Department of Anesthesia
Regional Anesthesia Rotation Syllabus
Edward R. Mariano, M.D.
Shobana Chandrasekhar, M.D.
Shawn Fouhy, M.D.
Mark Spurlock, M.D.
Introduction
Welcome to the Regional Anesthesia rotation! We hope you have an enjoyable and
educational experience while learning new techniques that will help broaden your
anesthetic practice.
This syllabus is meant to provide you with basic review articles and original articles from
peer-reviewed literature that are important to understand when developing your regional
anesthesia practice. Since this rotation and syllabus are relatively new, both will undergo
many steps in evolution. We encourage you to add to your syllabus during your
residency or practice as the body of knowledge in this specialty continues to grow.
The Regional Anesthesia rotation will introduce you to various peripheral nerve block
techniques designed for extremity surgery. The practice of regional anesthesia requires
patience, preparation, and a lot of hard work. You should not expect to master every
technique by the end of one month. However, you should have the knowledge and
confidence to continue practicing regional anesthesia for the appropriate indications after
the rotation ends.
Edward R. Mariano, M.D.
Course Director for the Regional Anesthesia Rotation
Director of Anesthesia, Outpatient Surgery Center
University of California at San Diego Medical Center
Course Objectives
Patient Care
Residents on the Regional Anesthesia rotation will develop their skills in the
following areas of clinical care:
 Patient preparation including detailed discussions of the risks and benefits of
regional anesthesia versus general anesthesia
 Appropriate monitoring and sedation for patients undergoing regional anesthesia
procedures
 Determining the indications for regional anesthesia particular surgical procedures
and selection of appropriate nerve block techniques
 Selection of appropriate local anesthetic medications
 Specific peripheral nerve block techniques of the upper and lower extremities
 Continuous peripheral nerve block catheter placement: indications, methods, and
management
 Nerve stimulation with elicitation of motor responses as a guide for nerve block
placement
 Ultrasound in the practice of regional anesthesia
 Assessment of nerve blocks and supplementation with additional distal nerve
blocks when necessary to establish surgical anesthesia
Medical Knowledge
Utilizing this syllabus, textbooks of anesthesia, and an atlas of regional
anesthesia, residents on the Regional Anesthesia rotation will expand and apply their
knowledge in the following areas:
 Peripheral nerve anatomy
 Physiology of nerve blockade
 Pharmacokinetics of local anesthetic medications and the relationship to onset,
duration, metabolism, and toxicity
 Pharmacology of local anesthetic additives such as epinephrine, clonidine, and
sodium bicarbonate
Practice-based Learning and Improvement
Throughout the rotation, resident performance will be constantly evaluated and
improved. Development of a safe practice in Regional Anesthesia is an ongoing process
that incorporates many factors including:
 Daily feedback from faculty regarding technical skills and patient preparation
 Feedback from patients regarding their overall satisfaction with the regional
anesthetic technique
 Up-to-date medical literature on new techniques and technological advances in
Regional Anesthesia

Outcomes studies of Regional Anesthesia for outpatient surgery
Interpersonal and Communication Skills
Residents will develop their communication skills on a daily basis in the following
areas:
 Patient preparation: Residents will learn how to objectively present the risks and
benefits of regional anesthesia as well as answer individual patient questions
 Communication with surgeons regarding the site of surgery, patient positioning,
and anticipated postoperative pain since these directly impact the choice of
regional anesthetic technique
 Patient follow-up: Each resident who performs a regional anesthetic technique is
required to call the patient the next day to assess duration of pain relief, incidence
of side effects, and overall satisfaction with the regional anesthetic technique
Professionalism
Residents will develop professionalism through their interactions with patients,
surgeons, and nurses. Residents will learn about appropriate patient selection for
regional anesthesia as well as respect for occasional dissenting opinions from patients
and surgeons. The Regional Anesthesia rotation will stress the importance of teamwork
among the entire perioperative staff from preoperative admission to the nurses in the
postanesthesia care unit (PACU).
