NYSORA NEWSLETTER SEPTEMBER 2012

The September 2012 NYSORA Newsletter

In this issue:

• A Letter from Your Editor
• Interview with Dr. Peter Cheng
• Interview with Dr. Julina Johami
• Feedback from Participants at NYSORA Kenya
• Save 20% on Hadzic’s Peripheral Nerve Blocks
• Discuss September NYSORA Newsletter

A Letter from Your Editor

Dear NYSORA Newsletter reader,

Greetings from your Editor. In this month's newsletter we are proud to include interviews with two renowned anesthesiologists and educators-Dr. Peter Cheng and Dr. Julina Johami. Each is very dedicated to teaching and promoting regional anesthesia, and their enthusiasm shines through in these interviews. I would also like to remind all about the next grand event-NYSORA Asia 2013 in Manila-which promises to be a fantastic experience. The official dates for the meeting are February 23-24, 2013. You can learn more at www.nysoraasia.com.

Best,
Clark Jaffe

INTERVIEW WITH DR. PETER CHENG
Dr. Peter Cheng is a staff anesthesiologist and director of regional anesthesia at Kaiser Permanente Riverside Medical Center in Southern California. He specializes in acute and chronic pain, and has lectured nationally and internationally in both areas. He will be speaking at the upcoming 11th Annual NYSORA Symposium (September 22 - 23 in New York City). His talk will focus on interesting cases involving regional anesthesia. We are all very excited to hear this talk, and as a preview we conducted a shortinterview with Dr. Cheng.

--Uma Shastri, MD

What originally sparked your interest in regional anesthesia?

As an anesthesia resident, many years ago when peripheral nerve stimulators were poorly designed, I became fascinated with regional anesthesia, but most of my peripheral nerve blocks failed. Nevertheless, I persisted and only began to understand the science and art of regional anesthesia after I learned ultrasound-guided regional anesthesia under the tutelage of Vincent Chan, MD.

What is the most recent (most novel) peripheral nerve block that you are currently using in your practice?

In Hong Kong, at the 2012 ISSPS Meeting sponsored by Manoj Karmakar, MD, I learned the shoulder block--suprascapular and axillary, not axillary brachial plexus--from Darcy Price, MD. For patients undergoing shoulder surgery and who have respiratory disease, I find this procedure invaluable, and also use it for my chronic pain patients.

Dr. Cheng with an attendee at a recent Stanford workshop.

You very correctly state that in order to be a good regionalist there is much more involved then just being skilled at performing blocks. What would you say are the top three factors that an anesthesiologist needs to consider when employing any peripheral nerve block technique?

As our patients present with a wealth of anatomical variants, and sometime with interesting pathological findings, we must learn to recognize them during insonation for regional anesthesia, and to individualize our techniques. No one technique fits all patients.

Instead of only insonating in the axial (transverse) plane, and at one location, I believe we should try to identify the distribution of the local anesthetic in at least two planes--axial and longitudinal. Additionally, in the axial plane, we should scan distal and proximal to the injection site.

To minimize complications, I strongly recommend supplementing the two dimensional image (B mode) with color Doppler sonography to distinguish vessels from other hypoechoic structure, including nerves. Most importantly, I look for possible neural swelling with injectate volume of 1 ml, which I repeat until the desired total amount of local anesthetic is achieved.

I think that your holistic approach has led you to recognize, and effectively manage these challenging cases. Without giving away your talk, can you just leave the readership with one of the cases that you will be discussing at the NYSORA symposium in September? This will allow the rest of us to think about the considerations, and management options.

I will only ask our readership one provocative question: Does diagnostic neural ultrasonography have a role for patients who develop post-injection neuropathy? My last case at our NYSORA 2012 meeting will explore this exciting option.

INTERVIEW WITH DR. JULINA JOHAMI

Please tell us a little about yourself. Where do you practice and what are your primary clinical interests?

For the past 7 years, Hospital Tuanku Ja'afar Seremban has been my place of practice. It is a tertiary referral centre with 850 beds serving the state of Negri Sembilan, Malaysia, with a population of a million.

Currently in Malaysia most anaesthesiologists spread their time between providing anaesthesia and being part of the critical care team. I am no different. The bulk of my practice involves providing anaesthesia for the surgical specialties at the hospital which is also the referral centre for elective upper and lower gastrointestinal surgery, knee and hip arthroplasty and retinal surgery to name a few. Seremban is situated just south of the capital Kuala Lumpur and being close to the North-South highway sees its fair share of trauma cases due to motor vehicle/road traffic accidents.

I particularly enjoy regional anaesthesia and paediatric anaesthesia.

