We all know that the word doctor comes from the Latin word docere, meaning to teach. NWAC Dubai 2010 obviously takes this deeper meaning seriously. NWAC's mission is solely for us to teach and learn from one another.
The primary teaching mode used at this world congress is the didactic model where research, facts, techniques and tools are presented by experts. The presenter and the audience then contemplate these things together moving as a group towards a deeper understanding of those things being taught. This is an honored and effective teaching method that reaches back to the beginning of teaching itself. We all remember "See one, do one, teach one". This approach, as effective as it is, does not fill every learning need. Medicine and anesthesia are complex and deep and require multiple modalities to address our learning and teaching needs. The faculty of NWAC Dubai 2010 realizes this and uses several approaches, tailoring each to its best use.
Problem Based Learning Discussions (PBLDs) are an excellent example of a different classical learning approach being used here at NWAC Dubai 2010, and that is the dialectic model. Also referred to as the Socratic Method, it is a relentless search for better practices through questioning and discussion.
The PBLD groups are small and their size and structure allows them to delve into the details and the deeper implications of a particular situation or problem.
We were able to sit in on a PBLD yesterday with NWAC Dubai 2010 faculty member Dr. Kristie Osteen playing the role of Socrates. There were seven people in the group including Dr. Osteen, an ideal number for the purpose. The subject was "Anesthesia for Patients Having Cataract Surgery – What Can Go Wrong?" This is an important line of inquiry considering the rising rates of cataract surgeries. The normal risks of anesthesia coupled with technical advances that make the surgeries themselves quicker, can lead to new problems that need to be examined. We'll use this PBLD as an example throughout our examination of the PBLD learning process.
Taking advantage of key learning opportunities
Let us start with the PBLD structure. A group is convened under a particular subject or line of inquiry. The facilitator presents a case study. The rest of the group reviews the case study and then the questions begin: "If you were treating this patient with this drug, what are the post operative implications?" and so on. By examining the scenario from different angles, information is revealed about the problem being discussed. For instance, in this PBLD it was revealed that a common practice in the USA (the use of a 2% lidocaine gel) is not being done at all in much of the developed world.
The questioning leads the group into new directions. A group member may find their assumptions challenged. This will force them to re-evaluate their treatments and common responses to situations. Though sometimes uncomfortable, this is extremely valuable. A fresh perspective is difficult to cultivate in a busy practice. For Dr. Osteen this is one of the greatest benefits to this learning approach. It makes us look anew at the challenges we face every day. It was clearly invigorating for those participating.
The group began to drop its guard as the result of joining in this mutual examination. Things then took a turn into richer territory as they each shared the full depth of their experiences. Now instead of a lecture where a teacher with 30 years of experience is explaining a situation, you had the combined experience of seven people (with a total of 100 years of experience or more) exploring a scenario together. In this PBLD there were techniques for stabilizing patients, GA vs. RA and the use of different drugs weighed and explored and shared amongst the participants. Through this experience each individual became enriched by the experiences of the whole group.
Dr. Osteen believes that this is the true purpose of the PBLDs, the free exchange of experience and ideas for the benefit of all the participants; for instance an important moment in this PBLD was when a participant asked if anyone had tried a particular approach to patient stabilization which she had been considering. The other members of the group and the facilitator weighed in with responses, examining the merits or pitfalls of the potential anesthetic technique. That was information and a discussion which that participant really desired and the group benefitted from looking at a situation from a new viewpoint. These moments are when the PBLD dialectic approach to learning can really shine.
Dr. Osteen has suggestions for those that would like to get the most from PBLD learning opportunities. For participants, she suggests studying any advance materials provided by the facilitator. At a minimum, write down and bring questions with you, and if you would like to go the extra mile, email them to the facilitator in advance of the program. Be unafraid to question and participate; the idea is to share experiences.
Her suggestions for facilitators are to prepare a topic and present it to the participants with any relevant material well in advance of the PBLD. Adapt your preparation if you get new information about the participants' needs prior to the event. She also suggests that you be fluid and adaptable. Keep engaging the group even if they aren't talkative at first, they signed up because they wanted to be there. Don't be slavish to the title or case study. For instance, in this PBLD a participant had a question about a procedure not covered in the title, but it was clearly relevant and a valuable portion of the session. You never know where the discussion may lead or what discoveries might be made along the way. Lastly, remember the conversation need not end when the time runs out. It can easily continue through email, forums or other means.
