What began with the pursuit of effective pain relief for joint replacement patients took anesthesiologist Joseph Marino, MD, across the country and onto the printed page. Dr. Marino was among the pioneers of using peripheral nerve blocks rather than narcotic pain relievers in joint replacement patients during the postoperative period. He found the benefits to be multiple - not only did patients experience a significantly greater degree of pain relief, but they did so without the side effects that commonly accompany narcotic pain remedies - confusion, grogginess, nausea, and respiratory depression.

"I knew that this was working for our patients, but there was a lack of empirical data published about the benefits of nerve blocks," Dr. Marino recalled. So he set out to perform his own study.

Three years later, after enrolling 225 patients in a randomized clinical trial comparing peripheral nerve blocks to patient controlled analgesia (PCA) in postoperative hip replacement patients, Dr. Marino has written two textbook chapters about this highly specialized procedure, presented a number of lectures to his colleagues around the region, spoken at the national Anesthesiology Society meeting held in San Francisco, and submitted his research findings to a major medical journal for publication.

This caliber of academic activity is more commonly associated with physician-scientists at large, academic medical centers. Dr. Marino and the Department of Anesthesiology at Huntington have created a model for establishing a postoperative pain service at hospitals around the country.

"Ten years ago, patient controlled analgesia was the standard of care for patients undergoing joint replacement surgery," Dr. Marino pointed out. These patients typically received a narcotic such as morphine infused through a pump. A button on the pump enables patients to administer the medication when dictated by their own pain level.

"Narcotic pain medicines are fraught with side effects, and the people most sensitive to these side effects, particularly confusion and respiratory depression, are the elderly," Dr. Marino said. "With the use of continuous peripheral nerve blocks as an alternative, many patients manage to receive no narcotics at all."

Others may receive a prescription for an oral narcotic medication when they leave the hospital. "The most painful post operative period is the first 72 hours after surgery, so the nerve block is continued for that period of time," Dr. Marino explained. "By the time patients are ready to leave the hospital the majority of their pain symptoms will have dissipated."

Debbie Patane knows first-hand how well the nerve blocks work. Three years ago, the 41-year-old mother of two underwent her first total hip replacement surgery. Mrs. Patane, a registered nurse who is married to a general surgeon, was given PCA in the form of a morphine pump following her surgery.

"The first night I was in tremendous pain and the PCA did not do much for me," she recalled.

Two years later, osteoarthritis forced her to return to her surgeons, David Weissberg, MD and Scott Alpert, MD, for her second total hip procedure. This time, she was given a nerve block while still in the recovery room.

"The difference was like night and day," Mrs. Patane said. "I was able to rest that first night, and get up and move around the next day."

"Joint replacement patients need to get up to begin therapy right away," Dr. Marino noted. Continuous peripheral nerve block techniques allow patients to participate in an accelerated physical therapy program which improves outcomes and reduces the duration of their hospital stay. Patients are examined daily by members of the Department of Anesthesiology to ensure adequate pain control as well as monitor for any block-related side effects such as numbness.

According to Dr. Marino, peripheral nerve blocks are superior to epidurals because they target one specific area without numbing the entire lower half of the body, allowing patients to get out of bed and walk shortly after surgery. However, placing peripheral nerve blocks is technically demanding and requires special training.

"For this reason, we are still one of only a handful of hospitals to offer this type of pain relief," Dr. Marino concluded. "Patients undergoing total joint replacements at other hospitals may not be given this option."

The Department of Anesthesiology is an integral part of Huntingon's Center for Orthopedics and Joint Replacement's commitment to providing patients with a safe and painless total joint replacement surgery experience.

Healthline February 2008