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Howard Fiedler felt no pain after his two knee-replacement surgeries.

He felt nothing in either leg for two days, thanks to the nerve blocks he was given before the operations -- the first in June 2003, followed by another last month. Even after the numbing agents ceased, the pain never came, unlike patients he met in rehabilitation who underwent surgeries without nerve blocks and ended up in significant post-operative pain.

"There were people there that had the same thing I had. They were in all kinds of pain all the time, taking all kinds of pain pills. They kept asking me if I wanted anything. I said, 'No, I don't have any (pain,)'" said Fiedler, 74, of Finleyville.

Before surgery, a thread-like catheter is inserted near the nerve responsible for sensations where the surgical cut will be, injecting a continuous drip of a numbing agent for up to three days. The catheter is attached to a small pump, which slowly releases the medication. Patients can remove the catheter themselves.

Continuous nerve blocks are being used more often as part of a multipronged attack on pain, according to area anesthesiologists, who perform the procedures before surgery and oversee post-operative pain management. The focus now is to rely less on narcotics such as morphine, and instead use nerve blocks to help patients recover more quickly and more completely, they said.

"This is the greatest thing I've ever had, I think," Fiedler said.

"One of the reasons patients stay in the hospital is because of the pain," said Dr. William Mizikar, acute pain service director at Allegheny General Hospital. "...It's a cost advantage for the hospital to get the patients home quicker plus comfort for the patients. ... There's more germs in the hospital than in homes."

The Joint Commission on Accreditation of Healthcare Organizations, an Illinois-based nonprofit that sets standards and accredits 15,000 medical institutions nationwide, began scrutinizing hospitals' post-operative pain management techniques more closely in 2000, forcing hospitals to focus on them as well.

"They basically decided that pain was something that should be paid attention to," said Dr. Jacques Chelly, director of orthopedic surgery and acute interventional postoperative pain service at UPMC Shadyside.

"It's become much more part of the care and training on the curriculum of anesthesiology residents," said Dr. Jeffrey Grass, chairman of anesthesiology of Western Pennsylvania Hospital. He developed the acute pain program at Johns Hopkins Hospital in Baltimore in the early 1990s and served as director of the Cleveland Clinic's program in the late 1990s.

"The attention to acute pain really evolved in the late '80s, early '90s," Grass said.

The focus then was on giving patients pain medication in devices they could control themselves, allowing them to take morphine or other painkillers at predetermined intervals if they chose, he said.

"It was well-established that many patients have significant pain post-operatively," said Chelly, who started an acute pain management program at Memorial Hermann Hospital in Houston five years before he was recruited to UPMC Shadyside in 2002 to launch one there.

The pain management program at UPMC Shadyside has quintupled in the past two years, up to 10 anesthesiologists from two, he said. The department, which started with orthopedic patients, has expanded to other surgeries, such as urologic, thoracic, breast, bone cancer, amputation and general surgery, and treats about 3,000 patients a year, said Chelly.

"It's just growing," he said. "More surgeons are coming to us."

Nurses now routinely check patients' pain level -- by asking patients to rate it on a 0 to 10 scale -- as they regularly check other vital signs, such as blood pressure and temperature.

Still, Chelly said, "Until recently, you would go and have surgery and your surgeon would say, 'You're going to have pain; pain is part of surgery.'" Now, doctors recognize maybe it doesn't have to be that way, he said.

He and other anesthesiologists said the continuous numbing agents have provided the biggest boon to patients' pain relief.

"Usually, they do very well with this technique in terms of pain," Chelly said. "I wish this technique would work for every patient. They don't always work. I would say it is high 90 percent."

Some nerve blocks, such as those used for joint replacements, numb a large area, while others, such as those used for hysterectomies, numb only the incision site.

For patients undergoing joint replacements, the continuous nerve blocks allow them to exercise more quickly by numbing pain in the entire leg, Chelly said.

"We want people to not feel the pain, but be able to move because that's how people get better -- by exercising," he said.

Allegheny General Hospital's Department of Obstetrics and Gynecology began using the continuous nerve blocks in January, said Dr. Eugene Scioscia, department chairman and program director.

"It basically anesthetizes the incision and nothing else," he said. "It minimizes the need for narcotics, if not eliminating them altogether."

Scioscia has used them to treat about 20 patients undergoing surgeries for hysterectomies, C-sections, ectopic pregnancies, ovarian cysts and fibroid removals. About 70 to 80 percent of patients benefited, he said.

His department still has not determined whether using nerve blocks shortens patient stays, but other doctors say that they have.

Scioscia's first patient to get one, Sandy Young, 54, of Bethel Park, was thrilled with how much the continuous nerve block deadened pain and quickened healing following a hysterectomy in January.

"It was wonderful. I've had surgery before -- abdominal surgery -- (and) I've had the Demerol and morphine and you're just kind of out of it for a few days. I didn't have that," she said. "...I just healed so much better."

As supervisor of AGH's labor and delivery nurses, Young said she has witnessed C-section patients do "surprisingly well" after getting continuous nerve blocks.

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