teaching regional anesthesia
TRANSCRIPT
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
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
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
0%
20%
40%
60%
80%
100%
Oct
No
v
De
c
Jan
Fe
b
Ma
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Ap
ril
Ma
y
Jun
e
July
Au
g
Se
pt
Oct
No
v
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Jan
Fe
b
Ma
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Ap
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Ma
y
Jun
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July
Au
g
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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?
0
20
40
60
80
100
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
ril
Ma
y
Jun
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July
Au
g
Se
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Oct
No
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Jan
Fe
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Ma
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Jun
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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
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003
Peripheral NerveBlocks
Residents/Month
Growth of a Teaching Program
0
1
2
3
4
5
6
7
8
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
0
5
10
15
20
25
30
35
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
Who pays the bill for teaching?
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
APS Faculty FTE RA Faculty FTE
APS Charges
OR Charges
Total Charges