Fortifying Our Future With PNB Training

Roy A Greengrass, MD, FRCP, Jacksonville, Fla.

Roy Greengrass

December, 2007

RECENTLY, A FOOT SURGERY patient took the initiative to cancel his case at one surgical facility and reschedule it at another. The reason: The original facility didn't offer peripheral nerve blocks while the second facility did, and the patient had learned that blocks would significantly reduce his post-op pain and minimize the need for opioids.

Not long ago, very few patients had even heard of PNBs. But today, as the number of blocks increase and patients talk with their friends and use the internet, they are coming to understand the benefits of PNBs, and they are demanding them for their procedures. While this is a positive trend, it also poses a major challenge to our profession, because patient demand for PNBs is in danger of exceeding the supply of practitioners trained to give them.

Fortunately, we in education are slowly waking up to these challenges and beginning to answer them.

For the first time, the ACGME Residency Review Committee now requires 40 PNBs. This small number cannot lead to mastery of PNBs, but it at least provides an introduction.

For post-residency training, regional anesthesia fellowships are becoming more and more common. And as fellows emerge from these programs and join surgical facilities across the country, they will create stronger regional anesthesia programs everywhere.

Manufacturers have also developed excellent, non-invasive teaching tools that facilitate learning - including ultrasound, percutaneous nerve mapping pens and virtual reality education platforms.

Corporations and institutions have also reintroduced in-depth cadaver dissections to these curricula, enabling residents and practitioners a first-hand view of the neural network in three dimensions. This training is essential for practitioners, so they can understand where the target nerve lies, how it courses over bone and through muscles, and what areas of the body it innervates.

Simultaneously, academic researchers have been shattering many of the myths that once surrounded peripheral nerve blocks. For a time, a lack of understanding of the benefits and the fear of inducing permanent neuropathies slowed the growth of PNBs. But meta-analyses of numerous studies now show that both single shot and continuous PNBs offer superior pain control, fewer side effects, and better patient satisfaction compared with traditional opioid-based pain treatments. In a recent prospective study of more than 1,200 consecutive PNBs, no patient sustained unresolved peripheral neuropathy - supporting earlier findings showing a low incidence of long-term injury.

If we can continue to accelerate the training of anesthesia professionals in peripheral nerve blocks, it's my hope that one day soon, every facility and every patient will have the opportunity to receive the benefits of regional anesthesia.

Dr. Greengrass is Associate Professor of Anesthesiology at the Mayo Clinic in Jacksonville, and is a regional anesthesia educator.


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