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Pain, Pain Go Away

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Dr. Lynn Martin is working to make Children's a national center of excellence in regional anesthesia.

Dr. Lynn Martin is working to make Children's a national center of excellence in regional anesthesia.

The day before Dr. Lynn Martin planned to drop out of his anesthesia residency program at Johns Hopkins University, he arrived in the OR to find that his first case of the morning was a boy who had been seriously burned and was receiving a series of skin grafts.

During surgical preparation, Martin suggested to the attending anesthesiologist that, in addition to general anesthesia, the child receive regional anesthesia to block nerve sensation in the area of the painful graft. The attending anesthesiologist agreed.

Hours later, Martin accompanied the boy back to his room. When his mother saw her son sitting in bed contentedly holding a balloon, she burst into tears. Fearing that he had done something wrong, Martin went to comfort her and find out why she was so upset. To his surprise, the mother told Martin that this was the happiest she had seen her child since his admission to the hospital several weeks before.

In that moment, Martin realized the power of regional anesthesia to help children begin their recovery without the stress of postoperative pain. The event not only cemented Martin's career in anesthesia, it continues to inform his leadership in the field.

Now the leader of Seattle Children's Department of Anesthesiology and Pain Medicine, Martin leads a team of nearly 40 pediatric anesthesiologists participating in a multi-year process to become proficient in regional anesthesia — a huge commitment considering that most pediatric anesthesia departments perform few regional anesthesia procedures and have only one or two trained clinicians.

A Best Practice

Regional anesthesia is not a new concept; in fact, it has been practiced for several decades to block peripheral nerves prior to surgeries in the lungs, abdominal-pelvic cavity, hips and limbs. Yet its use with children has lagged behind use with adults because of the difficulty injecting anesthesia near — but not into — tiny nerves.

"Delivering accurate regional anesthesia is one of the hardest things an anesthesiologist tries to do," explains Martin. "With infants and young kids it's doubly hard because their nerves are so much smaller than those of adults."

Yet those who practice regional anesthesia are strong advocates for its effectiveness.

"Regional anesthesia is a best practice," says Seattle Children's anesthesiologist Dr. Sean Flack. "It reduces the body's stress response to surgery and allows a lighter level of general anesthesia to be used during surgery."

The local anesthetics used in regional nerve blocks reduce — and may even eliminate — the need for narcotic-based pain medicines. These powerful painkillers can have side effects ranging from prolonged sedation and slowed breathing to stomach upset and hallucinations. Regional anesthesia, which does not contain narcotics, is particularly beneficial for infants since they don’t metabolize narcotics as well as older children.

Regional anesthesia can be administered through a single injection before surgery or delivered continuously through a catheter after surgery. A single-shot block provides many hours of postoperative pain relief while the catheter blocks nerve pain until it is removed.

A Rare Comparison

Fourteen-year-old Tyler Stedham was born with flat feet that never developed arches, a normal condition that affects approximately 20% of the population. But unlike most flat feet that are flexible, Tyler’s were rigid, which created so much stress on the joints of his heels and ankles that over time he could not walk without pain.

Ron Quam

Surgical resident Dr. Ron Quam checks Tyler Stedham’s foot for sensation during a postoperative check up.

Tyler underwent surgery on both feet in San Diego when he was 10, but the pain and rigidity of his feet worsened. By the time the Arlington High School freshman and his dad, John, met Children’s orthopedic surgeon Dr. Vincent Mosca, it was clear he needed more surgery on his feet.

The procedure, called triple arthrodesis, would immobilize the joints below Tyler’s ankles — and eliminate his pain — by fusing together the three severely degenerated joints of each heel and allowing the bones to grow solidly together while preserving range of motion in his ankles.

After waking from the surgery on his right ankle in September 2006, the first thing Tyler felt was pain — lots of it. “It was bad,” he recalls. “They gave me pain meds by mouth during the seven days I was in the hospital, and I was still in pain for a couple weeks after I went home.”

In May 2007, it was a different story. Before this second surgery, Children’s anesthesiologist Dr. Laurilyn Helmers inserted a catheter that delivered regional anesthesia into Tyler’s upper leg. The regional block numbed the nerves in his leg, ankle and foot for the first few days of his recovery.

“When I woke up from surgery the second time, I didn’t feel anything because my whole leg was numb,” remembers Tyler. “When they took the numbing thing out after three days, my leg still didn’t hurt. I left the hospital after only five days, and I got off the pain pills faster at home. My second ankle seems to be healing quicker, too.”

“Once you get behind in pain control, it’s hard to catch up,” explains Dr. Robert Sawin, Children’s surgeon-in-chief. “Regional anesthesia evens out the peaks and valleys of pain control and keeps you ahead of the pain.”

“Tyler’s experience with regional anesthesia is common,” says his surgeon, Dr. Vincent Mosca. “My patients who receive regional blocks are more comfortable, alert and less nauseated. It really improves their overall hospital experience.”

Improving Techniques

Though beneficial, regional anesthesia has risks: accidentally injecting a local anesthetic into a vein can cause seizure or cardiac arrest; injecting into a nerve may result in chronic pain or permanent nerve damage.

Most anesthesiologists are trained to deliver regional anesthesia using special needles that stimulate nerves to show where — and where not — to inject anesthesia into a child's body. However, this technique works only with motor nerves and can't be used on limbs with breaks or fractures. It also isn't useful when general anesthesia includes muscle relaxants.

However, improvements to ultrasound technology — including two-dimensional high-resolution viewing and faster processing — are making the delivery of regional anesthesia easier, safer and more accurate.

"The ultrasound technology allows us to see anatomical detail," says Dr. Corrie Anderson, a pain medicine expert at Children's. "We can use less local anesthesia for the nerve block, since ultrasound is much more accurate in pinpointing the optimal spot to target the injection."

Though only 30% of children's hospitals now use ultrasound guidance to administer regional anesthesia, Anderson believes it will eventually become the national standard of care.

"We're at the forefront of ultrasound guidance in pediatric regional anesthesia," comments Anderson. "As we get better at using ultrasound, I expect that the effectiveness of our nerve blocks will increase from about 80% to upwards of 99% and that our complication rates will decrease from one in 1,000 to one in 10,000 or lower."

A Center of Excellence

While Children's anesthesiologists work to master their regional anesthesia skills, Martin forges ahead with a much larger vision: to develop better standards of care in pediatric regional anesthesia and teach these best practices to clinicians across the country.

But first he's ironing out a nagging issue on his own home turf. After realizing that regional anesthesia was taking up precious OR time, Martin commandeered a little-used induction room outside the OR and turned it into a "block room." He's currently piloting the new process in a collaborative effort with orthopedic surgeons.

Martin is also busy exchanging ideas and techniques with other international regional anesthesia experts. Dr. Adrian Bosenberg, from Cape Town, South Africa, spent three months in summer 2006 instructing Children's anesthesiologists and impressing surgeons with his ability to use ultrasound to administer nerve blocks quickly.

Bosenberg and Dr. Peter Marhofer from Vienna, Austria, the first anesthesiologist in the world to administer a nerve block on a newborn weighing less than one pound, brought their expertise to Seattle Children's first annual pediatric regional anesthesia conference in September 2007.

Soon, Martin and his team will work with Bosenberg and other international investigators on new clinical studies to ensure that more children around the world wake up comfortable after surgery and stay that way.

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