Anesthesia residency training in regional anesthesiology and acute pain medicine: a competency-based model curriculum.
Regional anesthesia and pain medicine
Woodworth, G., Maniker, R. B., Spofford, C. M., Ivie, R., Lunden, N. I., Machi, A. T., Elkassabany, N. M., Gritsenko, K., Kukreja, P., Vlassakov, K., Tedore, T., Schroeder, K., Missair, A., Herrick, M., Shepler, J., Wilson, E. H., Horn, J. L., Barrington, M.
2020
Abstract
The Accreditation Council for Graduate Medical Education has shifted to competency-based medical education. This educational framework requires the description of educational outcomes based on the knowledge, skills and behaviors expected of competent trainees. It also requires an assessment program to provide formative feedback to trainees as they progress to competency in each outcome. Critical to the success of a curriculum is its practical implementation. This article describes the development of model curricula for anesthesiology residency training in regional anesthesia and acute pain medicine (core and advanced) using a competency-based framework. We further describe how the curricula were distributed through a shared web-based platform and mobile application.
View details for DOI 10.1136/rapm-2020-101480
View details for PubMedID 32474420
Abstract
Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours.Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System.Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus.LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.
View details for DOI 10.4103/joacp.JOACP_358_18
View details for PubMedID 32174670
View details for PubMedCentralID PMC7047671
Abstract
OBJECTIVE: The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view.DESIGN: Prospective descriptive trial on a novel approach.SETTING: Operating room and preoperative holding area at a tertiary care hospital.SUBJECTS: Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia.METHODS: Consented adult patients aged 30-80years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2-5MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10minutes.RESULTS: Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48hours after the procedure.CONCLUSIONS: We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.
View details for PubMedID 30865772
Abstract
PURPOSE: The local anesthetic injectate spread with fascial plane blocks and corresponding clinical outcomes may vary depending on the site of injection. We developed and evaluated a supra-iliac approach to the anterior quadratus lumborum (QL) block and hypothesized that this single injection might successfully block the lumbar and sacral plexus in cadavers and provide analgesia for patients undergoing hip surgery.METHODS: Ultrasound-guided bilateral supra-iliac anterior QL blocks were performed with 30 mL of India ink dye in six fresh adult cadavers. Cadavers were subsequently dissected to determine distribution of the dye. In five patients undergoing hip surgery, a unilateral supra-iliac anterior QL block with 25 mL ropivacaine 0.5% followed by a continuous catheter infusion was performed. Patients were clinically assessed daily for block efficacy.RESULTS: The cadaveric injections showed consistent dye involvement of the majority of the branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, and iliohypogastric nerve. The majority of cadaveric specimens (83%) also exhibited thoracic paravertebral spread of dye to the T10 level. No specimens showed L5 or sacral nerve root staining or caudal spread below L5. All patients had effective analgesia for total hip surgery and a T11-L3 sensory level following the initial bolus of local anesthetic as well as during the period of continuous catheter infusion.CONCLUSION: This cadaveric study and case series show that a supra-iliac approach to the anterior QL block involved T10--L3 nerve territories and dermatomal coverage with no sacral plexus spread. This technique may have clinical utility for analgesia in hip surgery.
View details for DOI 10.1007/s12630-019-01312-z
View details for PubMedID 30953311
Abstract
When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.
View details for PubMedID 31079833
Abstract
The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.
View details for DOI 10.1097/SAP.0000000000000873
View details for PubMedID 28118232
Abstract
The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.
View details for DOI 10.1097/SAP.0000000000000873
View details for Web of Science ID 000394386700004
Abstract
Patients diagnosed with breast cancer may opt to undergo surgical reconstructive flaps at the time of or after mastectomies. These surgeries leave patients with significant postoperative pain and sometimes involve large surgical beds including graft sites from the abdomen to reconstruct the breast. Consequently, multimodal methods of pain management have become highly favored. Quadratus lumborum catheters offer an opioid-sparing technique that can be performed easily and safely. We present a case of a patient who underwent a breast flap reconstruction and had bilateral quadratus lumborum catheters placed for perioperative pain control.
View details for DOI 10.1007/s00540-016-2160-y
View details for Web of Science ID 000376675600021
View details for PubMedID 26984687
Abstract
Recent evidence suggests that the saphenous nerve may be involved in the innervation of deeper structures at the medial ankle. In this study, we sought to determine the consistency and variability of the saphenous nerve innervation at the distal tibia and medial ankle joint capsule.One hundred three lower extremities from 52 embalmed cadavers were dissected to identify the deep branches of saphenous nerve along its distal course.In all specimens, the saphenous nerve had branches, emerging between 3.9 and 8.2 cm above the medial malleolus, to the periosteum of the distal tibia and the medial capsule of the ankle joint.Deep branches of the saphenous nerve innervate the periosteum of the distal tibia and talocrural capsule.