A break from our routines, combined with these varied opportunities to teach and learn in new settings, is perhaps one of the most valuable things that NWAC Dubai 2010 provides. Why is time away from our practices so important? Renowned management consultant Nancy Duarte made the following observation during an interview in the MIT Sloane Management Review: "We live and work in environments that want us to utilize all of our resources, to not waste space, time or talent by leaving them unused. But what happens when you use things to 100% capacity? When a desk is 100% covered with papers, it is no longer a useful surface. When people are kept busy 100% of the time, there is no time available to generate new ideas." Take advantage of opportunities to learn and teach and change your routine through PBLDs - it is time well spent. This antidote to routine will be continued at NWAC Rome 2011.
Participation at NWAC Dubai 2010 proves a positive experience for Baxter Healthcare Corporation
Global representatives from Baxter Healthcare Corporation have indicated their overall satisfaction of NWAC Dubai 2010, which has encouraged the company into strongly considering continued support for NYSORA in the future, according to senior global marketing manager, Baxter Healthcare Corporation, Specialty Therapies, Yosh Simlote.
"This is the first time we have exhibited and expect to continue supporting NYSORA," Simlote confirmed. "We are very pleased with the global audience and the interest we have received - not only in the products but also in the educational opportunities. NWAC Dubai 2010 has exceeded our expectations and we have been able to reach an audience we have not traditionally been able to." Simlote added that from now, the company would be engaged in the World Congresses, especially in New York City.
Dr. Sanjay Sinha talks to Michael McTigue about some exciting observations found on a study he is conducting regarding post operative analgesia for patients having total knee replacements
Dr. Sanjay Sinha from the US was excited to share some observations on a study he is conducting with his group. They are in the middle of a study where they are looking at post operative analgesia for patients having total knee replacements.
Their current practice in their hospitals is to do a femoral nerve catheter and a single injection sciatic nerve block for post operative pain. The patients get good analgesia after surgery, but the problem is that when they wake up from the sciatic nerve block they often have a temporary inability to dorsiflex the foot, commonly called foot drop.
The issue here isn't the foot drop as it will resolve itself. The issue is that the temporary foot drop from the sciatic nerve block can mask a permanent foot drop caused by injury to the sciatic nerve, which is a known potential complication of this surgery. This rare complication is a surgical concern; so many surgeons will not allow the sciatic nerve block, trading an easier recovery for the patient for earlier information on a potential foot drop situation. Though the surgeons in Dr. Sinha's practice allowed them to use sciatic nerve blocks, they still had tension between patient comfort and important information.
So they started to develop a technique where they selectively blocked the tibial nerve. As the sciatic nerve travels down the leg it branches and it is the common peroneal branch that is at risk during surgery. It is an injury to this branch that may cause a permanent foot drop. They thought that by selectively blocking the tibial nerve close to the popliteal crease they might be able to avoid the foot drop while simultaneously providing adequate pain control for the patient.
They are some two thirds of the way through their study comparing two groups. One group receives their usual practice of femoral nerve catheter and sciatic nerve block and the other group receives the femoral nerve catheter and a selective tibial nerve block, close to the popliteal crease, using a low volume of local anesthetic.
Postoperatively, Dr. Sinha looks to see if the patients have a foot drop or not, what their pain scores are, what their narcotic consumptions are and the study has revealed some interesting discoveries. The pain scores and narcotic consumption is the same between the two groups. In the tibial block group, 70% of the patients have no foot drop and 30% have some weakness. In other words, 100% of the patients can dorsiflex versus the small 20% that can dorsiflex after the sciatic nerve block technique. That's an exciting finding and Dr. Sinha expects that once the study is published and they have developed more comfort with the technique, they will change their practice to use this approach as their first choice in knee replacement surgeries.
Creative approaches and exciting discoveries found by the faculty and participants at NWAC Dubai 2010 result in unique learning experiences.
