ASRA Pain Medicine Update

The provision of regional anesthesia by nonanesthesiologists has been the subject of growing discussion.^[1] Emergency medicine (EM) and intensive care unit physicians are well positioned to learn ultrasound-guided procedural skills because of their regular use of ultrasound for focused assessment of trauma, vascular access and cardiac evaluation. However, we are still determining the best way to teach and assess competence in regional anesthesia.^[2] It would therefore not be reasonable to expect another specialty to be experts in these areas and be prepared to evaluate and ensure competency. Accordingly, for the benefit of our patients, we have a duty to share our knowledge of technical skills, but we must also expound the need for education regarding local anesthetic pharmacology, complications, and postoperative monitoring.

We are still determining the best way to teach and assess competence in regional anesthesia. It would therefore not be reasonable to expect another specialty to be experts in these areas.

We now recognize that performing a minimum number of blocks does not make one competent. The Halsteadian apprenticeship model of “see one, do one, teach one” is no longer reasonable. As Dr. Joseph Neal has pointed out, technical attainment does not imply comprehension regarding possible complications and their prevention or clinical acumen regarding which patients should not have a block.^[3] Technical performance is only one measure of competence. A survey of 171 US academic EM programs examining how ultrasound-guided nerve blocks were taught revealed that of the 121 participating institutions, 84% perform UGRA, but only 7% have a credentialing pathway.^[4] No programs have a quality assurance initiative, but 16% periodically assess physicians for competency in UGRA. Whether a valid and reliable regional anesthesia assessment tool is used by these institutions to gauge competency is unknown.

Regional anesthesia involves more than guiding a needle to a target. Nontechnical skills such as communication, situational awareness, teamwork, planning, resource management, and decision making have a considerable role in performance and hence patient safety.^[5] The level of mastery of a skill is measured on a spectrum ranging from competent to expert, which is the mastery with extensive knowledge of the whole skill domain, including nontechnical skills. Being an expert does not happen overnight; it comes with years of training, practice, and study of the literature for current evidence. The drive to become an expert is to provide the best quality care to our patients.

Collaboration between anesthesiologists and EM physicians has been shown to be successful in teaching femoral nerve blocks for patients presenting with hip fractures.^[6] In that study, every aspect of performance of the nerve block was designed in conjunction with an anesthesiologist with expertise in regional anesthesia. In other centers, nonanesthesiologists may not be cognizant of the importance of sterility, monitoring, sedation, local anesthetic dose and factors that affect it, procedure documentation, symptoms of toxicity, and the treatment of local anesthetic systemic toxicity (LAST). For example, the importance of post-block monitoring was reaffirmed following an emergency department fatality following a fascia iliaca block.^[7] Review of the case revealed insufficient documentation of the procedure as well as poor or lacking postprocedure observations. Specifically, the researchers concluded that opioids administered prior to the fascia iliaca block contributed to post-procedure apnea and, secondarily, cardiac arrest. The monitoring standards we observe and practice while performing regional anesthesia may not be as recognized or appreciated by nonanesthesiologists with limited training in regional anesthesia. Anesthesiologists are also better prepared and skilled to manage immediate complications following regional anesthesia such as LAST or oversedation. Anesthesiologists are pioneers in patient safety and must continue to advocate for the safe practice of regional anesthesia by nonanesthesiologists.

Anesthesiology residents are required to perform a minimal number of blocks during training, but many anesthesiologists do not continue to practice regional anesthesia after residency because of inadequate experience.^[8] Barrington et al. found that 10 hands-on training sessions, with accompanying didactic preparation and deliberate feedback from experts, were required to achieve proficiency in simply obtaining sonograms and identifying anatomical structures.^[9] Perhaps that training enables the anesthesiologist to be more aware of the other components essential to performing a nerve block. Yet, nonanesthesiologists with no formal training are taking up the ultrasound. We would caution any health care provider, including anesthesiologists, before performing an unsupervised nerve block after only a single teaching session.

Finally, little data are available regarding the incidence of complications by nonanesthesiologists. Even experts encounter complications, and thus it is important for each department to institute quality assurance programs to maintain or improve practice. It is routine practice for regional anesthesiologists to follow up their patients and document complications or side effects. Who takes responsibility for the patient with postoperative neuropathy who received a preoperative block in the emergency department, followed by an intraoperative block by the anesthesiologist, who then had traction and over-rotation of their leg to repair a hip fracture? Anesthesiologists working in institutions where blocks are performed by nonanesthesiologists should actively look for documentation of a block to avoid repeating a block leading to LAST and consider if repeating a block is worth the risk of neuropathy, even after 24 hours.           

Collaboration offers vast opportunity for learning, and we should not be resistant to overlapping skillsets, but expert training and patient safety should always take precedence over the yearning for medical professionals to venture outside their current scope of practice. Practitioners of regional anesthesia should (1) develop or follow protocols to prevent complication (eg, ASRA’s preblock checklist), (2) institute quality assurance programs to review complications and ensure practice improvement, and (3) develop training programs in conjunction with expert providers of regional anesthesia.

References

1. Pawa A, El-Boghdadly K. Regional anesthesia by non-anesthesiologists. Curr Opin Anaesthesiol. 2018;31:1–7.
2. McCartney CJL, Mariano ER. Education in ultrasound-guided regional anesthesia: lots of learning left to do. Reg Anes Pain Med. 2016;41:663–664.
3. Neal J. Education in Regional Anesthesia. Caseloads, simulation, journals, and politics: 2011 Carl Koller Lecture. Reg Anes Pain Med. 2012; 37:647–651.
4. Amini R, Kartchner JZ, Nagdev A, and Adhikari S. Ultrasound-guided nerve blocks in emergency medicine practice. J Ultrasound Med. 2016;35:731–736.
5. Fletcher G, McGeorge P, Flin R, Glavin R, Maran N. The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth. 2002;88:418–829.
6. Ketelaars R, Stollman J, van Eeten E, Eikendal T, Bruhn J, van Geffen GT. Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in the Netherlands. Int J Emerg Med. 2018;11:12.
7. Carlyon E. Regulation 28: report to prevent future deaths: Pamela Margaret Hands aka Horner. Cornwall, UK: 2017. https://www.judiciary.uk/wp-content/uploads/2018/02/Pamela-Hands-2017-0373_Redacted.pdf. Accessed August 15, 2018.
8. Ramlogan R, Manickam B, Chan VW, et al. Challenges and training tools associated with the practice of ultrasound-guided regional anesthesia: a survey of the American Society of Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med. 2010;35:224–226. https://doi.org/10.1097/AAP.0b013e3181c69c94
9. Barrington MJ, Viero LP, Kluger R, Clarke AL, Ivanusic JJ, Wong DM. Determining the learning curve for acquiring core sonographic skills for ultrasound-guided axillary brachial plexus block. Reg Anesth Pain Med. 2016;41:667–670. https://doi.org/10.1097/AAP.0000000000000487