• Joseph M. Neal, MD

       INTRODUCTION

Over the past 20 years, the importance of training anesthesiologists in regional anesthesia has become recognized worldwide. More practitioners use regional anesthetic blocks for their patients and choose regional anesthesia for themselves when they undergo surgery. Documented improved outcomes (eg, obstetric anesthesia, acute pain management, ambulatory surgery, etc) have also contributed to the increase in popularity and use of regional anesthesia in the recent years. Despite this trend, the quality of training in regional anesthesia is less than needed for residents and fellows, as well as for practicing anesthesiologists. Quality training in regional anesthesia is necessary to promote not only clinical competence but also practitioner confidence in the ability to perform the skill proficiently and safely. Surveys of residency programs demonstrate narrowing variability in training, and recent consensus-based regional anesthesia fellowship guidelines may further improve training at all levels. Academic programs have employed conventional and unconventional methods to compliment the exposure to regional anesthesia opportunities that residents and fellows receive in the operating room, obstetric suite, and pain clinic. In this chapter, these teaching concepts will be discussed as well as future goals for improving regional anesthesia training for all anesthesiologists.

       PAST & CURRENT TRAINING EXPERIENCE

Evolution of Regional Anesthesia Training

As early as the 1920s, there were dedicated teachers of regional anesthesia. In the United States, both Gaston Labat and lohn S. Lundy offered 3-month courses in the basics to interested practitioners. Of note, such teaching influenced many renowned anesthesiologists of the time, including Ralph Waters and Emery Rovenstine.¹ At that time, a few experts promoted regional anesthesia, including the members of the first American Society of Regional Anesthesia, which was founded by Labat. Nevertheless, prior to the last quarter century, only a few residency programs had officially incorporated regional anesthesia as part of their educational curriculum.

Figure 81-1. The use of regional anesthesia in residency training programs compared with general or local anesthesia for cases in 1980 (21.3%), 1990 (29.8%), and 2000 (30.2%). (Reprinted with permission from Kopacz DJ, Neal JM: Regional anesthesia and pain medicine: Residency training—the year 2000. Reg Anesth Pain Med 2002;27:9–14.)

        It was not until 1996 that the Anesthesiology Residency Review Committee ( RRC) of the Accreditation Council for Graduate Medical Education (ACGME) formally listed a minimal number of regional anesthetic blocks as a requirement of training in anesthesiology.² Prior to that time, regional anesthesia training varied widely in residency programs. For instance, a survey conducted in 1980 showed that regional anesthesia use ranged from 2.8 to 55.7% among responding training programs, with approximately 21% of all cases using regional anesthesia.³ Indeed, students of well- respected programs could graduate having performed fewer than a handful of spinal anesthetics. These numbers improved somewhat by 1990, but although regional anesthesia was utilized in more cases (29.8%), primarily reflecting increases in obstetric and pain management applications of regional techniques, the large discrepancy continued, with 2.8 to 58.5% total caseload experience.⁴ By the year 2000, the number of surgical cases with regional anesthetics did not significantly increase (30.2%) nor did the distribution of the types of anesthetics (Figures 81-1 and 81-2), but there was much less disparity in usage by training programs nationwide.⁵

Accreditation Agency Requirements

As the current RRC program requirements state, residents must perform 50 epidural, 50 spinal, and 40 peripheral nerve blocks plus an additional 25 nerve blocks for pain management.² The most recent survey shows that nearly all residents meet the requirement for neuraxial blocks, which does not stratify between lumbar and thoracic epidurals or account for continuous spinal or combined spinal-epidural experience. Indeed, although most residents exceed that required number, nearly half of their regional anesthesia training still occurs in the obstetric suite.⁵ These data are encouraging, since studies of clinical competence show it takes between 60 and 90 epidural blocks to reach at least 80% success^6–8 (Figure 81–3). Achieving a level of competency is reflected in resident confidence, as surveys of graduating residents showed more than 94% were very confident in their lumbar epidural skills.^8–10 Similar evidence exists for spinal blocks. Surveyed residents felt very confident in their ability to perform spinal anesthesia.⁹ Kopacz and colleagues demonstrated that at least 45 spinal anesthetics had to be performed before at least a 90% success rate was attained,’ a number much closer to the RRC requirement.

Figure 81-2. Distribution of types of regional anesthesia in residency training programs did not change significantly between 1990 and 2000 (p = 0.75). (Reprinted with permission from Kopacz DJ, Neal JM: Regional anesthesia and pain medicine: Residency training—the year 2000. Reg Anesth Pain Med 2002;27:9– 14.)

        The data for peripheral nerve block performance, however, is disappointing. Approximately 40% of all residents in the year 2000 had inadequate experience in peripheral nerve blocks.⁵ Not only is this unfortunate from an education standpoint, but it may present a patient safety issue. Residents not adequately trained in a particular block are unlikely to use that block in practice;¹¹ or worse, they may be asked to provide nerve block services without the necessary skills.^9–12 Multiple surveys have demonstrated that graduating residents do not feel confident in their peripheral nerve block skills⁹ (Figure 81–4). This may be especially true for lower extremity nerve blocks^12–13 (Figure 81–5). Furthermore, the vagueness of “40 peripheral blocks” allows this discrepancy between block types to occur. Indeed, 40 performances of any one nerve block will satisfy the training requirements by the RRC, but it will be inadequate to attain competency in other block techniques. Konrad and coworkers demonstrated that 70 axillary blocks are needed before an 85% success rate can be achieved⁶ (Figure 81-6). Rosenblatt and associates showed that more than 10 interscalene blocks are necessary before the resident attains at least 50% autonomy.¹⁴ Therefore, it is unlikely that many residents are developing the necessary proficiency because they are not performing enough peripheral nerve blocks. Furthermore, many teaching departments have fewer regional anesthesia teachers than they would prefer. A 2004 survey of department chairs noted that on average they would ideally hire two additional regional anesthesia specialists on their faculty.¹⁵

Figure 81-3. The learning curve for epidural anesthesia: demonstrating a minimum of 90 blocks to reach 80% success rate. (Reprinted with permission from Konrad C, Schuepfer G, Wietlisbach M, et al: Learning manual skills in anesthesiology. Is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998;86:635-639.)

Figure 81-4. The percentage of residents, per training year, who categorized themselves as “not confident” in performing a particular block. Exact percentages are listed for the CA-3 resident class. Residents felt least confident with peripheral nerve blocks, and no CA-3 resident admitted to being “not confident”for spinal or lumbar epidural anesthesia. (Reprinted with permission from Smith MP, Sprung J, Zura A, et al: A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. Reg Anesth Pain Med 1999;24:11-16.)

Figure 81-5. Percentage of peripheral nerve blocks performed in practice in the United States, as reported by practitioners. (Reprinted with permission from Hadzic A, Vloka JD, Kuroda MM et al: The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med 1998;23:241–246.)

Clinical Pearl

Related posts:

Regional Anesthesia in the Patient with Preexisting Neurologic Disease. The History of Local Anesthesia. Stimulating Catheters. Diagnosis & Management of Intraspinal, Epidural, & Peripheral Nerve Hematoma. Histology of Peripheral Nerves. Supraclavicular Brachial Plexus Block.