View details for DOI 10.1213/ANE.0000000000001168
View details for Web of Science ID 000374664400065
View details for PubMedID 26859876
Abstract
In 2009 and again in 2012, the American Society of Regional Anesthesia and Pain Medicine assembled an expert panel to assess the evidence basis for ultrasound guidance as a nerve localization tool for regional anesthesia.The 2012 panel reviewed evidence from the first advisory but focused primarily on new information that had emerged since 2009. A new section was added regarding the accuracy and reliability of ultrasound for determining needle-to-nerve proximity. Jadad scores are used to rank study quality. Grades of recommendations consistent with their level of evidence are provided.The panel offers recommendations based on synthesis and analysis of literature related to (1) the technical capabilities of ultrasound equipment and its operators, (2) comparison of ultrasound to other methods of nerve localization with regard to block characteristics, (3) comparison of block techniques where ultrasound is the sole nerve localization modality, and (4) major complications. Assessment of evidence strength and recommendations are made for upper- and lower-extremity, truncal, neuraxial, and pediatric blocks.Scientific evidence from the past 5 years has clarified and strengthened our understanding of ultrasound-guided regional anesthesia as a nerve localization tool. High-level evidence supports ultrasound guidance contributing to superior characteristics with selected blocks, although absolute differences with the comparator technique are often relatively small (especially for upper-extremity blocks). The clinical meaningfulness of these differences is likely of variable importance to individual practitioners. The use of ultrasound significantly reduces the risk of local anesthetic systemic toxicity as well as the incidence and intensity of hemidiaphragmatic paresis, but has no significant effect on the incidence of postoperative neurologic symptoms. WHAT'S NEW IN THIS UPDATE?: This evidence-based assessment of ultrasound-guided regional anesthesia reviews findings from our 2010 publication and focuses on new meta-analyses, randomized controlled trials, and large case series published since 2009. New to this exercise is an in-depth analysis of the accuracy and reliability of ultrasound guidance for identifying needle-to-nerve relationships. This version no longer addresses ultrasound for interventional pain medicine procedures, because the growth of that field demands separate consideration. Since our 2010 publication, new information has either supported or strengthened our original conclusions. There is no evidence that ultrasound is inferior to alternative nerve localization methods.
View details for DOI 10.1097/AAP.0000000000000331
View details for PubMedID 26695878
Abstract
We summarized the evidence for ultrasound (US) guidance for truncal blocks in 2010 by performing a systematic literature review and rating the strength of evidence for each block using a system developed by the United States Agency for Health Care Policy and Research. Since then, numerous studies of US guidance for truncal blocks have been published. In addition, 3 novel US-guided blocks have been described since our last review. To provide updated recommendations, we performed another systematic search of the literature to identify studies pertaining to US guidance for the following blocks: paravertebral, intercostal, transversus abdominis plane, rectus sheath, ilioinguinal/iliohypogastric, as well as the Pecs, quadratus lumborum, and transversalis fascia blocks. We rated the methodologic quality of each of the identified studies and then graded the strength of evidence supporting the use of US for each block based on the number and quality of available studies for that block.Since our last review, numerous studies have been published, especially for the paravertebral and transversus abdominis plane blocks, and 3 novel US-guided blocks (Pecs, quadratus lumborum, and transversalis fascia blocks) have been described. Although some of these studies support the use of US for performing these blocks, others do not. Additional studies have used US to improve our understanding of the anatomy pertinent to these blocks and evaluated the effect on patient outcomes and risk of complications.
View details for DOI 10.1097/AAP.0000000000000372
View details for PubMedID 26866299
Abstract
Interpretation of ultrasound images and knowledge of anatomy are essential skills for ultrasound-guided peripheral nerve blocks. Competency-based educational models promoted by the Accreditation Council for Graduate Medical Education require the development of assessment tools for the achievement of different competency milestones to demonstrate the longitudinal development of skills that occur during training.A rigorous study guided by psychometric principles was undertaken to identify and validate the domains and items in an assessment of ultrasound interpretation skills for regional anesthesia. A survey of residents, academic faculty, and community anesthesiologists, as well as video recordings of experts teaching ultrasound-guided peripheral nerve blocks, was used to develop short video clips with accompanying multiple choice-style questions. Four rounds of pilot testing produced a 50-question assessment that was subsequently administered online to residents, fellows, and faculty from multiple institutions.Test results from 90 participants were analyzed with Item Response Theory model fitting indicating that a 47-item subset of the test fits the model well (P = 0.11). There was a significant linear relation between expected and predicted item difficulty (P < 0.001). Overall test scores increased linearly with higher levels of formal anesthesia training, regional anesthesia training, number of ultrasound-guided blocks performed per year, and a self-rating of regional anesthesia skill (all P < 0.001).This study provides evidence for the reliability, content validity, and construct validity of a 47-item multiple choice-style online test of ultrasound interpretation skills for regional anesthesia, which can be used as an assessment of competency milestone achievement in anesthesiology training.
View details for DOI 10.1097/AAP.0000000000000236
View details for PubMedID 26017720
Abstract
Patients presenting for vascular surgery present a challenge to anesthesiologists because of their severe systemic comorbidities. Regional anesthesia has been used as a primary anesthetic technique for many vascular procedures to avoid the cardiovascular and pulmonary perturbations associated with general anesthesia. In this article the use of regional anesthesia for carotid endarterectomy, open and endovascular abdominal aortic aneurysm repair, infrainguinal arterial bypass, lower extremity amputation, and arteriovenous fistula formation is described. A focus is placed on reviewing the literature comparing anesthetic techniques, with brief descriptions of the techniques themselves.
View details for DOI 10.1016/j.anclin.2014.05.002
View details for PubMedID 25113725
Abstract
To determine the effectiveness of a short educational video and simulation on improvement of ultrasound (US) image acquisition and interpretation skills.Prospective, randomized study.University medical center.28 anesthesia residents and community anesthesiologists with varied ultrasound experience were randomized to teaching video with interactive simulation or sham video groups.Participants were assessed preintervention and postintervention on their ability to identify the sciatic nerve and other anatomic structures on static US images, as well as their ability to locate the sciatic nerve with US on live models.Pretest written test scores correlated with reported US block experience (Kendall tau rank r = 0.47) and with live US scanning scores (r = 0.64). The teaching video and simulation significantly improved scores on the written examination (P < 0.001); however, they did not significantly improve live US scanning skills.A short educational video with interactive simulation significantly improved knowledge of US anatomy, but failed to improve hands-on performance of US scanning to localize the nerve.
View details for DOI 10.1016/j.jclinane.2013.10.013
View details for PubMedID 24793714
