Future directions in regional anaesthesia: a reply.

Abstract

Turbitt et al. 1 and Ashken and Thompson 2 raise two valid points regarding the current shape of regional anaesthesia teaching and training. Turbitt et al. highlight that with the advent of ultrasound-guided techniques, the plethora of blocks available and rise of the ‘expert regionalist’, it is quite easy for many other anaesthetists to steer away from practising regional anaesthesia at an early stage of their career. In an effort to solve this problem the article goes on to list basic level (plan A) peripheral nerve blocks which they feel all anaesthetists should be able to perform. Ashken and Thomson, while supporting the concept, stress (via a survey) the difficulty in teaching even basic blocks. In effect, they are flagging the fact that there is a postcode lottery for the provision, teaching and training of regional anaesthetic techniques that exists throughout the UK. Although not all anaesthetists should be expected to perform all nerve blocks available (such as the plan B blocks described by Turbitt et al.), Regional Anaesthesia UK (RA-UK) feels all anaesthetists should be able to perform basic blocks as a requirement for achieving a CCT in anaesthesia. Ashken and Thompson raise the important point that the exact list of basic blocks will cause debate. A list of basic regional anaesthesia techniques should be pragmatic, evidenced-based and safe. Regional Anaesthesia-UK feels that the list as suggested by Turbitt et al. is appropriate, or even that put forward by Shonfeld and Harrop-Griffiths when they described ‘desert island blocks’ 3. Regional Anaesthesia-UK recommends the following basic level peripheral regional techniques: interscalene brachial plexus; axillary brachial plexus; rectus sheath; femoral nerve; and sciatic (popliteal level) nerve. These blocks have an excellent track record, are easy to teach and the anaesthetist that can perform all five can effectively anaesthetise the majority of the body. How do we achieve this basic level with the existing limitations in training? In the first instance, the importance of regional anaesthesia needs to be appreciated by governing bodies. Regional Anaesthesia-UK has been working with the Royal College of Anaesthetists on the curriculum redesign. Schools of Anaesthesia need to create training rotations so all trainees are exposed to the aforementioned basic blocks (as well as opportunities for advanced techniques) in an effort to combat the existing postcode lottery. In addition to on-the-job training, all anaesthetists should attend at least one regional anaesthesia course. The selection of course will depend on the individual anaesthetist's needs, but generally speaking the content can include a combination of model scanning, cadaveric anatomy and cadaveric needling. Regional Anaesthesia-UK now highlights the variation offered by courses through the RA-UK course approval process. Lastly, for training and career grade anaesthetists, RA-UK now offers a link network where anaesthetists interested in seeing blocks in action can contact experts around the country to arrange a visit. This is especially important when a new regional anaesthetic technique is introduced.