A survey on teaching ultrasound-guided chronic pain procedures in pain medicine fellowship programs.

BACKGROUND: Over the last decade ultrasound guidance (USG) has been utilized very successfully in acute pain procedures to confirm nerves' anatomic location and obtain live images. Not only the utilization, but the teaching, of USG has become an essential part of anesthesiology residency training. Prior to the introduction of USG, chronic pain procedures were always done either under fluoroscopy or blindly. USG offers advantages over fluoroscopy for completion of chronic pain procedures. USG decreases radiation exposure and the expenses associated with operating a fluoroscopy machine and allows live visualization of soft tissues and blood flow, a feature that fluoroscopy does not directly offer. Even today, the utilization and teaching of the technique for chronic pain procedures has not been as widely accepted as in acute pain management. OBJECTIVES: To understand the current practices and the factors affecting the teaching of ultrasound guided chronic pain procedures in chronic pain fellowship programs throughout the United States. STUDY DESIGN: Survey conducted by internet and mail. The survey was distributed to program directors of ACGME-accredited pain medicine fellowships. When the survey was distributed there were 92 accredited pain medicine fellowships. METHODS: REDCap survey software was used for designing the questionnaire and sending email invitations. Also, paper questionnaires were sent to those who did not respond electronically. Additional copies of the survey were mailed or faxed upon request. We received 43 responses (a response rate of 46.7%). Statistical analyses included frequencies, crosstabs, and nonparametric Spearman rank-order correlations. RESULTS: The majority of stellate ganglion blocks, occipital nerve blocks, and peripheral nerve blocks are currently being done under ultrasound guidance. Although interest among trainees is very high, only 48.8% of the fellowship programs require fellows to learn the technique before graduation and 32.6% of the program directors agree that teaching of USG should be an ACGME requirement for pain medicine fellowship training. Faculty training is considered to be the most important factor for teaching the technique by 62.8% of directors. In the opinion of the majority of program directors, the greatest factor that stands against teaching the technique is the fact that it is time consuming. Nearly half (44.2%) of program directors believe that the technique will never replace fluoroscopy; but one quarter (25.6%) think that the new 3D ultrasound technology, when available, will replace fluoroscopy. LIMITATIONS: A moderate response rate (46.7%) may limit the generalizability of the findings. However, our survey respondents seem to represent the study population quite well, although there was a bias towards the university-based programs. Training programs located at community-based hospitals and U.S. government installations were not as well represented. CONCLUSION: The teaching of ultrasound guided chronic pain procedures varies significantly between individual programs. Though many program directors do require that fellows demonstrate competency in the technique before graduation, as of today there is no ACGME guideline regarding this. The advancement in ultrasound technology and the increase in number of trained faculty may significantly impact the use of USG in training fellows to perform chronic pain procedures.

A case of intra-operative ventricular fibrillation: Electro-cauterization, undiagnosed Takotsubo cardiomyopathy or long QT syndrome?

INTRODUCTION: Cardiac arrest in the perioperative setting is an extremely serious event that is estimated to occur between 4.6 and 19.7 per 10,000 anesthetics.(1-5) While risk factors for cardiac complications can be identified pre- operatively, in many cases workup of risk factors are not indicated by standard pre-operative testing guidelines. PRESENTATION OF CASE: We present a case of a 47-year-old female undergoing an elective bilateral mastectomy who suddenly converted to ventricular fibrillation. While ventricular fibrillation is not a unique finding, our search for its etiology revealed two previously undiagnosed cardiac conditions, and possible electro- cautery induced ventricular fibrillation. DISCUSSION: In this case study, we discuss the possible etiology of ventricular fibrillation in our patient and highlight the importance pre-operative patient investigation and history provide. CONCLUSION: Searching for the potential causes that may have contributed to the cardiac arrest is an extremely useful exercise as it allows us to better prepare patients pre-operatively, improve intra-operative care, and prevent future cardiac events.