A Survey on Teaching Ultrasound-Guided Chronic Pain Procedures in Pain Medicine Fellowship Programs

Background: Over the last decade ultrasound guidance (USG) has been utilized very successfully in acute pain procedures to confirm nerves’ anatomic location and obtain live images. Not only the utilization, but the teaching, of USG has become an essential part of anesthesiology residency training. Prior to the introduction of USG, chronic pain procedures were always done either under fluoroscopy or blindly. USG offers advantages over fluoroscopy for completion of chronic pain procedures. USG decreases radiation exposure and the expenses associated with operating a fluoroscopy machine and allows live visualization of soft tissues and blood flow, a feature that fluoroscopy does not directly offer. Even today, the utilization and teaching of the technique for chronic pain procedures has not been as widely accepted as in acute pain management. Objectives: To understand the current practices and the factors affecting the teaching of ultrasound guided chronic pain procedures in chronic pain fellowship programs throughout the United States. Study Design: Survey conducted by internet and mail. The survey was distributed to program directors of ACGME-accredited pain medicine fellowships. When the survey was distributed there were 92 accredited pain medicine fellowships. Methods: REDCap survey software was used for designing the questionnaire and sending email invitations. Also, paper questionnaires were sent to those who did not respond electronically. Additional copies of the survey were mailed or faxed upon request. We received 43 responses (a response rate of 46.7%). Statistical analyses included frequencies, crosstabs, and nonparametric Spearman rank-order correlations. Results: The majority of stellate ganglion blocks, occipital nerve blocks, and peripheral nerve blocks are currently being done under ultrasound guidance. Although interest among trainees is very high, only 48.8% of the fellowship programs require fellows to learn the technique before graduation and 32.6% of the program directors agree that teaching of USG should be an ACGME requirement for pain medicine fellowship training. Faculty training is considered to be the most important factor for teaching the technique by 62.8% of directors. In the opinion of the majority of program directors, the greatest factor that stands against teaching the technique is the fact that it is time consuming. Nearly half (44.2%) of program directors believe that the technique will never replace fluoroscopy; but one quarter (25.6%) think that the new 3D ultrasound technology, when available, will replace fluoroscopy. Limitations: A moderate response rate (46.7%) may limit the generalizability of the findings. However, our survey respondents seem to represent the study population quite well, although there was a bias towards the university-based programs. Training programs located at community-based hospitals and U.S. government installations were not as well represented. Conclusion: The teaching of ultrasound guided chronic pain procedures varies significantly between individual programs. Though many program directors do require that fellows demonstrate competency in the technique before graduation, as of today there is no ACGME guideline regarding this. The advancement in ultrasound technology and the increase in number of trained faculty may significantly impact the use of USG in training fellows to perform chronic pain procedures. Key words: Ultrasound guidance, fluoroscopy, chronic pain procedures, regional nerve blocks, musculoskeletal procedures, implantable devices, pain medicine, fellowship training, anesthesia residency training</jats:p

Emergency percutaneous tracheotomy in failed intubation

AbstractObjectiveCricothyrotomy is the emergency surgical means of gaining access to the airways. However it holds a lot of problems to the patient and is only a temporary measure until a definitive airway is reached. Griggs’ forceps technique for elective bedside percutaneous dilational tracheotomy (PDT) is safe, fast, and carries fewer complications in expert hands. This study aimed at comparing between emergency cricothyrotomy and emergency PDT in patients with failed intubation.DesignA comparative double blind study.SettingEmergency room of Alexandria main university hospitals.Patients169 failed to intubate, failed to ventilate patients.MethodsThey were serially randomized into group I (85 patients): percutaneous cricothyrotomy and group II (84 patients): PDT using Griggs’ forceps technique.ResultsSuccess rate was 95.3% in group I and 97.6% in group II. Procedure duration (in minutes) was 1.85±0.36 in group I versus 1.46±0.31 in group II. Lung atelectasis occurred to 8.2% of patients in group I only. Vocal cord injury occurred to 4.7% of patients in group I versus 1.2% in group II.ConclusionEmergency PDT is feasible and safe in expert hands