We can hardly wait to see Dr. Sinha's complete study and wonder what we will discover at NWAC Rome 2011.
Micrel Medical Devices' Rythmic Connect System is raising interest
We talked today with Jean-Christophe Cascailh of Micrel Medical Devices. Micrel has just opened an office in Dubai and is pleased to be at NWAC Dubai 2011 to meet their new neighbors and doctors from around the world.
Micrel is a European company based in Greece specializing in ambulatory infusion devices; both syringe drivers for small volumes and volumetric pumps for large volume infusions.
Though these devices can be used for any infusion therapy that can be performed at home, it is of interest to the members of this congress for their use in pain management.
In Europe it is common for patients to be moved out of the hospital and into the home as soon as possible. The reductions to the costs of patient care are considerable when their care is transferred to outpatient and home nursing services.
This trend is spreading across the world and doctors are learning about the effectiveness of this approach, not only in cost reduction but also in the benefit to recovery that the home environment can provide for the patient.
Micrel's new Rythmic Connect system is of particular interest. The new system is the only one of its kind combining a volumetric infusion pump with a GPRS mobile phone. By continuously communicating with a web interface the system provides real time monitoring of the pump's status.
The system can be set to send SMS text alerts to doctors and nursing staff. This allows the care providers to evaluate performance and react appropriately to alarm situations, further enhancing patient care and saving unnecessary hospital visits.
Jean-Christophe was most excited by the results this system and their other products have had for patients and health authorities.
Paul F. White, PhD, MD, FANZCA, is a professor and Holder of the Margaret Milam Mc- Dermott Distinguished Chair, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas.
The effective treatment of acute postsurgical pain poses unique challenges for practitioners. An increasing number and complexity of operations are being performed on an outpatient basis where the use of conventional opioid-based intravenous (IV) patient-controlled analgesia (PCA) and central neuroaxial (spinal and epidural) analgesia are not practical techniques for pain management. This expanding patient population requires a perioperative analgesic regimen that is effective, has minimal side effects, is safe, and can be managed away from the hospital or surgical center.
The adequacy of postoperative pain control is an important factor in determining when a patient can be safely discharged from a surgical facility and has an influence on the patient's ability to resume normal activities of daily living. Perioperative analgesia has traditionally been provided by opioid analgesics. However, extensive use of opioids is associated with a variety of perioperative complications which can contribute to a delayed hospital discharge. Also, intraoperative use of large bolus doses or continuous infusions of potent opioid analgesics may increase postoperative pain as a result of their rapid elimination and/or development of acute tolerance. The use of partial opioid agonists is also associated with increased side effects and patient dissatisfaction compared to both opioid and non-opioid analgesics. Therefore, anesthesiologists and surgeons are increasingly turning to non-opioid analgesic techniques as adjuvants for managing pain during the perioperative period.
To minimize the adverse effects of opioid analgesic medications, multi-modal or "balanced" analgesic techniques involving the use of smaller doses of opioids in combination with non-opioid analgesic drugs have become increasingly popular approaches to preventing pain after surgery. As more extensive and painful operations are performed on an outpatient or short-stay basis, the use of multimodal perioperative analgesic regimens involving non-opioid analgesic therapies will likely assume a key role in facilitating the recovery process and improving patient satisfaction.
Recent evidence from Pavlin and colleagues has confirmed the importance of using nonopioid analgesics for controlling postoperative pain following ambulatory surgery. Moderate-to-severe pain immediately after surgery prolonged the recovery room stay by 40 to 80min depending on the severity. Use of local anesthetics and NSAIDs decreased pain scores and facilitated an earlier discharge home.
Additional outcome studies are needed to validate the beneficial effect of these non-opioid therapeutic approaches with respect to important recovery parameters. Although many factors other than pain must be controlled in order to minimize postoperative morbidity and facilitate the recovery process, pain remains a concern of all patients undergoing elective surgical procedures.
