This document discusses challenges and opportunities in teaching regional anesthesia. It notes obstacles like surgical culture which prefers general anesthesia and time constraints. Regional anesthesia education requires preparation, continuity of care, and appropriate sedation. Minimum requirements for regional blocks in academic programs are often not met due to long surgeries and sick patients. The document advocates for improving outcomes through regional techniques and emphasizes functional recovery, operating room efficiency, cost, and patient satisfaction as important new paradigms. It provides examples of improved outcomes with regional anesthesia and strategies for growing successful regional anesthesia programs.

1. Teaching Regional
Anesthesia
JC Gerancher MD
Associate Professor

2. Obstacles and Opportunities
• The educational process
• Prevailing surgical culture
• Patient autonomy
• Prevailing anesthesia culture

3. The educational process
• Time
• Preparation
• Intensified learning
• Continuity of care
• Appropriate sedation

4. 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.

5. 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.”

6. 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

7. Surgeons v. Anesthesiologists
(1=strongly disagree, 5=strongly agree)
Surgeons Anesthesiologists
RA decreases post-op pain?
RA improves OR efficiency?
Are RA’s successful?
3.6
2.2
3.1
4.2
3.4
3.8
Patient to choose?
Surgeon to choose?
Anesthesiologist to choose?
3.9
3.7
3.0
4.6
1.7
4.1
Choose RA for yourself? 3.8 4.6

8. Shifting Paradigms in
Anesthesia
• Survival: antiquity to 1880
• Progress: 1880 to 1920
• Safety: 1920 to 1980
• Outcome: 1980 to present

9. First paradigm: survival

10. Second paradigm: progress

11. Third paradigm: safety

12. The new paradigm: Outcomes
(patient satisfaction, functional recovery, OR efficiency, and cost)

13. 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

14. OR efficiency for outpatient knee surgery
(Williams et al 2000)
GA RA GA+RA
Anesthesia-controlled time (ACT) 20 11 16
Turn-over time (TOT)
(patient out to next patient in)
22 20 21
ACT+TOT
(dressing on to next prep begin)
42 31 37

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

17. Big MACtm
or a Napoleonic
Anesthetic (a little general)

18. 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

19. Anesthesia Culture
• Teach the teachers
• Anesthesia is ‘perioperative medicine’
• No one cares about how much you enjoy your
job except you

20. 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

21. One regionalist’s two year experience
with brachial plexus blockade
0%
20%
40%
60%
80%
100%
Oct
Nov
Dec
Jan
Feb
Mar
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
April
May
June
July
Aug
Sept
regional general combined ga and regional mac

22. What is the effect of one ‘regionalist’s
practice of brachial plexus block on an
anesthesia department?
0
20
40
60
80
100
Oct
Nov
Dec
Jan
Feb
Mar
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
April
May
June
July
Aug
Sept
'regionalist' other MD departmental average

23. 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

24. Growth of a Teaching Program
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003
Peripheral Nerve
Blocks
Residents/Month

25. Growth of a Teaching Program
0
1
2
3
4
5
6
7
8
2000 2001 2002 2003
Thoracic Epidurals
Continuous PNB
Residents/Month

26. 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.

27. 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

28. The Regional Anesthesia
Area

29. Supplies and Teaching Materials

30. The Regional Cart

31. 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

32. New billing codes

33. APS follow-up

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