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2011 Spring Newsletter
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Physicians committed to patient safety and comfort. |
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in this issue:
Letter from the President
Dear MSA Colleagues,
Spring time is upon us and I can feel the changes all around. The sun is warmer, the maple sap is running and finally some grass is emerging from under the heavy blanket of snow on my front yard. As I reflect on the past year, the most significant recollections are of change. We live in a time of change; not the slow predictable progression of seasons but the radical, fast- paced change of the unknown. I remember hearing Alan Greenspan in his testimony about the housing collapse and him saying he was unprepared for such a radical change and thought "things were going along alright." He didn't see the drastic changes coming that characterize our new reality.
We are seeing the same kind of radical transformation in Medicine. Health care costs continue to rise, resulting in increased charity care, an increased number of patients with government provided coverage, and patients unable to afford their part of the costs. Federal and state reforms have yet to fully take shape, and more decisions by default are being left to the government rather than remaining in the hands of the providers. The progressive movement by allied health providers, including increasing scope of practice and the new Doctor of Nursing Practice designation, continues at the state level.
We are fortunate in the MSA to have an active voice at both the national and state levels. I can't thank the members of the MSA enough for their activism on behalf of the MSA. We are fortunate to have the ASA President as a member of the MSA and an active state participant.
We continue to provide high quality, interesting meetings free of charge to our members, and the education committee is responsive to the interests and ideas of the membership at large. Over the last 5 years, spring meeting attendance has grown, and the fall meeting and workshop continue to exceed expectations.
Nonprofit Solutions, our management firm, continues to provide outstanding management and organizational assistance and I can't thank them enough for keeping the MSA on track.
The real heart of the organization, however, is the membership at large. I initially joined the executive committee to get a feel for the organization and secondarily to be able to bring information back to my group. I learned over the years about the commitment and untiring contributions that have been made to the MSA by its members, not out of personal gain, but out of a devotion to the medical practice of anesthesiology, and its growth, development and protection. I understand that this type of activity is not for everyone, but consider this is a call to all members. If you want to have a say in the outcome of the game, you have to get on the playing field. Sitting on the bleachers gets you a view but no say in the score. As changes come at an ever increasing pace and in ways that are unexpected, we need reasoned input now more than ever. Your PAC contributions help as well by maintaining a visible presence at the state government level. Please contact me or any other executive committee member to see how you can become involved.
Editor's Note
A Newsletter is Born
By: Adam Niesen, M.D.
Instructor in Anesthesiology, Mayo Clinic
As the sun shines outside, melting the snow that has accumulated over the long winter, thoughts of spring and new beginnings immediately come to mind. The coming spring brings an air of happiness and anticipation as the days grow longer and the plants grow greener. The publication of this newsletter marks a new beginning for the Minnesota Society of Anesthesiologists as well, like a seedling planted and waiting to grow and flourish in the summer sun.
The goal of our newsletter is to keep our members informed about the activities of and the opportunities afforded by the MSA. It also fulfills a request by the ASA to expand communications at the state society level, with each society publishing its own newsletter for its members. Our newsletter is initially planned to be published annually, between the MSA Fall and Spring Meetings. It is being published exclusively in an online format, which saves printing costs, keeps our carbon footprint small, and allows us to use the most up to date information in our articles. In addition, it is easy to include links to external information sources, such as in the update on the simulation requirement for Maintenance of Certification in Anesthesiology included in this issue.
While our initial edition is somewhat limited in length, it is our sincere hope that it is useful, interesting, and educational. However, this is just the beginning, and any feedback to help improve our newsletter would be greatly appreciated. Questions, comments, and suggestions can be sent to me directly at niesen.adam@mayo.edu. Thank you very much for reading!
MSA News
Connect with Colleagues and Learn What's New - A Review of the Fall Meeting and Preview of the Spring Meeting.
By: David Martin, M.D., Ph.D.
