Anesthesiologists who graduated from the two largest residency programs (Universidad Católica de Chile, Santiago, and the Universidad de Chile, Santiago) in Chile were surveyed to identify specific peripheral regional anesthesia technical competencies required in clinical practice. The two university-based programs include approximately 70% of the anesthesia graduates in Chile, so the survey population was a representative sample of practicing anesthesiologists. In addition, the survey response rate was >70%. The sample population and response rate assured that our data were valid and were representative of our population of practicing anesthesiologists.
Regional anesthesia represents a significant portion of regular clinical practice among Chilean anesthesiologists. Neuraxial techniques (e.g., spinal and lumbar epidural blocks) are commonly performed in clinical practice with a high level of confidence. This confidence is consistent with the perception that these specific techniques are thoroughly covered by the residency programs. The degree of exposure is great enough to ensure confidence in clinical performance after the training, which far exceeds ACGME requirements. Other studies performed abroad have obtained similar results [8].
A different situation occurs with PNBs. Previous studies in the literature report that a limited number of PNBs are performed during the residency period, and residents lack confidence in their ability to perform these techniques [9]. Specifically, Moon et al. surveyed third clinical anesthesia year residents from 14 residency programs in the United States of America. Authors assessed a pre-specified list of PNBs: interscalene, axillary, femoral, sciatic, popliteal, and lumbar plexus, among the rest of other possible alternatives. According to the authors, these nerve blocks were chosen because they represent frequently- performed blocks in clinical practice.
A wide diversity of described PNB techniques does exist. For instance, the last version of the guidelines for fellowship training in regional anesthesiology and acute pain medicine includes a list of at least twenty-four different types of block techniques that should be known and mastered by regional anesthesia fellows at the end of their training [10]. In the case of anesthesia residency programs, although the ACGME provides specific recommendations in terms of the minimum number of PNBs required at the end of the training period, it does not provide guidelines as to the specific types of blocks. Therefore, it is possible that residents may meet the requirement with a moderate to large number of one or two types of blocks, while being largely unfamiliar and unconfident with many other types.
In order to get better information regarding the actual needs our former residents should face on their clinical practice, our study asked for the techniques perceived as essentials by the anesthesiologist from a broader list of options. A similar methodology was employed by Ouanes et al. [11], but applying the survey among the faculty members of the 26 existing regional anesthesia fellowship programs in the United States and Canada. Based on those survey results, they identified the six anesthesia blocks most often performed at their institutions: interscalene, infraclavicular, supraclavicular, femoral, Labat or subgluteal sciatic, and popliteal sciatic. Although their results have some similarities with ours, the responders in Ounaes’ study were anesthesiologists dedicated to the practice and the teaching of regional anesthesia in academic centers. Our study tries to identify knowledge and skills that every general anesthesiologist should master after a residency program, instead of skills required by a fellow after at the end of at least a one- year training period.
A high proportion of surveyed anesthesiologists performed PNB regularly, and greater than one-half used continuous PNB techniques. There was a concordance between the techniques perceived as essential based upon actual clinical practice, the most commonly used PNBs, and the degree of confidence in performing them. This result may be because the residency programs are thoroughly training the residents in these procedures. Alternatively, alumni who did not acquire the necessary competencies during residency program may have self-trained to achieve the requirements of their clinical duties. The results did not support the second option. The respondents indicated that the primary source of training was the residency programs.
The results indicate that the curricula of Chilean residency programs in anesthesiology should focus on the femoral, interscalene, popliteal sciatic, and Bier nerve blocks. Beyond the general concepts underlying the performance of any PNB in a reliable and safe manner, training should be structured to assure the acquisition of practical skills for optimal performance in clinical practice.
According to the classification and definition of nerve block procedures proposed by Hadzic et al. according to the difficulty of their performance and the time required for mastering them [7], three of these four PNBs are intermediate blocks. The results suggest that the survey participants had reached sufficient expertise to successfully implement them in clinical practice.
A noteworthy aspect of our results was that a high proportion of respondents had ultrasound equipment in the workplace. They regularly used ultrasound as the guidance technique, either alone or in combination with peripheral nerve stimulation. Results previously published by our research team indicate that there has been a rapid increase in the use of ultrasound guided regional anesthesia among Chilean anesthesiologists [12]. The availability of ultrasound technologies experienced a 7-fold growth from 2009–2013. The findings of our current study are also relevant in terms of the contents and the competencies that should be covered by residency curricula. Because ultrasound guided regional anesthesia is often used by our graduates, teaching the fundamentals of ultrasonography, image interpretation, applied sonoanatomy, and teaching specific motor skills (e.g., optimal image acquisition and needle-probe alignment) are critical components that should be included in the residency curriculum.
PNBs were more likely to be used by anesthesiologists in clinical practice associated with a position at an academic institution. This finding was encouraging. The practice of regional anesthesia in academic environments represents a pathway by which the discipline will develop toward consolidation as a subspecialty, and ensure the training of future experts in the field.
There were several limitations of our study. The study sample included participants from only one country, and Chile has a relatively small and homogeneous population of anesthesiologists. The conclusions cannot be extrapolated to other South American countries, but the methodology used can easily be replicated, independent of sample size. Another limitation was that a risk of bias may have been introduced, because the survey was sent by email. Only anesthesiologists who had access to the Internet and used it regularly had the opportunity to respond.
A third study limitation was that the expressions of level of confidence of each anesthesiologist did not necessarily reflect the actual performance (e.g., success rate, rate of complications) of the individual.