Opioid analgesics will continue to play an important role in the management of moderate- to-severe pain after major Intracavitary surgical procedures. However, the adjunctive use of nonopioid analgesics will likely assume a greater role as minimally-invasive ("key hole") surgery continues to expand in the future. In addition to the local anesthetics, NSAIDs, COX-2 inhibitors, acetaminophen, ketamine, dextromethorphan, alpha-2 agonists, gabapentin, magnesium and neostigmine may prove to be useful adjuncts in the future management of postoperative pain. Adjunctive use of droperidol and glucocorticoid steroids also appear to provide beneficial effects in the postoperative period. Use of analgesic drug combinations with differing mechanisms of action as part of a multimodal regimen will provide additive (or even synergistic) effects with respect to improving pain control, reducing the need for opioid analgesics, and facilitating the recovery process. Safer, simpler, and less-costly analgesic drug delivery systems are needed to provide cost-effective pain relief in the post-discharge period as more "major" surgery is performed on an ambulatory (or short-stay) basis in the future. Despite the tremendous progress which has been made in our understanding of the pathophysiologic basis of acute pain, there remains a need for clinicians to implement evidence- based procedure- specific multi-modal analgesic protocols which are modified to meet the needs of individual patients in order to enhance the quality of postoperative pain management. There is a critical need for collaborations between the various health care providers involved in perioperative patient care in order to integrate improved perioperative pain management with the recently described fasttrack recovery paradigms. This type of combined approach is well-documented to improve the quality of the recovery process, reduce the hospital stay and postoperative morbidity, leading to a shorter period of convalescence after surgery. Rather than simply performing more meta-analysis and systematic reviews of the pain management literature, 280 clinical investigators need to return to the hard work of performing prospective, randomized clinical trials on a procedure- specific basis evaluating the use of different analgesic combinations as part of multimodal analgesic treatment regimens in the postoperative period. The increasing implementation of standardized pain evaluation and treatment protocols, as well as the use of multimodal non-opiod analgesic techniques, are hopeful signs that improvements in pain management are likely to continue in the years ahead.
In conclusion, the optimal analgesic technique for postoperative pain management would not only reduce pain scores and enhance patient satisfaction, but also facilitate earlier mobilization and rehabilitation by reducing pain-related complications after surgery. Recent evidence suggests that this goal can be best achieved by using a multimodal combination of pre-emptive techniques involving both central and peripheralacting analgesic drugs and devices.
Learning to Avoid Inadvertent Intraneural Injection with Vijay Patel, MD
"What kind of meat is that?" A common question overheard at the Safety Monitoring in Regional Anesthesia Booth in the Main Exhibition Hall. In this unique educational exhibit, a chicken meat model embedded with a nerve serves as a teaching tool for novices and experts in the field. The purpose of this demonstration is to allow delegates to practice a "mock nerve block" on the meat model while observing their own realtime injection pressures, which are displayed on a computer screen. With this novel contraption, users can see for themselves how an intraneural injection corresponds to high injection pressures on the screen. The lesson is invaluable, as research studies have shown that intraneural injections can lead to nerve damage. And while most practitioners think that they possess the tactile skills to differentiate between normal and abnormal pressures, most are surprised to see that this assumption can be way off.
BBraun, an exhibitor and sponsor of the NWAC conference, is featuring their new Stimuplex D Plus peripheral nerve block needle. The needle features particular laser etched markings, which provide for enhanced visibility under ultrasound guidance without impairing the well-proven puncture and nerve stimulation characteristics of the needle. The addition of the etching assists in block placement during the performance of ultrasound guided nerve blocks in combination with the use of a nerve stimulator, a concept that B Braun calls "Dual Guidance.” Other new B Braun devices available at the conference include:
A new ergonomic hub design for spinal needles featuring a special prism for immediate visualization of CSF backflow
A catheter fixation device that is easy to apply and designed to be patient friendly, providing reliable and safe fixation for all continuous regional anesthesia catheters
A needle guidance device that can be easily attached to most common ultrasound probes; the device helps to keep the needle visible in the ultrasound plane
The Stimuplex Guide and the SENSe function housed in their Stimuplex HNS 12 nerve stimulator to make needle placement with nerve stimulation easier for the practitioner.
B Braun representatives are available in the exhibition hall.
