CON: Novel Block Techniques Should Not Be Taught During Anesthesiology Residency

May 2019 Issue

  1. Michael O'Rourke, M.D. Associate Professor, Loyola University Medical Center Author


Anesthesiology residencies should graduate physicians skilled in providing competent and safe ultrasound-guided regional anesthesia (UGRA). However, with an ever-increasing number of regional anesthetics available, including new peripheral nerve block and fascial plane blocks, the best method to provide regional anesthesia education and training is not known. Given residents’ limited time and clinical exposure, the focus of their training should be in safe and proven regional anesthetic techniques and not in incorporating innovative or novel blocks.

The Number of Blocks is Daunting

The remarkable interest in UGRA in the past 10 years has produced an increasing number of regional anesthetic techniques described in the literature. More than 40 regional anesthetic techniques can be taught to anesthesiology residents as part of a UGRA curriculum, some of which are listed in Figure 1. Previous work has identified learning curves that set the number of procedures a trainee or novice needs to perform to gain technical proficiency in a particular regional anesthesia technique.[1–3] Although the number of procedures needed varied by study and type of block, more than eight sessions and sometimes many times that number were necessary to establish technical proficiency. If multiple sessions are required to gain the technical skills necessary to perform just a single basic block, then residents are unable to gain the experience to be competent and safe at performing all types of regional anesthesia procedures during the limited time of residency. The question then becomes, which regional anesthetic techniques should be taught during residency?

Figure 1: Regional anesthetic block techniques that could be taught during anesthesiology residency

Shoulder and Upper Extremity
Interscalene
Supraclavicular
Infraclavicular
Suprascapular
Axillary
Superficial cervical plexus
Deep cervical plexus
Bier
Digital nerve
Median nerve
Ulnar nerve
Radial nerve

Abdomen and Thorax
Pectoral nerve 1
Pectoral nerve 2
Paravertebral
Serratus plane
Erector spinae
Intercostal
Quadratus lumborum
Quadratus lumborum 2
Quadratus lumborum 3
Transversus abdominis plane (TAP)

Rectus sheath
Subcostal TAP

Back
Epidural, lumber
Epidural, thoracic
Spinal
Caudal
Lumbar plexus

Lower Extremity
Femoral
Adductor canal
Obturator
Lateral femoral cutaneous
Sciatic, popliteal approach
Sciatic, transgluteal approach
Sciatic, anterior approach
Sciatic, subgluteal approach
IPACK (interspace between the popliteal artery and the capsule of the posterior knee)
Ankle
Fascia iliaca

Graduates Need Competence in Safe and Effective UGRA

Residents have limited time and clinical exposure to gain skills and competence in performing safe and effective UGRA. It has been previously suggested that all residency graduates should master proficiency in a specified core group of widely applicable nerve blocks.[4] Establishing resident competence in a specified list of internationally agreed-upon regional anesthetic techniques could be an ideal way to improve regional anesthetic care. However, because of the large number of regional anesthetic techniques available, as well as variations in practice between residency training sites, this idyllic scenario is probably even further from reality today than when it was suggested in 2002.


Teaching a small number of regional anesthetic techniques and the processes and rationale that guide them is more likely to produce competence than focusing on new and innovative blocks.


Today, individual institutions tailor clinical pathways to the institution’s particular resources and patient characteristics; therefore, residents at different institutions will have exposure to different regional anesthetic techniques. If proficiency in individual regional anesthetic techniques requires repetition, as the learning curves suggest, then requiring all residency graduates to be proficient in a specific list of blocks is likely unachievable. Instead, each individual institution should focus UGRA education for a small number of regional anesthetic techniques that are frequently performed at that institution. At my own institution, the acute pain service (APS) faculty selected 12 core regional techniques (see Figure 2) for residents on our APS rotation. During the APS rotation, education and evaluation of technical competence are focused on those 12 techniques. Focusing UGRA residency training away from novel or innovative blocks and toward proven blocks that can be performed in sufficient numbers is more likely to produce technical proficiency in performing particular blocks and overall competence in regional anesthesia.

Figure 2: Core blocks taught during acute pain service rotation.

Interscalene
Supraclavicular
Infraclavicular
Paravertebral
Epidural, thoracic
Transversus abdominus plane (TAP)
Subcostal TAP
Femoral
Adductor canal
Sciatic, popliteal approach
IPACK (interspace between the popliteal artery and the capsuleof the posterior knee)
Fascia iliaca

Teaching Competent UGRA Is More Than Learning Block Techniques

Providing competent regional anesthesia care entails not just technical proficiency in performing blocks but also skills in clinical decision making, working on a team, and quality improvement.[5–7] Those nontechnical skills can be more difficult to teach and assess than technical proficiency yet are critical components of competency in regional anesthesia. Focusing regional anesthesia education on a small number of proven blocks and their associated safety and clinical decision pathways allows residents to learn both the technical and nontechnical aspects of those blocks. Developing critical decision-making skills for selected blocks in residency can serve as a template for future decision making in regional anesthesia and will prepare residents to incorporate yet-to-be described regional anesthesia techniques into their clinical practice following completion of their residency training.

The number of regional anesthesia techniques taught to ensure competence during residency may vary between institutions and even between individuals at a particular institution. However, teaching a small number of regional anesthetic techniques and the processes and rationale that guide them is more likely to produce competence than focusing on new and innovative blocks. It will also provide a solid foundation for residents to further their knowledge and skills by doing a fellowship program.

Conclusion

Regional anesthesia can provide a number of potential benefits for surgical patients. Accordingly, anesthesiology residencies are striving to provide competence in regional anesthesiology as part of a comprehensive training program. Although the clinical experience varies between individual residency programs, residents must learn technical and nontechnical aspects of regional anesthesia. Focusing regional anesthesia teaching on a small number of proven blocks that are part of proven clinical pathways rather than incorporating innovative or novel blocks into training is most likely to graduate residents who are competent in regional anesthesia.

References

  1. Rosenblatt MA, Fishkind D. Proficiency in interscalene anesthesia—how many blocks are necessary? J Clin Anesth 2003;15:285–288.
  2. Barrington M, Wong D, Slater B, Ivanusic J, Ovens M. Ultrasound-guided regional anesthesia: how much practice do novices require before achieving competency in ultrasound needle visualization using a cadaver model. Reg Anesth Pain Med 2012;37:334–339.
  3. Kopacz DJ, Neal JM, Pollack JE. The regional anesthesia “learning curve”: what is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996;21:182–190.
  4. Hadzic A, Vloka J, Koenigsamen J. Training requirements for peripheral nerve blocks. Curr Opin Anaesthesiol 2002;15:669–673.
  5. Neal J. Education in regional anesthesia: caseloads, simulation, journals, and politics. Reg Anesth Pain Med 2012;37:647–651.
  6. Sites B, Chan V, Neal J, et al. The American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy joint committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2010;35(suppl 1): S74–S80.
  7. Slater R, Castanelli D, Barrington M. Learning and teaching motor skills in regional anesthesia, a different perspective. Reg Anesth Pain Med 2014;39:230–239.

Tags: residency, novel blocks

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