Anesthesiologists at Shriners Hospital for Children-Spokane are studying a pain-control technique developed there, that they say reduces discomfort and recovery time for children after foot surgery.


The technique, developed by Dr. Roberto Auffant, the hospitals director of anesthesiology, involves applying a common numbing techniquepumping anesthetic drugs into a nerve using a catheterto the back side of the knee.


Patients who are having foot surgery often undergo an epidural injection, in which doctors numb the body from the waist down by placing a drug-dispensing catheter into a space near the spine where nerves carry signals from the lower body to the spinal cord.


Dispensing the drugs at the knee, as with Auffants technique, allows an anesthesiologist to anesthetize a smaller part of the body, he says. It also eliminates the need to insert a urinary catheter in the patient. The knee procedure is done while the patient is under general anesthesia, and it reduces pain in the hours and days after surgery, Auffant asserts.


A catheter for urine is an inconvenience, and most adults and children dont really like them, he says. If you can get away with controlling pain without it, its better.


Auffant and his staff use the block on patients who are having surgery on only one foot, he says. If the hospitals surgeons are operating on both of a patients feet, an epidural injection is more efficient, Auffant says.


Compared with an epidural injection, the block Auffant uses means a patient will need fewer aggressive pain medications, will be less sleepy after surgery, and will recover more quickly, he says.


Maggie Crabtree, spokeswoman for Shriners-Spokane, says Auffant has become widely known within Shriners 22-hospital system for his efforts in pain management.


Auffant says he began using the block technique in 1999, after a 7-year-old boy, whod undergone an epidural injection when doctors operated on one of his club feet, refused to undergo the waist-down numbing again.


He needed surgery on the other foot, but he was reluctant to have it because of the (urinary) catheter, Auffant says. We offered to just numb one foot, and the rest is history.


IRB approves study


The Institutional Review Board, which reviews the use of experimental procedures and devices here, last year approved a study of the blocks effectiveness on 40 patients. Since last July, Auffant and his staff members have tracked 30 patients. He says two study participants have experienced nausea as a side effect of the knee-level block, and the other 28 have reported no side effects. All 30 have told Auffant that the knee catheter reduced their pain and made the post-operative period more comfortable, he says.


The study, which is funded through private donations made to the Shriners foundation, will involve 10 more patients and is expected to be completed within the next three months, Auffant says. One component of the study is to examine the most appropriate doses of anesthesia to give patients.


We feel the doses were using are very conservative, he says. We probably can go up.


Auffant says the study is particularly important because it contributes to pediatric medical research. Children are a notoriously underexamined group in medicine, he says, and adds that numerous medications are used commonly in children despite warnings that pediatric research hasnt been conducted on those drugs.


Most of the children requiring foot surgery at Shriners-Spokane are between ages 7 and 18, Auffant says. Their surgeons often are trying to correct club feet, or other ankle and foot problems that require bones to be fused together.


We used to give kids a single injection (to manage pain after surgery), but that lasts only six to eight hours, he says. A kids pain doesnt go away in six to eight hours, especially after an ankle fusion, which is very painful.


Two main nerves, the sciatic and the saphenous, run down the legs. Auffant applies the block, where the sciatic nerve branches off into several smaller nerve paths. A line that looks like a strand of coarse, black hair is inserted into the sciatic nerve through a small, plastic catheter, or tube. The anesthetic trickles down the nerve branches and numbs 80 percent of the nerves in the foot and ankle, he says. The tube is taped down, and the line feeds the body a constant drip of anesthesia. Anesthesiologists refill the tube every eight hours, and remove it before the patient leaves the hospital.


The saphenous, which Auffant calls the rascal, runs down the inside of the calf and is responsible for 20 percent of the feet and ankles feeling. The saphenous nerve is deadened separately with an injection. The entire blocking procedure takes 20 minutes, he says.


On a recent Thursday, Tanishka Pierson, 18, was preparing to check out of Shriners-Spokane two days after having surgery on an ankle. Pierson has suffered from weak ankles her entire life, she says. Her problem is so severe that her ankles sprain without provocation, she says. Surgeons at Shriners-Spokane connected and tightened ligaments and tendons in her right foot and ankle, and Auffant applied the knee-catheter technique after the surgery.


The block helped, Pierson says. There wasnt much pain when I woke up. After it was taken out, though, the pain got worse and worse.


Piersons stay at Shriners-Spokane lasted a day and a half, but the block technique could make serious foot surgery an outpatient procedure at many hospitals, Auffant says. Donation-supported Shriners hospitals dont charge for any services and, therefore, typically allow children to stay in in-patient beds for longer periods than most hospitals do, Auffant contends.


The anesthesiology team at Shriners-Spokane has conducted other pain-management research projects in recent years. Auffant presented findings of a pain-management study done at seven Shriners hospitals at an annual workshop of the National Association of Childrens Hospitals and Related Institutions in 2000, Crabtree says. Shriners Spokane anesthesiologists also presented research on scoliosis-pain management at the Scoliosis Research Societys annual meeting in 2001, she says. Auffant has taught the knee-catheter technique for foot surgeries to anesthesiologists at two other Shriners hospitals in the U.S., and he says those doctors are seeing positive results.


Auffant adds, though, that the knee-level block technique is most popular with the hospitals nurses. He says the nurses now work with foot patients in less pain and discomfort than before. When a patient comes in for foot surgery, he says the nurses always ask him, Youre going to do the block, right?


Auffant, shaking his head and chuckling, says, Once you give the chocolate, you cant take it away, he says.