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Year : 2013  |  Volume : 7  |  Issue : 4  |  Page : 371-372

Clinical expertise in regional anesthesia: Anesthesiologists voice their need for formal training

Center for Pain Medicine, Summa Western Reserve Hospital,Cuyahoga Falls, Ohio, USA

Correspondence Address:
Samer Narouze
Clinical Professor of Anesthesiology and Pain Management, OUCOM, Clinical Professor of Neurological Surgery, OSU, Chairman, Center for Pain Medicine, Summa Western Reserve Hospital, 1900 23rd Street, Cuyahoga Falls, Ohio
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.121042

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Date of Web Publication7-Nov-2013

How to cite this article:
Souzdalnitski D, Narouze S. Clinical expertise in regional anesthesia: Anesthesiologists voice their need for formal training. Saudi J Anaesth 2013;7:371-2

How to cite this URL:
Souzdalnitski D, Narouze S. Clinical expertise in regional anesthesia: Anesthesiologists voice their need for formal training. Saudi J Anaesth [serial online] 2013 [cited 2022 Jan 20];7:371-2. Available from:

Regional anesthesia (RA), when applicable, provides outstanding postoperative analgesia, moderates stress responses, diminishes postoperative cognitive dysfunction, shortens hospital stay, and likely has anti-inflammatory and anticancer effects. It can also decrease the risk of chronic postoperative pain after surgery. [1],[2]

Although RA is assumed to be taught in routine anesthesiology training, this is not actually the case. Confidence in performing RA is not accompanied by competence even if formal training is provided. For instance, residents reported that they felt "very confident" of their skills after having performed less than 10 nerve blocks; however, studies have shown that approximately 45 spinal and 60 epidural blocks need to be performed by a resident, without any faculty assistance, for him/her to achieve a 90% success rate. [3] Merely meeting the technical requirements for performing blocks does not hold as much importance as overall competence for RA because if the physician is unsure about the indications and contraindications for the neural blockade, the optimal surgical condition and adequate postoperative pain control cannot be attained, even with a technically stellar procedure.

Harbi et al., [1] reported that almost 90% of surveyed anesthesiologists practice RA regularly, which is in stark contrast with the findings of the survey that reported that only 8 of 382 anesthesiologists who responded to the survey received formal training in RA and completed fellowships in RA, all of them-abroad. We appreciate that the authors are emphasizing on introducing formal training for RA in Saudi Arabia as many counties have previously attempted to introduce formal training for RA, and it has thus far been successful overall.

Ultrasound-guided RA (UGRA) is an important application of RA. The number of cases in which UGRA has been used has considerably increased over the last 10 years. Evidence for this is the exponentially increased volume of UGRA publications and number of formally trained UGRA anesthesiologists. [4] Ultrasonography provides real-time, noninvasive information about individual anatomy and allows anesthesiologists to observe needle advancement toward the targeted neural structure while avoiding damage to other vital adjacent structures and allowing us to observe the spread and navigate injection of local anesthetic solution. UGRA allows performance of a safer, faster, and more successful block. It has been recently shown that at least 28 attempts are needed to achieve dexterity in performing peripheral nerve blocks using ultrasound. [5] Meanwhile, only 7% of anesthesiologists who responded to Dr. Harbi's survey received formal training in UGRA and less than 50% of the anesthesiologists in Saudi Arabia were found to practice UGRA or both UGRA and nerve stimulation.

The study by Harbi et al., highlights two important points: First, RA is very commonly used in Saudi Arabia (88.2%), and anesthesiologists routinely perform RA. Second, physicians practicing RA in Saudi Arabia have demonstrated great accountability and desire to deliver better care for their patients: Almost 90% are willing to attend educational sessions for RA, and more than 7 of 10 anesthesiologists would like to attend these educational sessions 2-4 times a year. However, they find it difficult to nurture their learning interests because of the limited activities conducted. Continuing medical education (CME) needs to be set up for those who have already completed their residency. CME can be achieved by routine participation in workshops, conferences, online and paper self-assessment tests; practice improvement; reading patient-safety modules relating to RA practice patterns and peer letters of reference; and teaching, research, and administration of RA. There are no clearly defined milestones or a specified frequency of tasks for completing these requirements. This training can be provided within settings of residency programs. [4] This gives rise to the question of whether residents need evidence of formal training, a special professional certification, or credentialing for RA, which is still unanswered, although many professionals suggest that special certification for RA or UGRA is not currently required. [2]

In terms of implementation of RA, only minimal barriers have been reported in Dr. Harbi and colleagues' study: 0.9% of respondents reported that RA fails to provide adequate surgical conditions. In addition, only 1.4% of anesthesiologists reported surgeons' resistance to the use of RA, which is considered a plausible argument by many anesthesiologists. Less than 3% of the respondents said that RA is a time-consuming procedure. With proper training, adequate organizational setting, and education of surgeons and healthcare administrators, this barrier will likely become negligent.

In summary, practice of RA is successfully prevailing in Saudi Arabia. A program for formal training of and CME for RA should be designed to improve knowledge and skills necessary to maintain clinical competence while conducting RA.

  References Top

1.Harbi MA, Kaki AM, Kamal A, El-Dawlatly A, Daghistani M, Tahan MR. A Survey of the Practice of Regional Anesthesia in Saudi Arabia. Saudi J Anaesth 2013;7:367-70.  Back to cited text no. 1
2. [Last assessed on 2013 Feb 14].  Back to cited text no. 2
3.Smith MP, Sprung J, Zura A, Mascha E, Tetzlaff JE. A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. Reg Anesth Pain Med 1999;24:11-16.  Back to cited text no. 3
4.Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak-Nielsen ZJ, Ivani G. The American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy joint committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2010;35 (2 Suppl):S74-80.  Back to cited text no. 4
5.Barrington MJ, Wong DM, Slater B, Ivanusic JJ, Ovens M. Ultrasound-guided regional anesthesia: How much practice do novices require before achieving competency in ultrasound needle visualization using a cadaver model. Reg Anesth Pain Med 2012;37:334-9.  Back to cited text no. 5


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