The introduction of regional anesthesia (RA) is one of the most impactful advancements for the entire specialty of anesthesiology. It provides exceptional pain management, enhances patient safety, alleviates costs and allows for early convalescence in comparison to general anesthesia. Under the leadership of Division Chief Jeffrey Gadsden, MD, FRCPC, FANZCA, Duke Anesthesiology’s Orthopaedics, Plastics, and Regional Anesthesiology Division (a.k.a. the Regional Division) is taking steps to ensure that RA will continue to play an essential role in the future of Duke Anesthesiology.
Duke Anesthesiology was among the first anesthesiology departments in the nation to adopt RA techniques such as patient-controlled anesthesia and ambulatory pain pumps, ultrasound for the administration of peripheral nerve blocks (PNBs), continuous epidural catheters, and PNB catheters. Ever since, faculty members have continuously sought out ways to hone this technology. The Regional Division continues to explore new methods to improve continuous peripheral nerve blocks and ultrasound technologies.
Within the last year, the division has developed perioperative protocols for management of total joint replacement and spine surgery programs. Protocols include a multimodal analgesic approach to include the use of continuous peripheral nerve catheters to reduce acute pain and nausea following surgery. This allows for same day surgery mobilization of the patient and postoperative day 1 discharge for many of our hip and knee replacement patients. Patients are discharged day 1 post surgery with disposable nerve block pumps allowing for continued regional anesthesia at home. This has brought uniformity to patient care and improved length of stay and patient centered outcomes. Equally, the division has been working on new hip fracture protocols system wide to improve patient outcomes, pain management and length of stay of hip fracture patients who present in the emergency department. This ongoing collaboration between the Departments of Anesthesiology, Orthopaedics, Emergency Medicine and Internal Medicine ensues in early assessment of the hip fracture patient in the emergency department by the anesthesiologist, immediate placement of the femoral nerve catheter for pain management for the duration of their hospital stay. This will reduce opioid use and incidence of delirium in the hip fracture patient
The Regional Division has a unique advantage when it comes to providing top-notch patient care because of its close relationship to Duke’s Acute Pain Services (APS), directed by faculty member Brian Ginsberg MB, ChB, FRCA. Having long suspected the detrimental long-term effects of acute pain, Dr. Ginsberg was the first to establish a formal APS at Duke in 1987. “Acute pain is much more than just a symptom,” Dr. Ginsberg says. “We now know that it can lead to a multitude of longstanding physical consequences, such as the development of chronic pain.” Seeking out new approaches to combat this devastating consequence, APS joined forces with the Regional Division in 1998. Thanks to Dr. Ginsberg, this team has adopted a highly effective multimodal approach that involves the use of several different classes of analgesics and varying sites of analgesic administration. This enables them to provide top-notch pain relief with limited side effects.
Another way that the Regional Division improves care at the local, national, and international levels is through education. Duke’s Regional Anesthesiology & Acute Pain Medicine Fellowship Program is one of the most sought-after programs in the nation. The division boasts a highly acclaimed teaching model for resident training in RA that is designed to increase resident exposure to PNBs. In 2002, this model was highlighted in the journal Anesthesia & Analgesia due to its resonating success. This model has clearly illustrated the old adage that practice really does make perfect (or at least nearly perfect). The success rate of PNBs at Duke is 95%. Upon completion of this program, dedicated block residents and fellows become highly proficient at independently administering RA using a variety of techniques.
Furthermore, the division provides a variety of continuing medical education (CME) opportunities, which they hope to expand in the coming years. Dr. Grant currently leads an ultrasound preceptorship during the second week of every month, and Dr. Manning, in collaboration with Dr. Bass from University of North Carolina, Chapel Hill, organizes a joint meeting, Triangle Education Regional Lecture Series, three times per year for area faculty members, fellows and residents.
In addition to education, the Regional Division is exploring new opportunities in research. Dr. MacLeod leads the division’s research initiatives through his management of the Human Pharmacology Lab (HPL), where he governs a variety of studies and pharmacological trials. In the immediate future, the division plans to place a strong emphasis on research studies focusing on the use of continuous peripheral nerve catheters, non-opioid analgesics and anti-inflammatories in our joint replacement patients thereby reducing the amount of postoperative pain and inflammation and potentially reducing the incidence of chronic pain.
No one can say with any certainty what the next innovation will be to impact regional anesthesia. But one thing is for certain – the Orthopaedics, Plastics, and Regional Anesthesiology Division will be at the forefront of this discovery.