Vanderbilt Anesthesiololgy

Training Anesthesiology residents to be knowledgeable and competent to perform regional anesthesiology is a key part of the ‘Vanderbilt difference.’ Residents rotate for one month to the Vanderbilt Orthopedic Surgicenter (VOS) to learn regional anesthesia, specifically upper and lower limb peripheral nerve blocks. They perform an average of 68 blocks per month as follows:

Ambulatory Regional Anesthesia Rotation Objectives

I. Formulate a plan for the management of neural blockade

A. Preanesthesia management

1. Evaluation of patient, patient selection, and contraindications
2. Documentation of important preexisting neurologic problems
3. Presentation of anesthetic options, advantages and disadvantages
4. Be able to provide informed consent, describe risks and incidence of complications
5. Judicious use of sedating drugs

B. Anesthesia management

1. Choose local anesthetic according to length of surgery, site to be blocked, and patient concomitant disease
2. Learn the appropriate documentation of the technique with attention to details
3. Calculation of maximal dose
4. Resuscitation equipment
5. Selection and rationale of monitoring
6. Block trays
7. Choose the appropriate block for the site and type of surgery and post-op pain control

C. Intraoperative

1. Be able to verify the adequacy of an specific block in a systematic way according to the technique and the agent used
2. Be able to formulate an alternative plan to rescue an inadequate block
3. IV supplementation
4. Inhalational techniques
5. Supplemental blocks

D. Postoperative

1. Postop pain management
2. Special monitoring in postop period
3. Criteria for recovery room discharge
4. Criteria for home readiness
5. Special instructions to be given to the patient at discharge

II. Become knowledgeable in neural physiology and local anesthetic action

A. Nerve membranes, potentials and impulses

B. Mechanism of action of local anesthestics

C. Fiber size and function

D. Determinants of activity 

1. Protein binding 
2. PKa
3. Lipid solubility

E. Differential nerve blocks

III. Understand the clinical pharmacology, chemical properties, and absorption of the following local anesthetics:

A. Cocaine
B. Procaine
C. 2-Chloroprocaine
D. Tetracaine
E. Benzocaine
F. Lidocaine
G. Bupivicaine
H. Etidocaine
I. Mepivacaine
J. Prilocaine
K. Ropivacaine

IV. Be familiar with adjuvant techniques to modify onset, intensity, and duration of neural blockade

A. pH adjustment
B. Carbonated solution
C. Epinephrine addition
D. Pka modification
E. Mixtures of local anesthetics

V. Become proficient and confident in different regional anesthesia techniques, approaches, and anatomical landmarks as well as indications, nerves spare, and complications

A. Brachial plexus block above the clavicle

1. Classical supraclavicular approach 
2. Interscalene approach
3. Subclavian perivascular approach
4. Plumb-bob method
5. Complications
6. Phrenic nerve block
7. Pneumothorax
8. Spinal, epidural
9. Horner’s syndrome 
10.Recurrent laryngeal nerve block
11.Mechanism of hypotension and bradycardia

B. Brachial plexus block below the clavicle

1. Infraclavicular approach 
2. Axillary approach
3. Transarterial technique 
4. Paresthesia technique
5. Nerve stimulator technique
6. Importance of arm position during and after block 
7. Mid-humeral approach
8. Complications
9. Hematoma 
10.Vasospasm 
11.Pseudoaneurysm

C. Femoral nerve block and/or ‘3-in-1’ block

D. Sciatic nerve block

1. Classical Posterior approach
2. Lithotomy position approach
3. Anterior approach
4. Lateral approach

E. Ankle block

F. Spinal block

1. Midline approach
2. Lateral approach 
3. Taylor approach 
4. Hypobaric
5. Isobaric
6. Hyperbaric

G. Epidural block

H. Intravenous block

1. Site of action
2. Choice of veins
3. Proper cuff placement, size selection, and inflation pressures
4. Proper exsanguination
5. Proper techniques of cuff deflation
6. Plasma levels of local anesthetics
7. Time of tourniquet release
8. Mode of release
9. Management of of tourniquet pain and/or discomfort
10.Discuss the different reasons for leakage

VI. Understand the physiology of spinal anesthesia

A. Be able to discuss the concept of baricity, specific gravity and ‘fixed’ spinal
B. Orders of fibers blocked
C. Cardiovascular changes, mechanisms of hypotension
D. Pulmonary changes
E. Effect of positioning
F. Effect of volume, speed of injection
G. Thigh tourniquet pain management and its modification with local anesthetic chosen
H. Use of adjuncts

1. epinephrine
2. opiods
3. clonidine

VII. Understand, recognize, and be prepared to treat the complications of regional anesthesia

A. Systemic toxicity

1. Be able to discuss the factors that affect the rise and magnitude of blood levels
2. Site of injection
3 .Drug selection
4. Dose
5. Speed of injection
6. Vasoconstrictors 
7. Concomitant diseases
8. CNS effects
9. Cardiovascular effects

B. Vascular
C. Respiratory
D. Neurologic
E. Infections
F. Methemoglobinemia
G. Specific to spinal and epidural

1. Total spinal 
2. Headache
3. Back pain
4. Urinary retention

H. Issues related to preservatives and antioxidants

1. Methylparaben
2. EDTA
3. Bisulfite and pH

I. Allergy to local anesthetics
J. Tissue toxicity
K. Prevention techniques

VIII. Become knowledgeable in the anatomy and motor and sensory inervation of the following

A. Brachial plexus
B. Femoral plexus
C. Cervical plexus
D. Spine
E. Peripheral nerves in the antecubital fossa
F. Peripheral nerves in the popliteal fossa
G. Peripheral nerves at the ankle

IX. Become knowledgeable in the sensory dermatomes

X. Understand the proper use, electrophysiology, and desirable chracteristics of nerve stimulators

XI. Understand and be prepared to discuss the current controversies in regional anesthesia

A. Paresthesia or not paresthesia
B. Insulated needles or not insulated needles
C. Anticoagulation in regional anesthesia
D. Does regional anesthesia improve outcome?
E. Is lidocaine neurotoxic?
F. Should regional anesthesia be done on anesthetized patients?
G. ‘Immobile needle’ concept vs. multicompartment in axillary blocks
H. Transarterial vs. nerve stimulator techniques in axillary blocks

XII. Dissect and identify different structures in cadaver workstation

A. Neck
B. Axilla
C. Femoral area
D. Sciatic
E. Antecubital area
F. Ankle
G. Popliteal area

XIII. Become knowledgeable in the following topics related to continuous peripheral nerve block

A. Techniques
B. Choice of local anesthetics and concentration
C. Infusion rates
D. Cumulative systemic toxicity
E. Myotoxicity

The above goals and objectives will be evaluated as follows:

A set of keywords will be given at the beginning of the rotation that corresponds to the questions to be asked in the written test. It is the resident’s responsibility to read about those topics. Another set of keywords of the wrong answers will be given at the end for feedback and future study.