Developing a Training Program for Peripheral Nerve Blockade: The “Nuts and Bolts”


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Regional anesthesia has long been regarded as an art that is “poorly taught and seldom sought”1 and thus practiced only by a select few anesthesiologists. In recent years, though, regional anesthesia and in particular peripheral nerve blockade (PNB), has undergone a renaissance. This is due in large to the advent of ultrasound-guided regional anesthesia (UGRA), which offers the ability to visualize neural structures in relation to surrounding tissues, needle advancement in real-time, and local anesthetic spread around the nerves. To many practicing anesthesiologists, ultrasound guidance has significantly reduced the technical difficulty and the risk of failure. This, together with the current emphasis on ambulatory surgery and “fast-tracking” patients, has rekindled interest in performing peripheral nerve blocks.Now that regional anesthesia is no longer “seldom sought,” it is imperative to ensure too, that it is not “poorly taught.” The relative neglect of regional anesthesia has meant that there is currently a limited pool of experienced and enthusiastic teachers. Other challenges to adequate training in regional anesthesia include the rapidly evolving knowledge base, and the changes to the system of anesthetic training in general. Anesthesia has traditionally been taught by apprenticeship: trainees learn the principles and conduct of anesthesia in a clinical setting primarily by observing a skilled mentor and then imitating his or her skills.However, there are limitations to this model. First, the advances in modern medicine mean that the trainee must master a multitude of skills; this is extremely difficulty in the apprenticeship model of learning, given the inconsistency of case experience and learning opportunities. Second, there have been mandatory reductions in trainee duty hours across most anesthesiology training programs worldwide. This further reduces trainees' ability to obtain sufficient case experience and mentorship. Finally, increased public expectations with regard to the quality of healthcare, and a low tolerance for novice errors, have also imposed pressure on training.A more structured, learner-centered model, involving a specific rotation dedicated to regional anesthesia, may overcome some of these limitations.2 This can increase trainees' exposure to nerve blocks,3,4 although there is as yet no objective data to show that this translates into increased competency. Nevertheless this model is consistent with the modern education theory, and has found application in other aspects of anesthesia skills training; for example airway management.5 This article reviews some of the considerations involved in designing a structured training program in regional anesthesia.Objectives For Training in Regional Anesthesia/Peripheral Nerve BlocksThe objectives of the training program must be clearly defined from the onset. In the broadest sense, the program should provide a platform for residents and fellows to acquire an understanding of the core principles of regional anesthesia, proficiency in a variety of techniques, and the ability to apply these techniques appropriately in the perioperative management of patients. At a minimum, the defined objectives should meet the standards set by the relevant authority overseeing specialty certification. However, guidelines for adequate training in regional anesthesia are only loosely defined by most of the organizations responsible for accreditation in anesthesiology, and many do not specify the techniques or a minimum number of procedures that should be completed during residency. Some exceptions include the Accreditation Council of Graduate Medical Education (ACGME), which states that residents should perform at least 50 epidurals, 50 spinals, and 40 peripheral nerve blocks for surgical anesthesia; and the Royal College of Anaesthetists (UK), which has produced specific learning objectives pertinent to regional anesthesia that are an invaluable resource for any program director.

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