regional anesthesia

Training in regional anesthesia is one of the strengths of our residency program. A group of dedicated faculty concentrates their clinical time instructing residents in the principles and practice of regional anesthesia. The Department of Orthopedic Surgery at Columbia University Medical Center is consistently ranked one of the best in the country, and surgery involving the extremities, including all types of open fracture repair, corrective procedures of the hands and feet, and joint arthroscopy are performed daily, virtually all of them under regional anesthesia. We have a large cadre of orthopedic surgeons who specialize in sports medicine. Our residents are thus exposed to many young, healthy patients with sports-related injuries undergoing procedures under ambulatory regional anesthesia. Our Shoulder Service is particularly active: with most procedures performed under an interscalene brachial plexus block with/without an interscalene catheter for postoperative analgesia. We take care of an equally large group of elderly patients with significant pathology, undergoing upper and lower extremity joint replacements. Additionally we provide regional anesthesia services routinely to the vascular, abdominal, breast, gynecologic and transplant surgery patients encompassing a wide range of techniques including truncal nerve blocks as well as paravertebral blockade.

Major physiologic alterations brought about by general anesthesia can be avoided by the use of regional anesthetic techniques, and perioperative risk can be favorably influenced. Many of our blocks are performed with long acting agents that provide not only intraoperative anesthesia, but postoperative analgesia as well. The placement of perineural catheters (upper and lower extremity) and the use of continuous regional analgesia techniques are utilized to provide postoperative analgesia for an extended period of time. The combination of a varied caseload, a dedicated anesthesia faculty, and a high level of patient and surgeon satisfaction with regional anesthesia, makes this a wealthy and rewarding clinical experience and is one of the clinical rotations consistently requested by our residents.

The first rotation in regional anesthesia takes place in the CA-1 year. During this month, the resident performs central neuraxial blocks (epidural, spinal and combined spinal-epidural techniques) as well as a broad selection of upper and lower extremity peripheral nerve blocks for routine orthopedic procedures. Residents will gain experience performing these blocks under ultrasound guidance. A peripheral nerve stimulator may be added as an additional tool as well as for educational purposes. Management of moderate to deep sedation as an adjunct to regional anesthesia is developed during this month. The pharmacology and clinical use of local anesthetic agents as well as the anatomy and clinical application of peripheral and neuraxial blocks are major topics of study during the rotation.

In the second year, the resident is expected to decide independently which blocks will be appropriate for the planned procedure as well as which agents to use, and to defend their choice with the attending anesthesiologist. They are expected to identify ultrasound related anatomical landmarks for performance of regional techniques with minimal assistance, and initiate blocks for postoperative pain management. In addition to reviewing previously covered topics, new topics are introduced, including considerations for hip and knee replacement, thromboembolic prophylaxis, blood sparing techniques, orthopedic oncology as well as spinal trauma and surgery.

A CA-3 rotation is optional, but most seniors request an additional rotation as the “Block Room Resident” to gain additional experience in regional anesthesia. The CA-3 resident is expected to have mastered basic knowledge related to regional anesthesia, and should be able to perform regional techniques and manage patients during surgery with minimal assistance. The senior resident is introduced to controversial topics in regional anesthesia, exposed to relevant articles in the literature, and is encouraged to discuss pertinent issues with their attending in an "Oral Board" format. Brief clinical scenarios, such as management of a quadriplegic patient for shoulder surgery, a patient with sudden dyspnea following placement of an interscalene block, or a patient with a history of 'collapse' after local anesthetic administration in the dentist's office, are presented by the attending, and the resident is expected to be able to assess the situation, discuss treatment options, and defend their opinions. The CA·3 resident will also, in collaboration with the regional fellows, conduct a number of journal clubs during their rotation.

Experience will be gained in placement of peripheral nerve catheters for postoperative continuous regional analgesia. This is an exciting technique that has gained in popularity, and is poised to become the preferred technique for managing postoperative pain following major orthopedic as well as numerous general surgical procedures. The CA-3 resident will become familiar and proficient in a variety of regional anesthesia techniques for vascular, breast, thoracic, gynecologic and abdominal surgery.  These regional anesthesia procedures are one component of a multimodal postoperative pain management approach managed by our Acute Perioperative Interventional Pain Service (APIPS). In this way the resident is exposed to the full spectrum of regional anesthesia techniques that are utilized for intraoperative anesthesia and postoperative analgesia.

Unique educational experiences for Columbia anesthesia residents and fellows include the opportunity to teach in the Columbia Medical School Anatomy Laboratory.  Residents and fellows teach the medical students about the clinical applications of the brachial plexus, lumbar and sacral plexus and also have the opportunity to help dissect the cadavers for a greater understanding of human anatomy. Additionally during the PGY-1 year, residents have a one-day symposium taught by Columbia faculty on the use of ultrasound in clinical practice.  This course includes lectures on regional anesthesia and hands-on scanning opportunities as well as phantom needling practice as well as access to a full on-line curriculum.

Faculty:
Anthony (Robin) Brown, MBChB., FFA(SA)
Connie Chung, MD
Anis Dizdarevic, MD
Danielle Ludwin, MD
Robert Maniker, MD
Leena Matthew, MD
Oliver Panzer, MD

Fellows 2013-2014:
Lauren Parnell, MD Residency: Columbia University, New York, NY
Tanzina Khan, MD Residency: Columbia University, New York, NY
Armand Wilhelm, MD Residency: Columbia University, New York, NY

Fellows 2014-2015:
Ryan Ivie, MD - Residency: Columbia University, New York, NY
Lisa Jacob (Kilcoyne), MD - Residency: Columbia University, New York, NY
Vibhuti Kowluru, MD - Residency: Columbia University, New York, NY

For further information, write or contact
Anthony (Robin) Brown. MBChB_,FFA(SA)
Clinical Professor of Anesthesiology and Vice Chair
Director, Orthopedic and Regional Anesthesia
Department of Anesthesiology.
Columbia University Medical Center
630 West 168th Street
New York. NY 10032
Telephone: 212-305-3166
Fax: 212-305-2182
Email: arb6@cumc.columbia.edu

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Columbia University Medical Center Department of Anesthesiology