some to be more accurate.
In 1994, Mallon published the first study on the use of pain pumps. The prospective study looked at 48 patients undergoing arthroscopic acromioplasty; one group of 24 patients received a catheter that delivered a 2% solution of lidocaine for 72 hours following surgery. The control group did not receive the pain pump. Results showed that subjective pain levels were lower and that the use of pain medication was lower in the pain pump group at a statistically significant level in the P .01 to P<.02 range.
Mallon co-authored a study with Felix H. Savoie, MD, that was published in Arthroscopy in 2000. Surgeons placed an indwelling pain control infusion catheter at the operative site in 62 consecutive patients undergoing arthroscopic subacromial decompression. Thirty-one patients received 0.25% bupivacaine and the remainder received saline infusions, each at the rate of 2 mL per hour.
Patients tabulated the amount of narcotic and non-narcotic medication used in the first week following surgery and also evaluated their pain using the Visual Analog Scale. The results showed that there was a statistically significant difference in pain in all parameters tested in the bupivacaine group when compared with the control group (P<.05).
At the 2001 meeting of the American Academy of Orthopaedic Surgeons, Duralde presented a poster comparing the use of interscalene block analgesia to a marcaine pump following outpatient open rotator cuff repair.
Patients were randomly assigned to receive either a preoperative interscalene block (36) or a pain pump (29) inserted in the subacromial space at the end of the surgery. After a bolus of 0.25% marcaine, an infusion of 5 cc per hour was delivered over two days. Patients were allowed to take Percocet and Toradol.
Patient satisfaction
“Overall patient satisfaction in the pain pump group was 90% on the first night and 90% on the second night as well. In the interscalene block group, patient satisfaction the first night was 89% and the second night it dropped to 70%,” Duralde said.
|
Late last year, Carlos A. Guanche, MD, published an article in the Journal of Shoulder and Elbow Surgery evaluating the use of pain pumps following arthroscopic surgery for decompression of the subacromial space and repair of torn labrums in the glenohumeral joint. For the blinded study, 50 patients were randomized to receive either the pain pump as per the manufacturer’s instructions or a dummy pain pump that was simply taped to the skin.
“There was essentially no difference between the two groups, other than the fact that the patients who had the pain pump left the recovery room on average 30 minutes earlier, but in terms of longer pain relief or any increased ability to do anything earlier, there was absolutely no difference,” said Guanche, who practices at the Southern California Orthopedic Institute in Van Nuys, Calif.
While he used the pumps “off and on” before he did the study, he no longer does so. When he did his study, all patients received a bolus of marcaine in the subacromial space prior to surgery and that likely explains his study’s results. “I think the reason that the patients didn’t have a lot of pain was that their pain was sort of blocked to begin with,” said Guanche, who now uses preoperative anesthetic as his standard of care.
Becoming unnecessary
Guanche’s views echo those of others who no longer use pain pumps. Duralde said that since his practice has begun to do more arthroscopic rotator cuff repairs that are less painful postoperatively, pain pumps have become unnecessary. “We’re finding that we may not need it [a pain pump] any more, because for the open surgery it was great, but for arthroscopic surgery, the interscalene block seems to be enough.”
Donald Johnson, MD, director of the Sports Medicine Clinic at Carleton University in Ottawa, said the emergence of multimodal approaches have changed how he manages pain. He used to use pain pumps following anterior cruciate ligament reconstruction, but now uses preoperative NSAIDs, femoral nerve blocks, and intraarticular and incisional injections of marcaine and morphine. “It’s a pretty aggressive pain management, and we just didn’t need the pain pumps.”
Mallon said he no longer uses the pumps because he finds interscalene blocks to be more effective and also because insurance companies in his area will not pay for them.
Unlike some other surgeons, Ticker plans to continue using pain pumps because he believes they are very effective, easy to use and dependable. “These are going to settle into the market somehow and there are going to be surgeons who choose to use them and surgeons who choose not to use them. It all depends upon who has had positive experiences similar to mine. If surgeons see that these devices are effective, then they’ll be used more and more.” One of the hospitals where he operates has begun keeping pumps in stock.
Ticker also said that surgeons must determine for themselves if the pain pumps have applications not just in the shoulder but also in other parts of the body. Several researchers are investigating the use of pain pumps following anterior cruciate ligament reconstruction and total knee replacement.
Ticker and others agree that more data might help persuade surgeons to use these tools. There are now, at most, 15 published studies on pain pumps, and most of those focus on their use in the shoulder. Many surgeons who have used the pumps believe that more randomized, blinded trials could clarify whether lidocaine, marcaine or some other drug is best to use, and what rate of drug infusion is optimal. Duralde said studies could also be done to examine the possible placebo effect of patient-controlled analgesia.
Guanche said another thing may contribute to the longevity of pain pumps — their popularity with patients. He has patients who request pain pumps, and he said it can be difficult to make patients understand why he does not use them.
“It’s hard to tell people that this so-called pain pump that magically delivers anesthesia to your joint is not all that it’s made out to be.”
For more information:
- Savoie FH, Field LD, Jenkins RN, Mallon WJ, et al. The pain control infusion pump for postoperative pain control in shoulder surgery. Arthroscopy. 2000;16(4):339-342.
- Quick DC, Guanche CA. Evaluation of an anesthetic pump for postoperative care after shoulder surgery. J Shoulder Elbow Surg. 2003;12(6):618-621.
- Duralde XA, McCollam S, Scherger A. Postoperative pain management following outpatient open rotator cuff repair: A comparison of interscalene block analgesia versus marcaine pump. PE252. Presented at the American Academy of Orthopaedic Surgeons 68th Annual Meeting. Feb. 28-March 4, 2001. San Francisco.