Chair, MSA Education Committee Associate Professor of Anesthesiology, Mayo Clinic
The Education Committee of the Minnesota Society of Anesthesiologists has been hard at work identifying the educational needs of the membership and designing meetings to meet those needs. For example, ultrasound technology has dramatically changed the landscape of regional anesthesia. Many of our members have expressed a desire to improve their familiarity with this technology. At our last MSA meeting on November 5, 2010, we met at the Westin Edina Hotel for a stimulating half-day session of lectures about regional anesthesia, followed by a series of workshops in the afternoon that taught a variety of ultrasound-guided regional anesthesia techniques. Despite the first severe winter storm of the season, attendance was very good and post-meeting evaluations gave very high marks for the usefulness of this meeting.
The next MSA meeting will be Saturday, April 9, 2011, at the Sofitel Hotel in Bloomington, MN. Registration and social gathering start at 7:00. Dr. Lynn Martin, M.D., M.B.A., current President of the Society for Pediatric Anesthesia, will speak about regional anesthesia for pediatric patients. His second lecture will be a very timely update on the important issue of anesthesia-related neurotoxicity in infants. Dr. Mark Warner, M.D., the current President of the American Society of Anesthesiologists, will speak to us about future technologies in anesthesia and how they will affect our practice and improve patient safety. Dr. Warner will also update the membership on current topics being faced by the ASA, including legislative and reimbursement issues. Finally, Dr. Richard Prielipp, M.D., M.B.A., Chair of the Department of Anesthesiology at the University of Minnesota, will speak to us about Patient Safety: Past, Present, and Future. We will conclude with the annual business meeting which includes updates to the membership about current activities of the Minnesota Society of Anesthesiologists, as well as election of officers for the next year.
The Spring Meeting promises to be a very interesting venue for continuing medical education, as well as an excellent opportunity to socialize with friends and colleagues across the state. I look forward to seeing you at the Spring Meeting, and welcome any suggestions or requests for future meetings of the Society.
Resident's Corner
The Benefits of Resident Involvement in the Minnesota Society of Anesthesiologists
By: Bryan Pershing, M.D.
CA-2 Resident, Mayo Clinic
As a class representative to the Minnesota Society of Anesthesiologists (MSA) my most important role is to disseminate information about the MSA in a manner that not only educates my classmates but actually encourages active participation. I am often asked, "What does the MSA do for me?"
Each year the Minnesota Society of Anesthesiologists sponsors two residents from the University of Minnesota and two residents from Mayo Clinic to act as class representatives. These residents are expected to attend quarterly meetings with the MSA board of directors and to attend the semi-annual state society meetings. Resident representatives keep their classmates up to date on developments within the MSA as well as the American Society of Anesthesiologists (ASA). The resident representatives also recruit membership to, and participation in, respective Political Action Committees. Resident representatives are provided financial assistance to attend the annual meeting of the ASA where they serve as voting delegates in the resident House of Delegates. They also attend the yearly legislative conference in Washington, D.C. The challenge for these representatives is to periodically break down months or years of political dialogue into a form that an extremely busy resident will appreciate. Resident representatives are also able to collaborate with senior MSA leaders in active lobbying both at the state and federal levels. With the future of American health care continuing to evolve, the role of the MSA (and ASA) in helping shape how residents will practice in the future cannot be overstated. However beyond the politics, the MSA provides many other opportunities for medical students and residents alike.
The twice yearly meetings held by the MSA are extremely educational. World class lectures from visiting professors, enlightening debates from giants in the field and interactive workshops that facilitate hands on learning are only a portion of the opportunity provided. Time allotted for breaks and lunches also allows residents to meet and network with anesthesiologists from around the state. Whether receiving advice from recent graduates or observing the discussion of new retirees, residents are richly rewarded for their attendance.
Recently the MSA has embarked on larger public educational programs through various media to help inform everyone about the role of the anesthesiologist. When surveyed, patients consistently report confusion as to the role of various providers involved in the anesthesia care team and prefer to know when a physician is involved in their care. Following the MSA spring meeting, the ASA will sponsor a media training program for those interested. The MSA has consistently supported the Anesthesia Patient Safety Foundation (APSF) and the Foundation for Anesthesia Education and Research (FAER). The APSF has had a profound impact in leading the patient safety initiatives credited with saving thousands of lives and FAER has provided millions of research dollars to anesthesiologists and anesthesia residents across the nation. I consider myself fortunate to serve as a class representative and am grateful for the support of the Minnesota Society of Anesthesiologists.