Dr. Johami (center) and Dr. Mafeitzeral (MSIGRA member) conducting a workshop at the recent Malaysian Society of Anaesthesiologists Annual Scientific Meeting 2012 Pre-Congress Workshop in US-guided Regional Anaesthesia in Kuantan, Pahang.

What do you feel is the value of regional anesthesia in pediatrics?

Regional anaesthesia in the paediatric population should be performed more regularly. In my opinion, the joy and satisfaction of seeing a pain-free child who is coherent and alert post-operatively is priceless. And that is one of the main reasons why I am a proponent of regional anaesthesia in children. The advent and increased use of ultrasound-guided regional anaesthesia has made a tremendous impact in the practice of regional anaesthesia not only in the adult population but also in paediatric age group. USGRA has improved the safety profile of block performance. This should prompt us to perform regional anaesthesia more frequently in children.

What is the state of pediatric regional anesthesia in Malaysia? Are there any obstacles to its practice?

Malaysia often follows the trends happening in the world of anaesthesia. Here there is a certain hesitance to performing regional anaesthesia in the paediatric population. That cannot be denied. Worry about nerve damage is real. Often this hesitance stems from a variety of reasons: lack of knowledge, a lack of interest in the performance of regional anaesthesia and also a shortage of equipment required to perform the blocks. Many smaller centres are not equipped with nerve stimulators or ultrasound machines. After all, the children are under general anaesthesia anyway...so why would they need a peripheral nerve block? Having said that there is a growing interest in regional anaesthesia and paediatric regional anaesthesia. Our workshops are often the most popular at local conferences so I'm hoping that as more anaesthesiologists are exposed to regional anaesthesia it can only result in regional anaesthesia being adopted into clinical practice more enthusiastically not only in the adult patients but also the children.

Your society, the Malaysian Society of Anaesthesiologists, created a special interest group in regional anesthesia. What were its objectives and what has been the result of its work?

The Malaysian Special Interest Group in Regional Anaesthesia (MSIGRA) started out small but we are an enthusiastic bunch and had big plans. It came about in 2008 after four friends threw ideas at each other over a coffee break during a small workshop on regional anaesthesia. We agreed that it would be a great idea to gather anaesthesiologists who shared the passion for regional anaesthesia into a cohesive group. And so these core members set out to recruit RA comrades and through various meetings resolved to set-up the SIG.

The main objective of our SIG was to establish a local, regional and international network connecting RA enthusiasts. Through the SIG, we would also be able to share resources and provide a forum for discussion. The bulk of our work has been in the dissemination of RA knowledge and information via the organising of workshops and teaching/training programs. This method has proven to be very popular and effective in achieving our objective of "spreading the word." The Ministry of Health Malaysia had also enlisted the help of the SIG in formulating the National Regional Anaesthesia Registry which was launched this year.

It was hard work and continues to be challenging. The future for our SIG is to encourage research at the local level and to set-up collaborative efforts with our friends in the RA field both regionally and internationally. We are also working towards formulating a training program in regional anaesthesia and setting-up a training centre in Regional Anaesthesia.

Dr. Hanapi Md Tahir (founding MSIGRA member), workshop facilitator at NYSORA Asia 2009 KL.

Do you plan on attending the NYSORA Asia meeting in 2013 in Manila? If so, what do you hope to learn and experience at these events?

I am looking forward to joining in the fun at NYSORA Asia in Manila next year along with other members of the MSIGRA. It would be a great opportunity to catch-up with friends from the region and those from further afar. I hope that the MSIGRA members will be able to contribute actively towards the meeting as speakers and also workshop facilitators after now running many workshops here in Malaysia. As always, the conference will provide updates on the most recent developments in the world of regional anaesthesia and pain management. It will be a chance for me to learn about the Filipino culture too as I have never visited Manila before.

Dr. Shahridan Fathil, MSIGRA Convener, currently attached to Alexandra Hospital, Singapore. Invited speaker and facilitator at loco-regional conferences in RA.

What are some of the unique aspects of practicing anesthesiology in Malaysia?

I am blessed as I work in a facility that is fully equipped with the most up-to-date tools to provide anaesthesia. However, this isn't the case in the more remote areas of Malaysia. Thus, there still exists the challenge of providing safe anaesthesia with more modest equipment.

We in Malaysia share the similar fate of tight healthcare resources that is common the world over. This makes providing the best of anaesthetic care to the public sometimes difficult. So we come up with innovative ways to make do with the resources that we have apportioned to us.

The multicultural population in Malaysia always provides for a colourful experience in the medical world. Communication is often tricky with the many languages that are spoken by our patient community. There also sensitivities peculiar to an ethnic group which we in the medical profession must be aware of. The multicultural population also provides us with the opportunity to compare and contrast the effects of anaesthesia in the different groups allowing for distinctive and unique research ideas.

