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Scope and Duration of Training
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Regional anesthesia training is a subspecialty focused on the
perioperative management of patients receiving neuraxial or peripheral
neural blockade for anesthesia or analgesia. Fellowship training should be
concerned with the development of expertise in the practice and theory of
regional anesthesiology.
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The time required for sub-specialty training in regional anesthesia
shall be 12 months. There should be enough flexibility to allow the Program
Director to tailor the program to meet the individual needs of their
fellows. Specialized clinical rotations of less than 12 months may be made
available but the minimum amount of training necessary to use fellowship in
the diploma language is 1 year.
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Institutional Organization
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Relationship to a Core Program
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Institutions with sub-specialty training in regional anesthesia must
have a direct affiliation with an ACGME (or similar, eg, RCPC or RCA)
accredited residency in anesthesiology. If the institution in which the
fellowship is based is other than the primary institution of an accredited
residency, a written agreement linking the two, and an evaluation protocol
consistent with ACGME (or equivalent) approved standards for residency
programs must be prerequisites.
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Institutional Policy and Resources
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The fellowship must be recognized and approved by the institution's
division of Medical Education.
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Program Director and Faculty
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The Director of the fellowship training program must be an ABA
Board-Certified anesthesiologist (or equivalent, eg, FRCPC, FRCA) who has
completed 1 year of fellowship training in regional anesthesia or is a
dedicated and skilled practitioner of regional anesthesia. The Program
Director must also have an academic and/or clinical affiliation with an
ACGME (or recognized equivalent) accredited institution.
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The majority of the faculty in the training program must be
Board-Certified (or equivalent) in Anesthesiology. A division of the faculty
in the training program must also demonstrate an expertise in regional
anesthesiology and/or related disciplines such as acute pain medicine. The
number of faculty in a program may vary based on the number of fellows in
training; however, a minimum of two regional anesthesia faculty must be
maintained.
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Facilities and Resources
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Suitable equipment for the performance of a wide variety of regional
anesthetic techniques must be available. Such equipment must include nerve
simulators, neuraxial and peripheral block supplies, catheter systems, and
the basic requirements for conducting general anesthesia, according to the
ASA standards.
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Dedicated and acceptable on-call facilities must also be maintained if
fellows are expected to take in-house call.
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Appropriate support services, which may include, but are not limited to
anesthesia technical and pharmacy support should be available as needed by
the program.
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A departmental library, or portion of the institutional library,
dedicated to anesthesiology with literature specific to the practice of
regional anesthesia must be maintained.
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The Educational Program
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The clinical program will serve as the cornerstone of the fellowship
training in regional anesthesia. In order to achieve the necessary level of
expertise, fellows should be familiar with the indications,
contraindications, techniques, and complications of the techniques listed on
the following pages:
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- Superficial cervical plexus block
- Axillary brachial plexus block
- Intravenous regional anesthesia (Bier block)
- Wrist block
- Digital nerve block
- Intercostobrachial nerve block
- Saphenous nerve block
- Ankle block
- Spinal anesthesia
- Lumbar epidural anesthesia
- Combined spinal-epidural anesthesia
- Femoral nerve block
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Intermediate Techniques
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- Deep cervical plexus block
- Interscalene block
- Supraclavicular block
- Infraclavicular block
- Sciatic nerve block: posterior approach
- Genitofemoral nerve block
- Popliteal block: all approaches
- Suprascapular nerve block
- Intercostal nerve block
- Thoracic epidural anesthesia
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- Continuous interscalene block
- Continuous infraclavicular block
- Continuous axillary block
- Thoracolumbar paravertebral block: single injection or continuous
- Lumbar plexus block
- Combined lumbar plexus/sciatic block
- Continuous femoral nerve block
- Sciatic nerve block: anterior approach and parafemoral technique
- Obturator nerve block
- Continuous sciatic nerve block
- Continuous popliteal block: all approaches
- Cervical epidural anesthesia
- Cervical paravertebral block
- Maxillary nerve block
- Mandibular nerve block
- Retrobulbar and peribulbar nerve block
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Fellows will be required to complete a formal rotation in acute pain
management. This rotation will include multimodal analgesic techniques such
as neuraxial and peripheral nerve catheters, local anesthetics and narcotic
infusions, and nonnarcotic analgesic adjuvants. Indications,
contraindications, side effects, potential complications, and daily
management of patients on the acute pain service should be stressed.
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Fellows should complete daily case logs to track their clinical
experience. These logs should be reviewed regularly with the appropriate
faculty advisor.
