I am Dr. Amina Benyoucef, an Algerian anesthesiologist, and I work in the Military Hospital of Algiers in Algeria. Following residency, I practiced obstetric anesthesia for four years, before transitioning to work in the intensive care unit where I remained for three years.

In our institution, anesthesia is administered in a multidisciplinary operating theater that includes all surgical specialities. Regional anesthesia has been provided in this environment, with nerve stimulation since 2002 and ultrasound guidance since 2008. Secondary to the composition of my standard clinical practice, I have not practiced peripheral nerve blocks since 2018, when I had the opportunity to provide anesthesia for thoracic and vascular surgery.

Nowadays, to be an anesthesiologist and to not practice regional anesthesia is a “mess.” Obvious advantages to regional anesthesia include its ability to provide an alternative to general anesthesia, facilitate early extubation, and promote perioperative opioid-sparing strategies.

However, obtaining competency in regional anesthesia is a difficult task to achieve. Barriers to mastery of regional anesthesia that I encountered included the need to maintain skill in the provision of anesthesia for thoracic and vascular surgeries, including carotid surgery, abdominal aortic surgery, and peripheral vascular surgery. In addition, I had significant resident education and operating room administration responsibilities that consumed significant time resources.

Thanks to my professors, colleagues, and residents (a younger generation for whom ultrasound guidance learning is more easily assimilated), I was able to make incremental strides and improved my regional anesthesia skills. I then was fortunate enough to experience a "second birth" of anesthesia knowledge when I discovered the international world of anesthesia available through social media.

I have long thought that social media platforms were potentially dangerous, but, since then, my perspective has dramatically changed. 

The first person I interacted with through social media was Dr. Nabil Elkassabany, who oriented me immediately to ASRA, and it was here that my adventure started. The publications of the different societies (ASRA, the Regional Anesthesia of United Kingdom, and the European Society of Regional Anaesthesia and Pain Therapy) were, for me, a treasure map that ultimately led to advanced skills in regional anesthesia and pain medicine.

In my daily clinical practice, I am generally responsible for the provision of perioperative analgesia in patients scheduled for thoracotomy. I first provided analgesia via thoracic epidural, as this was a technique that I was comfortable performing and it was long considered the gold standard. However, because of an enhanced recovery after surgery strategy, and, to be up to date, I switched to the thoracic paravertebral block: the new ultrasound-guided gold standard analgesic technique for thoracotomy.

I was, of course, assisted by my Algerian senior faculty but struggled with how to improve my knowledge and select my lectures in this rapidly evolving field.

This is how, by following Dr. Amit Pawa’s advice through his publications and opinions shared on Twitter, I strove to improve my performance and knowledge and could (as he mentioned) separate paravertebral block from, paraspinal "paravertebral by proxy" techniques.^[1]

Recently, a British regional anesthesia expert: Dr. Gordon Launcelott, shared a quote from Japanese Buddhist Suzuki Rosh, “In the beginner's mind there are many possibilities, but in the expert’s, there are few.”

This last decade has been marked by the appearance of novel interfascial plane blocks,^[2] famous for their safety and ease, among them the erector spinae plane block (ESPB), described by Dr. Mauricio Forero in 2016.^[3]

In contrast to what was reported, I encountered more issues with the ESPB mastery than with paravertebral blocks, where the retreat of the pleura was a guarantor of the block’s success. The ESPB is a fascial plane block, and I was initially stressed by a high rate of intramuscular injections and failures of the analgesic technique in a patient undergoing a very painful surgery. I shared my experience with other anesthesiologists active on Twitter, and I was surprised to discover that I wasn’t the only one encountering this situation. Via social media, I was able to obtain precious advice from pioneers of this technique. Through the advice of Drs. Mauricio Forero and Serkan Tulgar, my performance improved and my learning trajectory was steepened.

I was also inspired by their previous studies and attempted to emulate them, by performing MRI imaging after injection through the catheter of a thoracic ESPB, which greatly facilitated my understanding of this block.^[4,5]

So many questions came after: what is the real mechanism of action of thoracic fascial plane blocks? Why do they offer less opioid sparing during surgery? Does myorelaxant reduce local anesthetic spread?

I found some answers in the article authored by Drs. Hesham Elsharkawy, Amit Pawa and Edward R. Mariano.^[2] I then solicited their opinion on Twitter and it ignited a great international experts’ debate!

Furthermore, the ASRA News article written by Drs Vishal Uppal and Vivian Ip^[6] describing the ESPB reassured me and confirmed that, even if anesthesia is an evidence-based medicine, personal practice and opinions can be different.

In my practice, I commonly manage anesthesia for sternotomy, and I have encountered good perioperative results with the utilization of a “light” thoracic epidural analgesic block and general anesthesia, especially for patients with myasthenia gravis. Here again, I looked for alternative techniques and, thanks to Drs. Elkassabany and Tulgar, I discovered the pecto intercostal fascial block and the transversus thoracic plane block^[7] as analgesic alternatives for the anterior portion of the thorax.

The year 2020 has been, and still is, unfortunately, a landmark year because of the COVID-19 pandemic.  Despite the challenges that I encountered in my workplace, the ASRA team was a great support!  In an era of fear, vulnerability, and decreased work efficiency, the ASRA RAPP podcast hosted by Dr. Rajnish Gupta was able to impart a positive side to this catastrophic period. The entire anesthesia community worked side by side and shared their initial data and experience to fight the virus and limit its damage. Embracing social media and its ability to maintain a worldwide community through scientific education and publications, has kept the globe connected during these challenging times.

As I continue my regional anesthesia adventure on the same treasure map, I hope to cross more steps, with more ease, more precision, and less possibilities with the support of the Algerian anesthetic community and the knowledge that ASRA and its dedicated membership are there to navigate this journey at my side.

Amina Benyoucef, MD, is an assistant professor at the Central Military Hospital of Algiers in Algeria.

References

1. Pawa A, Wojcikiewicz T, Barron A, et al. Paravertebral blocks: anatomical, practical and future concepts. Curr Anesthesiol Rep. 2019;9:263-70. doi: 10.1007/s40140-019-00328-x
2. Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med. 2018;43:341-6. doi:10.1097/AAP.0000000000000750
3. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–7. doi: 10.1097/AAP.0000000000000451
4. Celik M, Tulgar S, Ahiskalioglu A, Alper F. Is high volume lumbar erector spinae plane block an alternative to transforaminal epidural injection? Evaluation with MRI. Reg Anesth Pain Med. 2019;44:906-7. doi:10.1136/rapm-2019-100514.
5. Schwartzmann A, Peng P, Maciel MA, Forero M. Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study. Can J Anesth. 2018;65:1165–6.
6. Uppal V, Ip VHY. Curb your enthusiasm: erector spinae plane block–‘because it is easy’ is not a good reason to do it! ASRA News. 2019;44:8-12.
7. George R, Dahl K, de Haan JB. How I do it: transversus thoracic plane and pecto-intercostal fascial block. ASRA News. 2020;45:39-45.