Improved residents' knowledge after an advanced regional anesthesia education program.

BACKGROUND: Although residents in anesthesia are confident in performing neuraxial anesthesia, many are not confident in performing peripheral nerve blocks. The purpose of this study was to evaluate the effectiveness of a structured regional anesthesia teaching program in a large academic medical center. METHODS: Residents participated in regional anesthesia didactics that took place in a unique resident education program scheduled during two fully protected teaching days a month. The curriculum included hands-on cadaver workshops in the anatomy lab, hands-on ultrasound workshops, hands-on nerve stimulator and surface anatomy workshops, and simulator sessions related to complications of regional anesthesia. Before beginning the formal regional anesthesia teaching program, residents completed a pretest composed of 25 multiple choice questions (MCQ) and a three-section observed standardized clinical examination (OSCE). Seven months later, approximately 1 month after completion of the regional anesthesia curriculum, the residents were evaluated again with the exact same tests. Pretest and post-test results for both the MCQ and the OSCE were compared by using a paired t-test for statistical means. RESULTS: Post-test results were significantly improved (P < 0.05) across all clinical anesthesia (CA) years and for both the MCQ and OSCE examinations. Post-test results were also significantly improved (P < 0.05) across all CA years for each of the three sections of the OSCE. CONCLUSION: The formal regional anesthesia teaching program developed by the departmental faculty was effective in improving resident knowledge.

Spontaneous Retroperitoneal Hematoma After Total Hip Arthroplasty.

Spontaneous retroperitoneal hematomas are a rare yet potentially devastating occurrence associated with antiplatelet and anticoagulant therapies. We present a case of a spontaneous retroperitoneal hematoma post-operatively after a total hip arthroplasty surgery performed under a midline approach spinal anesthetic. A 79-year-old male with a BMI of 25.72 kg/m2 presented for anterior total hip arthroplasty. A midline approach with an uncomplicated spinal anesthetic was performed. On the night of postoperative day 0, the patient received a prophylactic dose of dalteparin. The patient reported back pain, contralateral leg numbness, and weakness that began overnight on postoperative day 0. A computed tomography (CT) scan confirmed a 10 cm, contralateral retroperitoneal hematoma. The patient underwent interventional radiology embolization followed by surgical evacuation and demonstrated improvement in the neurologic function of his affected leg. Despite the rarity of a spontaneous retroperitoneal hematoma formation in the perioperative period, it could be simultaneously evaluated when performing an MRI to rule out spinal hematoma if a patient suffers a post-op neurologic deficit after a neuraxial technique. Understanding the evaluation and timely treatment of patients at risk for a perioperative retroperitoneal hematoma could help clinicians prevent a permanent neurologic deficit.

Two Cases of Intraoperative ECG Artifact Mimicking Ventricular Tachycardia and How to Know When It Is Real.

Electrocardiographic (ECG) artifacts may resemble ventricular tachycardia (VT), leading to inappropriate therapies. Despite extensive training, electrophysiologists have still been shown to misinterpret artifacts. The literature is scant regarding the intraoperative identification by anesthesia providers of ECG artifacts resembling VT. We present two cases of the intraoperative occurrence of ECG artifacts resembling VT. The first case involved a patient undergoing extremity surgery after receiving a peripheral nerve block. The patient was treated with a lipid emulsion for a presumptive local anesthetic systemic toxicity diagnosis. The second case was a patient with an implantable cardiac defibrillator (ICD) with suspended anti-tachycardia functionality due to the location of the surgery in the region of the ICD generator. The second case's ECG was identified as an artifact, and no treatment was initiated. Misinterpretation of intraoperative ECG artifacts continues to lead clinicians to institute unnecessary therapies. Our first case occurred in the context of a peripheral nerve block leading to the misdiagnosis of local anesthetic toxicity. The second case occurred during the physical manipulation of the patient during liposuction.

Proximal Ultrasound-Guided Posterior Tibial Nerve Block for the Removal of Calcaneal Hardware.

The anesthetic technique for calcaneal surgery has been reported to include peripheral nerve blocks, such as a sciatic block in the popliteal fossa, followed by intraoperative sedation. Sciatic nerve blocks are associated with limb weakness and fall risk. We present a case of a patient presenting for outpatient calcaneal surgery. The anesthetic plan consisted of a proximal, ultrasound-guided, single-injection selective posterior tibial nerve block followed by intraoperative sedation. The nerve block was performed, surgery concluded, and the patient received six hours of postoperative analgesia. Once the nerve block effects receded, the postoperative pain was managed with only over-the-counter analgesics while the patient was at home. We recommend an ultrasound-guided proximal posterior tibial nerve block for outpatient surgery involving the calcaneus to preserve lower extremity motor strength and provide postoperative analgesia.