Degree of Difficulty in Placing the Needle for Neuroaxial Block-A Scoring System
Anesthesiologists are familiar with the use of ASA Anesthesia Risk Scale and its attendant benefits for patient care. The scale is used preoperatively by anesthesia professionals to assess the patient's physical status and the potential risk for various anesthesiarelated events, allowing the practitioner to develop an appropriate management plan in advance of the operative procedure. Doctors Adel Nour and Ammar Salti, both practitioners at the Zayed Military Hospital, Abu Dhabi, UAE, had another idea. Why not develop a scoring system to assess the anticipated difficulty of successful neuroaxial block placement preoperatively?
Their goal was to develop a simple clinical scoring system that could be used as a reliable assessment tool. The proposed scoring system uses the simple principle of a ratio of umbilical girth-to-back length to categorize patients into a range of difficulty from A through to D. Dr. Nour discussed their hypothesis, testing and results. To test the idea, two studies were conducted. In the first, back length was measured from the spine of C7 to a point midway between the two posterior superior iliac spines. Scatter diagram results of the data collected were plotted and a trend appeared. In the second study, ultrasound was added to view the lumbar spine area to measure the depth of the ligamentum flavum and the interspinous distance. The time in seconds from the start of skin puncture until the retrieval of cerebrospinal fluid, the number of trials, and failed spinal was counted.
The initial results are that this classification system is clinically significant. Subjectively, it was easier to palpate the patient's back for landmarks and spinal anesthesia was completed more quickly for those patients in group A. Back palpation difficulty and the amount of time needed to perform spinal anesthesia was longer and the number of punctures increased along a continuum from those patients in group B through to C and D, with the patients in group D at the end of the continuum.
Dr. Nour discussed their hypothesis, testing, and results. He and Dr. Salti found that the use of a girth-to-back length ratio is an easy, simple clinical scoring system to classify patients presented for neuroaxial block according to the expected difficulty.
There are several advantages to using this system. First of all, it is simple and cheap; a tape measure and a ratio calculation are all that is needed. Secondly, because the categorization scheme improves the identification potential difficulty in needle placement, the practitioner can make more judicious use of ultrasound guidance, which improves the level of quality of care for the patient and cost effectiveness of use of resources.
Dr. Nour welcomes discussion, comments and questions from his colleagues in the field. He can be reached at mailto:Adelahmednour@yahoo. com. He also encourages his colleagues to conduct a similar study in their institution to add to the body of knowledge regarding the scoring system.
Regional Anesthesia 'Invades' Cardiac Surgery at NWAC Dubai 2010
One of the more unusual presentations was given by Richard Kowalewski, MD, PhD, FRCPC. Dr. Kowalewski gave an overview of his use of thoracic epidural and high spinal anesthesia for cardiac surgery. He and his cardiac group began the use of this technique in Canada in the early 1990s. They have a combined experience of over 10,000 spinal injections for cardiac surgeries with no neurological complications. According to Dr. Kowalewski, high spinal anesthesia is a routine anesthetic technique for all cardiac surgeries in his institution. This includes patients with much compromised left ventricular function and severe aortic stenosis.
He argued that the denervation of the surgical site, in general, plays a very important role in preventing the physiological stress response to surgery. He pointed out that the hemodynamic stress response to surgical wounding is only one of many stress responses occurring during and after surgery. Other responses exist and play an important role in the recovery period. They are the humoral, metabolic, homeostatic, and inflammatory stress responses, all of which are followed by immunosupression. He stated that anesthesia is not about heart rate and blood pressure, or even pain, during perioperative period. Anesthesia in the perioperative period is about what happens to the body on the metabolic and cellular level.
The other aspect of neuraxial anesthesia for cardiac surgery is cardiac sympathectomy, which his group has found to be very beneficial for the heart and cardiovascular system.
Dr. Kowalewski compared thoracic epidural versus high spinal anesthesia used for cardiac surgery and concluded that, in his opinion, high spinal anesthesia is much more user friendly and safer than epidural anesthesia as far as epidural hematoma and neurological complications are concerned.
Dr. Kowalewski is Clinical Assistant Professor in the Division of Cardiac Anesthesia, at the LIBIN Cardiovascular Institute of Alberta, Foothills Medical Centre, University of Calgary, Alberta, Canada and he invites question or comments on this subject. He can be contacted on ogopogo@me.com.
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