Teaching Regional Anesthesia

JC Gerancher MD

Associate Professor

Obstacles and Opportunities

• The educational process

• Prevailing surgical culture

• Patient autonomy

• Prevailing anesthesia culture

The educational process

• Time • Preparation• Intensified learning• Continuity of care• Appropriate sedation

Regional Anesthesia at Academic Anesthesiology Programs

• Long surgeries on sick inpatients

• Minimum teaching requirement for regional anesthesia (40 PNB’s, 50 spinals, 50 epidurals) may be inadequate and often not met.

• Acute pain services, pre-op clinics, and post-op services are available.

Surgical Culture: quotes from colleagues

• “I have to do a neurovascular exam.”• “What’s the sense of doing two anesthetics?

That just adds more complications.”• “Severe pain has not been a big problem for

me in my practice.”• “He’s healthy. He’ll do fine.”• “I’ll put local in the wound.”• “I can’t see putting my patients through that.”• “You just want to bill for your fancy blocks.”

Surgical Culture

• Never appear to delay surgery• Avoid the ‘sick and crazy’ patient pitfall • Pick your surgeons more than your battles• Prevent and manage complications• Encourage positive reinforcement• Use appropriate sedation

Surgeons v. Anesthesiologists(1=strongly disagree, 5=strongly agree)

Surgeons Anesthesiologists

RA decreases post-op pain?RA improves OR efficiency?Are RA’s successful?

3.62.23.1

4.23.43.8

Patient to choose?Surgeon to choose?Anesthesiologist to choose?

3.93.73.0

4.61.74.1

Choose RA for yourself? 3.8 4.6

Shifting Paradigms in Anesthesia

• Survival: antiquity to 1880

• Progress: 1880 to 1920

• Safety: 1920 to 1980

• Outcome: 1980 to present

First paradigm: survival

Second paradigm: progress

Third paradigm: safety

The new paradigm: Outcomes

(patient satisfaction, functional recovery, OR efficiency, and cost)

Functional Recovery after TKA (Capdevila et al 1999)

PCA FNB LEA

24o mobility milestone 74% 90% 94%

48o mobility milestone 84% 100% 100%

Degree flexion day 5 60o 80o 85o

Degree flexion day 7 80o 90o 90o

Day of discharge 50 40 37

OR efficiency for outpatient knee surgery

(Williams et al 2000) GA RA GA+RA

Anesthesia-controlled time (ACT) 20 11 16Turn-over time (TOT)(patient out to next patient in)

22 20 21

ACT+TOT(dressing on to next prep begin)

42 31 37

Patient acceptance

• Preoperative patient education• General anesthesia is not ‘sleep’• Emphasize postoperative analgesia • Follow-up and advertise

Big MACtm or a Napoleonic Anesthetic (a little general)

What Clinical Anesthesia Outcomes are Important to Avoid?

(Macario et al 1999)

• Patients were asked to rank ten outcomes on a ‘willingness to pay’ basis

• Vomiting> gagging on the endotacheal tube> incisional pain > nausea > recall without pain > residual weakness > shivering > sore throat > somnolence

Anesthesia Culture

• Teach the teachers• Anesthesia is ‘perioperative medicine’• No one cares about how much you enjoy your

job except you

What is a “successful” block?

• Dependable surgical anesthesia

• Provision for tourniquet anesthesia

• Latency appropriate for the clinical situation at hand

• Provision of postoperative analgesia

• Associated with patient satisfaction

• Safety with few side effects

One regionalist’s two year experience with brachial plexus blockade

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regional general combined ga and regional mac

What is the effect of one ‘regionalist’s practice of brachial plexus block on an

anesthesia department?

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'regionalist' other MD departmental average

The Regional Anesthesia & Acute Pain Management Service At WFU

• APS and OR Regional are one rotation • a daily commitment of 4 resident full-time

equivalents outside of the routine OR care team

• A dedicated RN to facilitate block placement• Reduced intraoperative OR coverage for the

supervising attending • pre-operating room block placement and

block testing• multi-modal analgesia: long-lasting local

anesthetics, COX-2 inhibitors, and po opioids

Growth of a Teaching Program

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2000 2001 2002 2003

Peripheral NerveBlocks

Residents/Month

Growth of a Teaching Program

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2000 2001 2002 2003

Thoracic Epidurals

Continuous PNB

Residents/Month

The Regional Anesthesia and Acute Pain Management Section At WFU

(RAAPM)

• Dedicated 24/7/365 faculty for acute pain• One-on-one supervision while blocks are

being placed.• Requires 3.3 FTE for these two activities.• Involves 6 Faculty at our institution.• Continuous quality improvement with

surgeons, nursing, pharmacy and rehab• Continuous monitoring of billing practices.• No involvement by Chronic Pain Clinic.

Clinical Workload of Faculty

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M T W Th F Sa Su M T W Th F Sa Su

APS Patient Census

Patients blocked for pop management

Patients blocked for surgery

Operating rooms covered

The Regional Anesthesia Area

Supplies and Teaching Materials

The Regional Cart

Who pays the bill for teaching?

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APS Faculty FTE RA Faculty FTE

APS Charges

OR Charges

Total Charges

New billing codes

APS follow-up

“Hey daddy, what kinda regional did that man have?”