How I Do It:
Ultrasound-Guided Thoracic Paravertebral Block
By: Adam Niesen, M.D.
Instructor in Anesthesiology, Mayo Clinic
Overview
Paravertebral block is defined as injection of local anesthetic in the paravertebral space adjacent to the vertebral column, in close proximity to emerging spinal nerves. It was first performed by Leipzig in 1905 and had an initial peak in popularity in the 1920s and 1930s, after which it largely fell into disuse until Eason and Wyatt refreshed interest in the block in 1979.1-2 Injection of local anesthetic into the paravertebral space results in unilateral somatic and sympathetic blockade which typically spreads over multiple dermatomes.3 Paravertebral block results in a lower incidence of hypotension compared to an epidural, even when bilateral blockade is performed.4-5 In addition, paravertebral blockade achieves a lower incidence of urinary retention and postoperative nausea and vomiting when compared to a thoracic epidural.5 It has been suggested that paravertebral block can be performed in situations that thoracic epidural placement would be contraindicated or difficult, such as patients with sepsis, preexisting neurologic disease, difficult spine anatomy, or while under general anesthesia; although the risk associated with performing paravertebral block under these conditions has not been quantified.1,5 Thoracic paravertebral blockade is useful in many types of surgical procedures, including but not limited to intrathoracic, chest wall, abdominal, and breast procedures. It has also been used for analgesia following rib fractures. Depending on the intended surgical procedure, paravertebral blockade can be used as the primary anesthetic, postoperative analgesia, or both. In addition to reductions in acute pain, paravertebral block has been shown to reduce the occurrence of chronic pain in breast surgery patients, and may reduce the recurrence of breast cancer if performed preoperatively in patients undergoing surgical resection.6-8 Although there are a handful of techniques for ultrasound guided paravertebral blockade in the literature, they tend to employ scout imaging without real time guidance, an out-of-plane approach, or an in-plane approach with the needle trajectory in an oblique lateral-to-medial direction toward the neuraxis.9-14 When the oblique lateral-to-medial approach is used, there is a frequent occurrence of epidural, mediastinal, and pleural placement of paravertebral catheters in cadavers.13 The technique that follows has not yet been described. It affords the potential combined advantages of a real-time in-plane needle approach, a needle path that is not directed toward the neuraxis, and the ability to visualize multiple levels with the same ultrasound image. Real-time in-plane ultrasound guidance may provide additional benefits over traditional blind techniques by minimizing the unknown needle tip location when bone is not contacted at the expected depth. Additionally, visualizing the needle may decrease the risk of the most feared complication of pleural puncture and pneumothorax, while allowing confirmation of deposition of local anesthetic in the paravertebral space.
Clinically Relevant Anatomy
The paravertebral space in the thoracic region is bounded posteriorly by the superior costotransverse ligament, transverse processes and ribs, while the anterior boundary is the parietal pleura. Laterally, the paravertebral space becomes continuous with the intercostal space. The medial border consists of the vertebral body, intervertebral disc, and the intervertebral foramen, which provides a route of communication between the paravertebral space and the epidural space (Figure 1). The contents of the thoracic paravertebral space include fat, the spinal nerve, dorsal ramus, intercostal vessels, communicating rami, and the sympathetic chain in the anterior portion of the space. Technique:
Patient position: The patient is placed in a sitting position, with the neck flexed and hands on the lap. Resting the patient's head on an adjustable height table topped with a pillow assists in maintaining a consistent position, particularly once sedation is given. Keep the patient's head in neutral rotation and flexed position (looking straight at the floor) to assist with ideal imaging and anatomic relationships. Avoid placing the patient's arms on the tray during positioning, in order to prevent the scapulae obscuring the field of view and acting as an obstacle to needle entry.
