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Orthopaedics,
Plastics, and Regional Anesthesiology
Clinical Program
The Division of Orthopaedic, Plastics, and Regional Anesthesiology was formed in July 1998. The division serves a large patient population requiring total joint replacement, adult and pediatric spine surgery, advanced plastic surgery, and orthopaedic trauma and surgery, including hand surgery. The division operates in concert with Duke Hospital’s Acute Pain Service and the Musculoskeletal Center, directed by Dr. Brian Ginsberg and Dr. Tad Vail, respectively. This arrangement offers patients a team approach to anesthesia, surgery and postoperative analgesia. The division consists of regional anesthesiologists trained in the delivery of state-of-the-art neuroaxial and peripheral nerve blocks. In order to further improve the pain management offered to our patients, Dr. Kathryn King, a member of the regional division, took on some of the responsibilities of the Acute Pain Service (APS). We hope to improve the continuation of care for our patients throughout both the perioperative and postoperative periods.
The major corner stone of any academic division is patient care, and we continuously strive to offer patients the best care by using the latest technology available. This year has seen a continued usage of peripheral nerve catheters in our upper and lower limb surgery cases performed at Duke North Hospital. This has allowed us to offer our patients continuous post operative analgesia for approximately three days, leading to a greater patient satisfaction especially in the total knee arthroplasty patients.
The division under the guidance of Dr. Stuart Grant successfully introduced ultrasound-guided placement of central venous lines as well as peripheral nerve blocks, thus improving safety and reliability. We continue to investigate the new peripheral block stimulating catheters which will greatly improve our success rate. Our division is at the forefront of developing a new slow release epidural morphine drug; this drug may simplify postoperative pain management by offering a technique that can deliver pain relief for 48 hours with a single epidural injection. It will obviate the need for an indwelling epidural catheters thus simplifying postoperative anticoagulant practice.
Faculty members play instrumental roles in the administrative aspects of the department. Dr. David Hardman in his role as chairman of the financial committee within the department has been heavily involved in introducing a new financial plan. Drs. Gavin Martin and Steve Parrillo have continued to take part in the daily running of the Duke North operating rooms in their roles as co-chairs of Duke North Hospital Perioperative Services group, with Drs. Holly Muir, Brett Stolp and Tony Roche. Drs. Grant and Dara Breslin are actively involved with the Education Committee; with their excellent service, we hope to continue offering our residents educational opportunities in using all types of regional techniques for managing postoperative pain.
Within our state, Drs. Jennifer Fortney and Hardman have continued to play an important role in the North Carolina Medical Society.
Anesthesiologists and CRNAs: A Team Approach
The faculty of the regional group work in close collaboration with the CRNAs, forming a team that specializes in regional anesthesia. We wish to thank all the CRNAs for their expertise and hard work that allow us to offer our patients such a high standard of care.
Training Program
Dr. Breslin was the 2004 Burnell Jose Visiting Professor to South Australia, where he gave 14 lectures on the use and benefits of regional anesthesia, including the Maurice Sando Memorial lecture, titled "Peripheral Nerve Catheters: Are They Worth the Trouble?” Dr. Mary Burnell is a former president of the Australian College of Anesthetists and Dr. Ivan Jose is a retired president of the College of Surgeons. The visiting professorship occurs once every three years.
Dr. MacLeod has continued to update his web-based education site, “The ABCs of Regional Anesthesia.” This site not only offers the residents descriptions of the regional anesthetic techniques but includes films of blocks being performed and direct links to relevant literature.
Dr. Breslin continues to play a leading role in resident education utilizing the Simulator Lab producing a number of regional anesthesia complication scenarios. Anatomical models were recently purchased to aid in the training of residents and medical students. These models allow us to demonstrate the anatomy of various nerve plexuses and their relationship to important landmarks. Dr. Breslin took on a new role this year as director of the Orthopedic House Officers Anesthesia Education program. The orthopedic residents as part of their training are now spending two weeks training within the department. The aim of this program is to allow them to be exposed to the anesthesiology work up required to ensure that their patients are adequately prepared for surgery. We also hope to add to their education in the areas of resuscitation and pain management.
For the first time, Dr. Grant with the help of Drs. Breslin, MacLeod, Grichnik, and Swaminathan ran an intensive ultrasound course in Las Vegas prior to the American Society of Anesthesiology (ASA) annual meeting. This course was extremely well attended by over 100 participants and received outstanding. This course dealt with the use of ultrasound in the placement of peripheral nerve blocks as well as the use of ultrasound for the placement of central lines. Dr. Grant will be running a number of similar courses during the 2005 calendar year, including a meeting at the ASA. Dr. Grant is continuing his work on developing a simulator program specifically designed for teaching peripheral nerve blocks.
The division participated at the 7th Annual Duke Cardiothoracic Update, held at Hilton Head Island, South Carolina. We held a peripheral nerve block workshop and a workshop demonstrating ultrasound-guided placement of central lines and peripheral nerve blocks.
During the meeting, Dr. Breslin presented evidence on the possible benefits of regional anesthesia compared to general anesthesia alone as part of the lecture series. We will again be participating at this annual meeting next year, with an increased role including numerous lectures on the performance of peripheral nerve blocks and the recent advancements in these techniques.
Research Program
Dr. Martin has continued studies this year looking at the use of a novel new delivery system for morphine (DepoDur). DepoDur is based on liposomal technology that allows the slow release of morphine into the epidural space over a 48 hour period with the use of a single epidural injection. The present study is looking at the feasibility of using only oral medication postoperatively for supplemental pain medication. This may not only obviate the need for epidural catheters but also the need for patient controlled analgesia. This drug was approved by the FDA in July 2004 for use in managing acute postoperative pain. Preliminary results have been published as abstracts and presented at national meetings. They show superior pain relief compared to conventional intravenous opioids for up to 48 hours postoperatively. Three papers have been accepted for publication next year in peer-reviewed journals.
During the summer Dr. MacLeod assumed the directorship of the Human Pharmacology Laboratory when the former director, Dr. Jacques Somma, returned to his native Canada. In addition, Dr. Keita Ikeda, PhD, joined the lab in July. His invaluable biomedical engineering skills were quickly put to use as he helped develop the software to run a new computer-controlled gas delivery system. This has been developed in conjunction with the Respiratory Laboratory at the University of Toronto. The sequential gas delivery system allows precise control of end-tidal concentrations of both oxygen and carbon dioxide. The device is currently being used in an NIH-funded study to validate a new cerebral oximeter.
Drs. Keifer and Wright are continuing their research work into the effects of dexmedetomidine upon the EEG and the auditory evoked potential during sedation.
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Gavin Martin, MB, ChB, DA, FRCA
Chief, Orthopaedics, Plastics, and Regional Anesthesiology
Assistant Clinical Professor of Anesthesiology
Office: (919) 681-5410
E-mail: marti091@mc.duke.edu
Faculty
Ellen M. Flanagan, MD
Jennifer T. Fortney, MD
Stuart A. Grant, MB, Ch.B, FRCA
H. David Hardman, MD, MBA
David B. MacLeod, MB, BS, FRCA
Stephen J. Parrillo, MD
Fellows
Todd Stevens, MD
CRNA Coordinator
Henry J. Walker, CRNA, MS, MBA
CRNA Staff
Patricia M. Allusshuski, CRNA, MSN
Ann M. Connell, CRNA
David H. Gleason, CRNA
Timothy McCarl, CRNA
Yvonne Overcast, CRNA
Dale Potter, CRNA
Susan Tomso, CRNA
Joe Rybiki, CRNA
Support Staff
Katherine Siler
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