ASRA Pain Medicine Update

I can easily recall an experience I had during the first week of my regional anesthesia second-year rotation. I was preparing ropivacaine for the first few cases of the day when the attending anesthesiologist said, “Let’s do an adductor canal block [ACB] instead of a femoral block for the patient scheduled for knee arthroplasty today.” I was excited for the novelty of the procedure because ACB had first been described in the literature only 4 years prior. However, ACBs were not routinely practiced at my institution yet, and I felt nervous because I lacked experience with the procedure. Nevertheless, we performed the block effectively, and the patient had satisfactory analgesia with the expected outcome of little noticeable leg weakness. I felt thrilled that I had learned a new technique that had the potential to be the future standard of analgesia for total knee arthroplasties. Unfortunately, I had few additional opportunities to practice ACBs during my residency training, and my proficiency at performing them developed not during residency but in fellowship.

Today, ACB may not be part of the standard of care for knee surgeries in every institution across the United States, but the nerve block has become much more widely practiced since its initial description in 2007.^[1] Newer techniques developed in the past decade, such as the ACB and transversus abdominis plane blocks, are commonplace in clinical practice yet only now are being integrated into anesthesiology training with enough frequency to ensure proficiency by graduation. In today’s fast-moving clinical environment, a 10-year lag is too slow. Novel regional anesthetic techniques should be integrated into residency training now for several key reasons.

As instructors of regional anesthesia, our duty is to ensure that residency graduates are reasonably exposed to the most up-to-date, evidence-based, efficacious, and safe techniques available for the provision of patient care.

We Have a Responsibility as Regional Anesthesiologists in Academic Settings

As instructors of regional anesthesia, our duty is to ensure that residency graduates are reasonably exposed to the most up-to-date, evidence-based, efficacious, and safe techniques available for the provision of patient care. I would also argue that it is our duty as teachers to assess when a new technique has enough supportive evidence and adequate risk profile to be integrated into residency training in an expeditious manner. Furthermore, proficiency in a regional anesthesia technique does not develop over a weekend course or following limited patient encounters but rather requires at least 15 to 20 blocks for the proceduralist to experience consistent success and confidence.^[2],[3] Thus, residents should have adequate exposure to newer techniques during training, an environment where guiding expertise is immediately available and safety margins can be maximized.

Graduates Need Up-to-Date Skill Sets

In an era dominated by social media, electronic communication, and online resources, clinical integration of novel nerve block techniques has become more rapid than ever before. This has the potential to benefit patients and hospital administration by providing improved pain control, minimizing opioid use, and reducing lengths of hospital admissions.^[4–6] Moreover, other medical specialties are using the techniques, with emergency medicine residencies increasingly incorporating peripheral nerve blockade into their curricula.^[7],[8] If our residency graduates are not as up to date and skilled in novel regional anesthesia techniques as other medical providers, we may see decreased demand for anesthesia services in areas outside the operating room.

We Should Teach Novel Techniques to Foster Innovative Thinking

The use of ultrasound guidance for peripheral nerve block placement during residency training has been steadily increasing over the past two decades. Among anesthesia residency programs in 2012, approximately 75% used an ultrasound for peripheral nerve blockade.^[9] Today, ultrasound-guided regional anesthesia is fairly ubiquitous. Ultrasound’s direct visualization of block targets has no doubt expanded residents’ understanding of anatomy and enabled new approaches to traditional nerve blocks through innovative thinking. As educators, we should encourage our residents to expand this path of innovation as well as mentor trainees to assess the benefits and drawbacks of any novel technique through critical thinking. We should teach residents, via example, how to critically evaluate new techniques and compare them with the established blocks.

We Should Have a Pragmatic Educational Approach

A recent study demonstrated that the incorporation of regional anesthesia techniques into the management of surgical cases has increased since 2000.^[10] The current Accreditation Council for Graduate Medical Education anesthesia residency guidelines require the performance of 40 peripheral nerve blocks during training without any language that specifies which types of blocks should be included.^[11] Different residents may require different amounts of exposure to be proficient in any given regional anesthesia procedure. For some residents, limiting training to meet minimum requirements for a list of core blocks would prevent them from being exposed to novel regional anesthesia techniques. Each residency program is unique in what it is able to offer. However, consider whether we should pause and, with a wide-angle lens, reflect on which blocks would be most useful for our trainees to learn, given trends in clinical practice.

Conclusion

Anesthesiology trainees should be exposed to novel block techniques during residency. Doing so helps our graduates have up-to-date skills and encourages innovative thinking. As regional anesthesia experts, we should be aware of techniques that are poised to have the most significant impact on clinical practice and teach them to the next generation of anesthesiologists.

References

1. Krombach J, Gray AT. Sonography for saphenous nerve block near the adductor canal. Reg Anesth Pain Med 2007;32:369–370.
2. Rosenblatt MA, Fishkind D. Proficiency in interscalene anesthesia—how many blocks are necessary? J Clin Anesth 2003;15:285–288.
3. Moon TS, Lim E, Kinjo S. A survey of education and confidence level among graduating anesthesia residents with regard to selected peripheral nerve blocks. BMC Anesthesiol 2013;13:16.
4. Kumar K, Kirksey MA, Duong S, Wu CL. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg 2017;125:1749–1760.
5. Kettner SC, Willschke, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth 2011;107(S1):i90–i95.
6. Guay J, Parker MJ, Griffiths R, Kopp S. Peripheral nerve blocks for hip fractures. Cochrane Database Syst Rev 2017;5:CD001159.
7. Wilson CL, Chung K, Fong T. Challenges and variations in emergency medicine residency training of ultrasound-guided regional anesthesia techniques. AEM Educ Train 2017;1:158–164.
8. Amini R, Kartchner JZ, Nagdev A, Adhikari S. Ultrasound-guided nerve blocks in emergency medicine practice. J Ultrasound Med 2016;35:731–736.
9. Helwani MA, Saied NN, Asaad B, Rasmussen S, Fingerman ME. The current role of ultrasound use in teaching regional anesthesia: a survey of residency programs in the United States. Pain Med 2012;13(10):1342–1346.
10. Neal JM, Gravel Sullivan A, Rosenquist RW, Kopacz DJ. Regional anesthesia and pain medicine: US anesthesiology resident training—the year 2015. Reg Anesth Pain Med 2017;42:437–441.
11. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in anesthesiology. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/040Anesthesiology2018.pdf?ver=2018-06-14-142529-527. Updated July 1, 2018. Accessed March 11, 2019.