10/15/2015

Clinicalexpertiseinregionalanesthesia:Anesthesiologistsvoicetheirneedforformaltraining

SaudiJAnaesth.2013OctDec7(4):371372.

PMCID:PMC3858684

doi:10.4103/1658354X.121042

Clinicalexpertiseinregionalanesthesia:Anesthesiologistsvoicetheirneedfor
formaltraining
DmitriSouzdalnitskiandSamerNarouze
CenterforPainMedicine,SummaWesternReserveHospital,CuyahogaFalls,Ohio,USA
Addressforcorrespondence:Dr.SamerNarouze,ClinicalProfessorofAnesthesiologyandPainManagement,OUCOM,ClinicalProfessorof
rd
NeurologicalSurgery,OSU,Chairman,CenterforPainMedicine,SummaWesternReserveHospital,190023 Street,CuyahogaFalls,Ohio,
USA.Email:narouzs@hotmail.com
Copyright:SaudiJournalofAnaesthesia
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Regionalanesthesia(RA),whenapplicable,providesoutstandingpostoperativeanalgesia,moderatesstress
responses,diminishespostoperativecognitivedysfunction,shortenshospitalstay,andlikelyhasanti
inflammatoryandanticancereffects.Itcanalsodecreasetheriskofchronicpostoperativepainaftersurgery.
[1,2]
AlthoughRAisassumedtobetaughtinroutineanesthesiologytraining,thisisnotactuallythecase.
ConfidenceinperformingRAisnotaccompaniedbycompetenceevenifformaltrainingisprovided.For
instance,residentsreportedthattheyfeltveryconfidentoftheirskillsafterhavingperformedlessthan10
nerveblockshowever,studieshaveshownthatapproximately45spinaland60epiduralblocksneedtobe
performedbyaresident,withoutanyfacultyassistance,forhim/hertoachievea90%successrate.[3]Merely
meetingthetechnicalrequirementsforperformingblocksdoesnotholdasmuchimportanceasoverall
competenceforRAbecauseifthephysicianisunsureabouttheindicationsandcontraindicationsforthe
neuralblockade,theoptimalsurgicalconditionandadequatepostoperativepaincontrolcannotbeattained,
evenwithatechnicallystellarprocedure.
Harbietal.,[1]reportedthatalmost90%ofsurveyedanesthesiologistspracticeRAregularly,whichisin
starkcontrastwiththefindingsofthesurveythatreportedthatonly8of382anesthesiologistswho
respondedtothesurveyreceivedformaltraininginRAandcompletedfellowshipsinRA,allofthem
abroad.WeappreciatethattheauthorsareemphasizingonintroducingformaltrainingforRAinSaudi
ArabiaasmanycountieshavepreviouslyattemptedtointroduceformaltrainingforRA,andithasthusfar
beensuccessfuloverall.
UltrasoundguidedRA(UGRA)isanimportantapplicationofRA.ThenumberofcasesinwhichUGRA
hasbeenusedhasconsiderablyincreasedoverthelast10years.Evidenceforthisistheexponentially
increasedvolumeofUGRApublicationsandnumberofformallytrainedUGRAanesthesiologists.[4]
Ultrasonographyprovidesrealtime,noninvasiveinformationaboutindividualanatomyandallows
anesthesiologiststoobserveneedleadvancementtowardthetargetedneuralstructurewhileavoidingdamage
toothervitaladjacentstructuresandallowingustoobservethespreadandnavigateinjectionoflocal
anestheticsolution.UGRAallowsperformanceofasafer,faster,andmoresuccessfulblock.Ithasbeen
recentlyshownthatatleast28attemptsareneededtoachievedexterityinperformingperipheralnerveblocks
usingultrasound.[5]Meanwhile,only7%ofanesthesiologistswhorespondedtoDr.Harbi'ssurveyreceived
formaltraininginUGRAandlessthan50%oftheanesthesiologistsinSaudiArabiawerefoundtopractice
UGRAorbothUGRAandnervestimulation.
ThestudybyHarbietal.,highlightstwoimportantpoints:First,RAisverycommonlyusedinSaudiArabia
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Clinicalexpertiseinregionalanesthesia:Anesthesiologistsvoicetheirneedforformaltraining

