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A type of infusion pump, manufactured by Fresenius.

An infusion pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used.

Infusion pumps can administer fluids in ways that would be impractically expensive or unreliable if performed manually by nursing staff. For example, they can administer as little as 0.1 mL per hour injections (too small for a drip), injections every minute, injections with repeated boluses requested by the patient, up to maximum number per hour (e.g. in patient-controlled analgesia), or fluids whose volumes vary by the time of day.

Because they can also produce quite high but controlled pressures, they can inject controlled amounts of fluids subcutaneously (beneath the skin), or epidurally (just within the surface of the central nervous system – a very popular local spinal anesthesia for childbirth).

Types of infusion

The user interface of pumps usually requests details on the type of infusion from the technician or nurse that sets them up:

To get the entire dose of antibiotics into the patient, the "volume to be infused" or VTBI must be programmed for at least 30 CCs more than is in the medication bag; failure to do so can potentially result in up to half of the antibiotic being left in the IV tubing.

Some pumps offer modes in which the amounts can be scaled or controlled based on the time of day. This allows for circadian cycles which may be required for certain types of medication.

Types of pump

A Baxter International Colleague CX infusion pump
Patient in an intensive care unit in a German hospital in 2015, with two staples of four to five stationary infusion pumps each, on top right behind him (resp. behind the visitor).

There are two basic classes of pumps. Large volume pumps can pump fluid replacement such as saline solution, medications such as antibiotics or nutrient solutions large enough to feed a patient. Small-volume pumps infuse hormones, such as insulin, or other medicines, such as opiates.

Within these classes, some pumps are designed to be portable, others are designed to be used in a hospital, and there are special systems for charity and battlefield use.

Large-volume pumps usually use some form of peristaltic pump. Classically, they use computer-controlled rollers compressing a silicone-rubber tube through which the medicine flows. Another common form is a set of fingers that press on the tube in sequence.

Small-volume pumps usually use a computer-controlled motor turning a screw that pushes the plunger on a syringe.

The classic medical improvisation for an infusion pump is to place a blood pressure cuff around a bag of fluid. The battlefield equivalent is to place the bag under the patient. The pressure on the bag sets the infusion pressure. The pressure can actually be read-out at the cuff's indicator. The problem is that the flow varies dramatically with the cuff's pressure (or patient's weight), and the needed pressure varies with the administration route, potentially causing risk when attempted by an individual not trained in this method.

Places that must provide the least-expensive care often use pressurized infusion systems. One common system has a purpose-designed plastic "pressure bottle" pressurized with a large disposable plastic syringe. A combined flow restrictor, air filter and drip chamber helps a nurse set the flow. The parts are reusable, mass-produced sterile plastic, and can be produced by the same machines that make plastic soft-drink bottles and caps. A pressure bottle, restrictor and chamber requires more nursing attention than electronically controlled pumps. In the areas where these are used, nurses are often volunteers, or very inexpensive.

The restrictor and high pressure helps control the flow better than the improvised schemes because the high pressure through the small restrictor orifice reduces the variation of flow caused by patients' blood pressures.

An air filter is an essential safety device in a pressure infusor, to keep air out of the patients' veins. Small bubbles could cause harm in arteries, but in the veins they pass through the heart and leave in the patients' lungs. The air filter is just a membrane that passes gas but not fluid or pathogens. When a large air bubble reaches it, it bleeds off.

Some of the smallest infusion pumps use osmotic power. Basically, a bag of salt solution absorbs water through a membrane, swelling its volume. The bag presses medicine out. The rate is precisely controlled by the salt concentrations and pump volume. Osmotic pumps are usually recharged with a syringe.

Spring-powered clockwork infusion pumps have been developed, and are sometimes still used in veterinary work and for ambulatory small-volume pumps. They generally have one spring to power the infusion, and another for the alarm bell when the infusion completes.

Battlefields often have a need to perfuse large amounts of fluid quickly, with dramatically changing blood pressures and patient condition. Specialized infusion pumps have been designed for this purpose, although they have not been deployed.

Many infusion pumps are controlled by a small embedded system. They are carefully designed so that no single cause of failure can harm the patient. For example, most have batteries in case the wall-socket power fails. Additional hazards are uncontrolled flow causing an overdose, uncontrolled lack of flow, causing an underdose, reverse flow, which can siphon blood from a patient, and air in the line, which can cause an air embolism.

Elastomeric pumps, also known as balloon pumps or ball pumps, rely on the gradual contraction of an internal elastomeric reservoir to deliver medication at a pre-determined flow rate over several hours or days. These pumps do not require electricity and offer simplicity and portability, making them suitable for administering various medications, including antibiotics, in situations where continuous, low-rate infusion is required. These features make them useful for infusions in outpatient settings, such as outpatient parenteral antibiotic therapy (OPAT). However, due to their limited features and programmability, they are not suitable for all medications or flow rates.[1][2]

Safety features available on some pumps

The range of safety features varies widely with the age and make of the pump. A state of the art pump in 2003 might have had the following safety features:

By 2019 intravenous smart pumps were being introduced. They could include wireless connectivity, drug libraries, profiles of care areas, and soft and hard limits.[3]

Safety issues

Infusion pumps have been a source of multiple patient safety concerns, and problems with such pumps have been linked to more than 56,000 adverse event reports from 2005 to 2009, including at least 500 deaths.[4] As a result, the U.S. Food and Drug Administration (FDA) has launched a comprehensive initiative to improve their safety, called the Infusion Pump Improvement Initiative.[5] The initiative proposed stricter regulation of infusion pumps. It cited software defects, user interface issues, and mechanical or electrical failures as the main causes of adverse events.

See also

References

  1. ^ Diamantis S, Dawudi Y, Cassard B, Longuet P, Lesprit P, Gauzit R (February 2021). "Home intravenous antibiotherapy and the proper use of elastomeric pumps: Systematic review of the literature and proposals for improved use". Infectious Diseases Now. 51 (1): 39–49. doi:10.1016/j.medmal.2020.10.019. PMID 33576336. S2CID 230762015.
  2. ^ Spencer-Jones J, Luxton T, Bond SE, Sandoe J (August 2023). "Feasibility, Effectiveness and Safety of Elastomeric Pumps for Delivery of Antibiotics to Adult Hospital Inpatients-A Systematic Review". Antibiotics (Basel, Switzerland). 12 (9): 1351. doi:10.3390/antibiotics12091351. PMC 10525832. PMID 37760648.
  3. ^ Davis, S.; Blanchard, C.; Lewis, J. (26 October 2018). "Implementing Smart Pumps to Enhance Patient Safety". Hospital Pharmacy. 54 (4): 217–219. doi:10.1177/0018578718809252. PMC 6628554. PMID 31320768.
  4. ^ Pharmacy Practice News, May 2010
  5. ^ "White Paper: Infusion Pump Improvement Initiative". FDA. 14 January 2020.