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Fellows must be able to show competency in the following areas:
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- Demonstrate rational selection of regional anesthesia for specific
clinical situations
- Demonstrate effective anxiolysis of patients by both pharmacological and
interpersonal techniques
- Demonstrate cost-effective management decision
- Demonstrate ability to rescue failed regional anesthesia techniques
- Demonstrate effective management of isolated peripheral nerve and central
neuraxial blocks with respect to the physiologic consequences both
intraoperatively and postoperatively
- Demonstrate successful use of a peripheral nerve stimulator for neuronal
blocks
- Demonstrate effective management of regional anesthesia in critically ill
patients
- Demonstrate knowledge of practice management principles as they relate to
regional anesthesia
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Exposure to regional anesthetic techniques involving pediatric and
ambulatory surgery patients is strongly encouraged. Access to cadavers
and/or electronic models would greatly enhance the educational program
experience, as would exposure to advanced localization techniques for block
placement (eg, ultrasound), where feasible. Physiologic and pharmacologic
consequences of regional anesthesia must be stressed. Particular attention
should be focused on the potential respiratory and hemodynamic perturbations
which accompany performance of neuraxial and peripheral nerve blocks.
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Didactic Educational Program
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A didactic and educational program specifically dedicated to regional
anesthesia practice must also be a part of fellowship training.
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A lecture series or Grand Rounds which covers topics relevant to, but
not limited to, regional anesthesia, shall be held no fewer than 12 times
per year. A “Journal Club” (current literature review) should be held at
least once monthly. Fellows should present articles at least twice in 12
months under the supervision of an attending anesthesiologist. A case
conference specifically designed for fellows and supervised, or given, by a
qualified faculty member shall occur at least once per month.
Fellows shall be expected to deliver a Grand Rounds lecture, including a
relevant literature review at least once during the course of the
fellowship.
Fellows should appreciate the practice of regional anesthesia from a
multidisciplinary approach including joint conferences with surgical or
medical colleagues.
Fellows should have the opportunity to learn teaching techniques by
educating junior residents during the academic year.
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By completion of the accredited program, the fellow is expected to have
a working knowledge base consisting of the following:
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- Understands general attributes of local anesthetic pharmacology
- Understands specific clinical attributes of various local anesthetics,
including onset, duration, motor/sensory differentiation, toxicity, and
treatment
- Understands principles and indications for various local anesthetic
adjuvants, including epinephrine, phenylephrine, opioids, sodium
bicarbonate, and clonidine
- Understands principles of and options for regional anesthetic procedures
- Understands complications of regional anesthetic techniques
- Understands principles of regional anesthesia as they apply to pain
management
- Understands outcome studies related to the influence of regional anesthesia
on perioperative outcome
- Develops familiarity with major scientific studies related to regional
anesthesia
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Expectations for Fellows
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Fellows shall have the opportunity to participate in clinical and/or
laboratory research and be given appropriate nonclinical time to fulfill
these goals. There will be opportunities for the fellow to become involved
in research already in progress or to develop an original project. In either
case, an appropriate attending anesthesiologist will be appointed to mentor
and assist the fellow to facilitate these goals. The types of activities
that would suffice as academic projects include a research paper and/or case
report submitted to a peer-review journal and presented; a clinical chart
review or a review article submitted to, and accepted by a peer-reviewed
journal; a book chapter; or other endeavor.
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Expectations for Faculty
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The quality of the educational environment of the parent and integrated
institutions is of paramount importance to the program. Adequate
documentation of scholarly activity on the part of the program director and
the teaching faculty at the parent and integrated institutions must be
submitted at the time of the program review. Scholarly activity at
affiliated institutions cannot account for or substitute for the educational
environment of the parent and integrated institutions.
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Documentation of scholarly activities is based on:
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Active participation of the faculty in clinical discussions, rounds,
and conferences in a manner that promotes a spirit of inquiry and
scholarship. Scholarship implies an in-depth understanding of basic
mechanisms of normal and abnormal states and the application of current
knowledge to practice.
Participation in journal clubs and research conferences.
Participation in research, particularly in projects funded following peer
review that result in publications or presentations at regional and national
scientific meetings.
Active participation in regional or national professional and scientific
societies, particularly through presentations at organizations' meetings and
publications in their journals.
Offering of guidance and technical support (eg, research design,
institutional committee protocol approval, statistical analysis) for fellows
involved in scholarly activities.
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While not all members of a teaching faculty can be investigators,
clinical and/or basic science research must be ongoing in the department of
anesthesiology of the parent and integrated institution(s). The faculty, as
a whole, must document active involvement in all phases of scholarly
activity as defined above in order to be considered adequate to conduct a
program of graduate education in anesthesiology.
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Fellows should possess communication skills sufficient to solicit and
impart information. The fellow must be able to clearly delineate options
available to the patient regarding regional anesthesia as well as the risks
and benefits in a manner that is understandable to the patient.
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Fellows must be able to work in a team environment, communicating and
cooperating with surgeons, nurses, pharmacists, physical therapists, and all
members of the perioperative team.
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By the end of the fellowship, successful graduates will be able to:
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- Appreciate the roles of other members of the team
- Communicate clearly in a collegial manner that facilitates the achievement
of care goals
- Help other members of the team to enhance the sharing of important
information
- Formulate care plans that utilize the multidisciplinary team skills, such as
a plan for facilitated recovery
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As per ACGME Residency Guidelines, the attending faculty will be evaluated
by the fellows twice annually.
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Written evaluations of fellows by all faculty with whom they have worked
shall occur quarterly. The results of these evaluations shall be recorded
and reviewed with the fellows by the program director no less often than
every 6 months.