Equipment: A curvilinear probe (SonoSite C60 2-5 MHz, SonoSite Incorporated, Bothell, WA) produces the optimal combination of anatomic and needle imaging. A 100mm 21-gauge short-bevel needle (Stimuplex STIM-A21100, B. Braun Medical Incorporated, Bethlehem, PA) is used. The ultrasound machine is positioned to the side of the patient being blocked, although it is simple and comfortable to perform bilateral blocks without moving the machine (Figure 2).
Approach: After identifying and marking the desired levels to be blocked by classic palpation of spinous processes, which often can be assisted and confirmed with ultrasound imaging, the patient's skin is prepared with sterile cleansing solution over a wide area, and sterile drapes are applied. The probe is covered with a sterile plastic transducer sheath (CIV-FlexTM Transducer Cover, CIVCO, Kalona, IA). The probe is placed parallel to the direction of the neuraxis approximately 2.5 cm lateral to the spinous process. Transverse processes appear as hyperechoic semicircles with distinct black shadow deep to the hyperechoic surface (Figure 3).
The transducer position is adjusted, typically with very small movements in the medial-lateral plane until the tendon slip of the paraspinal musculature appears as a bright line spanning between adjacent transverse processes. Deeper to this structure lies the superior costotransverse ligament within the window between transverse processes; however it can be quite difficult to formally visualize this structure. The deeper bright white line that is visible between adjacent transverse processes represents the pleura. As expected, the lung causes significant beam attenuation deep to the pleura. The target for the needle tip is between the tendon slip of the paraspinal musculature and pleura. It is not necessary to contact the transverse process as in traditional techniques. The needle is advanced in-plane, in a caudal to rostral trajectory
(Figure 4).
The needle angle required can be quite steep, which may diminish the quality of needle visualization, necessitating the use of tissue distraction as a surrogate for the actual needle image. An in-plane approach allows one to see tissue distraction across the entire length of the needle, providing a more accurate determination of the location of the needle tip. Hydrodissection using saline, 5% dextrose, or local anesthetic also assists in determining the location of the needle tip. As the needle is advanced, indention of the tendon slip is typically observed, then both a tactile pop and visible recoil of this structure to its original position as the needle tip passes through it and into the paravertebral space are frequently observed. After negative aspiration, local anesthetic is injected. The local anesthetic should be observed expanding the space below the tendon slip and above the pleura; the injection should displace the pleura to a deeper position on the screen, which indicated accurate needle placement. Local anesthetic can be seen spreading to adjacent levels, both by observation of pleural distraction through adjacent windows and by a distinct "shimmer", "static", or "snow" appearance of the local anesthetic expanding the paravertebral space in adjacent windows. The volume of local anesthetic injected at each level is dependent upon the number of levels injected and whether unilateral or bilateral blockade is planned. On average, I use 20-30 mL of local anesthetic per side, divided between the injected levels. If there is concern regarding total local anesthetic dose, the concentration is reduced to an acceptable level for the planned injection volume.