(88.2%),andanesthesiologistsroutinelyperformRA.Second,physicianspracticingRAinSaudiArabia
havedemonstratedgreataccountabilityanddesiretodeliverbettercarefortheirpatients:Almost90%are
willingtoattendeducationalsessionsforRA,andmorethan7of10anesthesiologistswouldliketoattend
theseeducationalsessions24timesayear.However,theyfinditdifficulttonurturetheirlearninginterests
becauseofthelimitedactivitiesconducted.Continuingmedicaleducation(CME)needstobesetupforthose
whohavealreadycompletedtheirresidency.CMEcanbeachievedbyroutineparticipationinworkshops,
conferences,onlineandpaperselfassessmenttestspracticeimprovementreadingpatientsafetymodules
relatingtoRApracticepatternsandpeerlettersofreferenceandteaching,research,andadministrationof
RA.Therearenoclearlydefinedmilestonesoraspecifiedfrequencyoftasksforcompletingthese
requirements.Thistrainingcanbeprovidedwithinsettingsofresidencyprograms.[4]Thisgivesrisetothe
questionofwhetherresidentsneedevidenceofformaltraining,aspecialprofessionalcertification,or
credentialingforRA,whichisstillunanswered,althoughmanyprofessionalssuggestthatspecial
certificationforRAorUGRAisnotcurrentlyrequired.[2]
IntermsofimplementationofRA,onlyminimalbarriershavebeenreportedinDr.Harbiandcolleagues
study:0.9%ofrespondentsreportedthatRAfailstoprovideadequatesurgicalconditions.Inaddition,only
1.4%ofanesthesiologistsreportedsurgeonsresistancetotheuseofRA,whichisconsideredaplausible
argumentbymanyanesthesiologists.Lessthan3%oftherespondentssaidthatRAisatimeconsuming
procedure.Withpropertraining,adequateorganizationalsetting,andeducationofsurgeonsandhealthcare
administrators,thisbarrierwilllikelybecomenegligent.
Insummary,practiceofRAissuccessfullyprevailinginSaudiArabia.Aprogramforformaltrainingofand
CMEforRAshouldbedesignedtoimproveknowledgeandskillsnecessarytomaintainclinicalcompetence
whileconductingRA.
REFERENCES
1.HarbiMA,KakiAM,KamalA,ElDawlatlyA,DaghistaniM,TahanMR.ASurveyofthePracticeof
RegionalAnesthesiainSaudiArabia.SaudiJAnaesth.20137:36770.[PMCID:PMC3858683]
2.[Lastassessedon2013Feb14].http://www.asra.com/Newsletters/Feb_09.pdf.
3.SmithMP,SprungJ,ZuraA,MaschaE,TetzlaffJE.Asurveyofexposuretoregionalanesthesia
techniquesinAmericananesthesiaresidencytrainingprograms.RegAnesthPainMed.199924:1116.
[PubMed:9952089]
4.SitesBD,ChanVW,NealJM,WellerR,GrauT,KoscielniakNielsenZJ,IvaniG.TheAmerican
SocietyofRegionalAnesthesiaandPainMedicineandtheEuropeanSocietyofRegionalAnaesthesiaand
PainTherapyjointcommitteerecommendationsforeducationandtraininginultrasoundguidedregional
anesthesia.RegAnesthPainMed.201035(2Suppl):S7480.[PubMed:20216029]
5.BarringtonMJ,WongDM,SlaterB,IvanusicJJ,OvensM.Ultrasoundguidedregionalanesthesia:How
muchpracticedonovicesrequirebeforeachievingcompetencyinultrasoundneedlevisualizationusinga
cadavermodel.RegAnesthPainMed.201237:3349.[PubMed:22354107]
ArticlesfromSaudiJournalofAnaesthesiaareprovidedherecourtesyofMedknowPublications

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