The awareness of anaesthesiology among the general public is still poor. The pre-operative meeting with the anaesthesiologist is often also an education opportunity for the anaesthesiologist to introduce to the patients his/her role. There have also been many national programs in held in conjunction with World Anaesthesia Day to improve public awareness about anaesthesia.

Dr. Shahridan and Dr. Johami (with delegates from Thailand and Philipines) at NWAC Dubai 2010.

The NYSORA Asia meeting took place in Kuala Lumpur in 2009. What are some of your favorite memories from the meeting?

NYSORA Asia KL 2009 was truly memorable! It was the first time members of the MSIGRA participated in and contributed towards an international conference. It was nerve-wracking but totally enjoyable. The conference itself was a resounding success and that motivated us to organise more workshops. Being the host country, we also had the honour of taking our speakers and workshop facilitators out to tour Kuala Lumpur. I remember how some of our speakers like Admir Hadzic and Manoj Karmakar were willing to try Pewter decoration. They were great sports.

On a more personal note, the KL meeting was the beginning of me being part of the NYSORA Preceptorship program. This allowed me to be part of the associate faculty at the inaugural NWAC Dubai 2010 and the 4th Pan-Asian NYSORA Symposium 2010 in Bangkok, Thailand. The experience I garnered from these meets has helped me tremendously when I run workshops here in Malaysia. I now have many friends the world over connected through the common love of regional anaesthesia. Priceless!

FEEDBACK FROM NYSORA KENYA
The following quotes are from attendees of NYSORA’s educational mission to Nairobi, Kenya on July 30, 2012. The meeting was a great success and NYSORA looks forward to additional events in Africa.

From Dr. Speciousa Mbula:

--The meeting gave me confidence to continue doing more regional. We now try to do ankle and foot surgeries using a sciatic and femoral nerve blocks. Our previous choice was spinal then we do a block after surgery for analgesia. We are glad that we can now do this for surgery and post operative analgesia. On average I now do 5 blocks a day including teaching and supervising my colleagues in regional anaesthesia.

--The NYSORA faculty were very skilled and very knowledgeable yet humble. They had good interpersonal skills and treated the volunteers (the medical students) very well. The students (1st year students) were telling me that they now want to do anaesthesia in residency.

From Dr. Mpoki Ulisubisya:

--It was highly valuable to learn the practical application of the anatomical details of nerves and what ultrasonography does in regional anaesthesia

--The NYSORA faculty were informed, accommodating, and up to date.

Participants at NYSORA Kenya.

From Dr. Jimmie Kabugi:

--The NYSORA faculty were impressive! Their knowledge of regional anesthesia is outstanding. I noted that they were very good teachers and could easily pass on their knowledge.

--Anyone attending a NYSORA event will most definitely learn the art and science of regional anesthesia.

From Dr. Jane Gwaro:

--I especially liked the use of the human models to demonstrate ultrasound in nerve blocks. It was great to appreciate and learn this.

--The NYSORA faculty provided an unforgettable learning experience. They were wonderful and involved the participants in the training.

JAMA Review of NYSORA's New Textbook
on Peripheral Nerve Blocks

SAVE 20% AT MCGRAW-HILL WEBSITE, www.mhpprofessional.com

The Journal of the American Medical Association had a very favorable review of the new NYSORA textbook in their July 18 issue. Here are a few excerpts. The full review is at http://jama.jamanetwork.com.

“The list of peripheral nerve blocks is substantial and covers upper extremity, lower extremity, and truncal nerve blocks. Although some clinicians will want to skip directly to the section dealing specifically with ultrasound-guided nerve blocks, readers should not overlook the chapters on nerve stimulation and surface landmark techniques; these dynamic chapters cover a significant amount of anatomical pearls relevant to ultrasound-guided techniques. Plenty of “Tips” are located throughout each chapter. A short section discusses ultrasound basics and techniques for optimizing images. Readers new to the use of ultrasound will find these chapters particularly helpful.”

“The final section is a large repository of ultrasound images, with and without labels, paired with prepared human cross-sections. In addition, the images show placement of the ultrasound probe on the skin to help orient the reader. This will be of particular importance for readers looking for a quick review and reminder prior to probe placement.”

“There are an impressive number of regional anesthesia books on the market, and they all have their value. But when it comes to learning regional anesthesia, it's the subtleties of performing blocks that is key. No book comes closer to teaching the art of regional anesthesia than this one does. The previous edition was published in 2004, and a lot has been added to this edition. Apart from dedicating half the book to ultrasound techniques, whole sections are devoted to cadaver and ultrasound images and surface anatomy. In short, this is the only book one needs to learn and become proficient in performing regional anesthesia.”