Clinical Pearls:
Summary
Thoracic paravertebral blockade is a technique to provide anesthesia and/or analgesia for a variety of procedures, with fewer undesired side effects than comparable thoracic epidural. The use of direct ultrasound as described may aid in the placement of local anesthetic in the desired location and avoidance of pleural puncture. Avoiding bony contact may also be more comfortable for patients than traditional techniques where the needle is "walked off" the transverse process. Acknowledgments
A similar version of this article appeared in the November 2009 edition of the American Society of Regional Anesthesia and Pain Medicine News. References
1. Richardson J and Lonnqvist PA. Thoracic paravertebral block. British Journal of Anaesthesia. 1998; 81:230-238. 2. Eid H. Paravertebral block: An overview. Current Anaesthesia & Critical Care. 2009; 20:65-70. 3. Karmakar M. Thoracic paravertebral block. Anesthesiology. 2001; 95:771-780. 4. Davies RG, Myles PS, and Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy - a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. 2006; 96(4):418-426. 5. Naja Z, Lonnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia. 2001; 56:1181-1201. 6. Iohom G, Abdalla H, O'Brien J, et al. The associations between severity of early postoperative pain, chronic postsurgical pain and plasma concentration of stable nitric oxide products after breast surgery. Anesthesia & Analgesia. 2006; 103:995-1000. 7. Kairaluoma PH, Bachmann MS, Rosenberg PH, Pere PJ. Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesthesia & Analgesia. 2006; 103:703-708. 8. Exadaktylos AK, Buggy DJ, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006; 105:660-664. 9. Pusch F, Wildling E, Klimscha W, and Weinstabl C. Sonographic measurement of needle insertion depth in paravertebral blocks in women. British Journal of Anaesthesia. 2000; 85(6):841-843. 10. Jamieson BD and Mariano ER. Thoracic and lumbar paravertebral blocks for outpatient lithotripsy. Journal of Clinical Anesthesia. 2007; 19(2):149-151. 11. Hara K, et al. Ultrasound guided thoracic paravertebral block in breast surgery. Anaesthesia. 2009; 64:223-225. 12. Shibata Y, Chin KJ. Thoracic paravertebral block. Ultrasound for Regional Anesthesia http://www.usra.ca/sb_thoracic. 13. Luyet C, et al. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. British Journal of Anaesthesia. 2009; 102(4):534-539. 14. Ben-Ari A, et al. Ultrasound-guided paravertebral block using an intercostal approach. Anesthesia & Analgesia. 2009; 109(5):1691-1694.  Figure 1 - Artist's rendering of paravertebral space anatomy. Used with permission of Mayo Foundation for Medical Education and Research.
Figure 2 - Patient positioning, machine location, and hand position for  Figure 3 - Ultrasound anatomy for thoracic paravertebral block. Solid arrows = tendon slip of the paraspinal musculature, TP = transverse process, dashed arrows = parietal pleura.  Figure 4 - Ultrasound image showing needle imaging for thoracic paravertebral block. Solid arrows = tendon slip of the paraspinal musculature, TP = transverse process, dashed arrows = parietal pleura, arrowheads = needle image with tip just below tendon slip of the paraspinal musculature, asterisk = small amount of local anesthetic injection. MOCA
Simulation for MOCA
By: Laurence Torsher, M.D.
Assistant Professor of Anesthesiology and Medical Education, Mayo Clinic
Maintenance of Certification in Anesthesiology (MOCA) is the process, administered by the American Board of Anesthesiology (ABA), to maintain board certification. ABA diplomates who received board certification during the year 2000 or later have time limited board certification and MOCA is a requirement. For those who do not hold a time limited certificate, enrollment in the MOCA process is voluntary.
Requirements for MOCA are outlined in detail on the ABA web page. Note that requirements are slightly different depending on the year of certification or commencement of the MOCA process as outlined towards the bottom of the ABA web page listed above.
Part IV of the MOCA process requires completion of a simulation course. These courses are carried out at ASA endorsed centers around the United States. The endorsement process was developed to ensure that members received a high quality simulation experience. There are currently more than 20 centers across the USA, with more centers being added on a regular basis. The ASA maintains a listing of simulation sites and links for registration.
Within the Midwest, the Mayo Clinic offers simulation courses meeting the MOCA part IV requirements.In 2011, courses will be offered on May 7, September 30, and October 1. Registration details are available here.
The University of Minnesota will soon be an endorsed center as well and will also be offering endorsed simulation courses meeting MOCA part IV requirements.
Members can learn about dates and locations of courses from the listing of simulation centers with the link above, or by accessing the ASA listing of meetings and events here, and
then select the filter for the category of "Simulation Education."
Editor's Note: The Minnesota Board of Medical Practice now recognizes board certification and maintenance of certification as satisfying the CME requirement for the period in which certification or recertification occurs. Read the statement regarding this policy here.
Connect with MSA
If you are a physician anesthesiologist who is not a member of the Minnesota Society of Anesthesiologists, this e-mail communication is sent as a courtesy for your information. We encourage you to visit the MSA Web site at www.msaconnect.org to view the benefits available to members. |