Systems-based Practice
Residents on the rotation will have an introduction to the impact of regional
anesthesia on the overall perioperative experience:
 Outcomes data regarding patient satisfaction with pain control, decreased
incidence of side effects such as nausea and vomiting, and faster recovery
 Early discharge for patients who do not require intensive postoperative nursing
care, thereby decreasing the length of PACU stays
 Economic considerations by decreasing PACU costs and avoiding unplanned
hospital admissions
 The anesthesiologist’s role as perioperative physician: performing preoperative
procedures, providing intraoperative anesthesia, and managing postoperative pain
Resident Responsibilities
As an anesthesiologist, you have probably learned the importance of preparation for your
cases. This is especially true for regional anesthesia. Proper preparation will
undoubtedly assure better results and happier patients, nurses, and faculty. The resident’s
responsibilities can be divided into the preoperative, intraoperative, and postoperative
periods.
Preoperative
 Discuss all cases the night before with your attending.
 Review relevant literature and anatomy from the syllabus and a regional
anesthesia atlas the night before. Specifically, review the indications, anatomy,
performance, and complications of the blocks you will be performing.
 Get to the hospital early! Early morning preparation is the key to getting the first
cases of the day started on time. We usually place the first blocks before morning
conference and then 45-60 minutes prior to surgical start time throughout the day
so there is adequate time for teaching, block assessment, and supplementation.
 Bring the block cart over to outpatient surgery. It is located in Ron Rusk’s office.
Ensure that it has been restocked. If not, ask an anesthesia tech to help you
restock it, or do it yourself. You should wheel the cart into the PACU and place it
against the wall by the first bed. We will use the first two PACU beds to place
the blocks.
 Ask the pre-op nurse (Sue, Sharon, or Ben) to prepare your patients early and
place them in pre-op rooms.
 Draw up your local anesthetics for the first case. For most blocks combined with
MAC, this will be either 0.5% bupivacaine or 1.5% mepivacaine. Lower
concentrations of local anesthetics are adequate for blocks combined with general
anesthesia.
 For a nerve stimulator block using bupivacaine, draw up 40 cc of 0.5% with
1:400,000 epinephrine into two 20 cc syringes connected by a 3-way stopcock to
the stimulating needle. For mepivacaine, draw up 40 cc of with 1:200,000 epi and
4 cc of NaHCO3 (1 mEq per 10 cc of anesthetic).
 For an axillary block, draw up 30 cc of 0.5% bupivacaine with 1:400,000 epi or
30 cc of 1.5% mepivacaine with 1:200,000 epi and 1 mEq of NaHCO3 per 10 cc
of local into three 10 cc control syringes. You should also draw up 1% lidocaine
for local anesthesia.
 Local anesthetics for ankle, wrist, or digital blocks should not contain epi.
 Set up the OR as you usually would to perform a GA if needed.
 Have drugs available for sedation for each procedure. Fentanyl 250 mcg and
midazolam 4 mg should be more than adequate for each block.
 Prepare your resuscitation drugs and bring them with you to the block area in case
of emergency.
 Ensure that oxygen, face masks, nasal cannulae, and a Mapleson circuit are
available.










Discuss the anesthetic plan and surgical approach for each patient with the
surgeon to determine surgical dermatome, patient positioning, location of
tourniquet, and any other special needs (i.e. skin or bone grafting).
Greet the patient in the pre-op room. Discuss the anesthetic options including
risks and benefits of each procedure.
Bring the patient to the PACU to place the block.
Position the patient, place monitors (Sp02, NIBP, +/- EKG) and oxygen.
Provide adequate patient sedation.
Identify surface landmarks.
Perform the block using sterile technique.
Allow time for the block to set up.
Assess the block using the “4 P’s.” To do this, you must have good functional
neuroanatomy knowledge. You should review the brachial plexus, lumbar
plexus, lumbosacral plexus, and dermatomes. This should include the origin and
termination of the involved nerves as well as muscles innervated and sensory
distributions.
Be prepared to supplement the block prior to surgery. This may involve repeating
the block or supplementing individual nerves of the plexus to be blocked, or
infiltration of local anesthetic by the surgeon. Remember than regional anesthesia
is not an “all-or-nothing” concept. Placing a neuraxial block for lower extremity
surgery or performing GA should be alternatives in case a peripheral nerve block
is inadequate for surgery.
Intraoperative
 Before the surgeons start, you should be convinced it will provide surgical
anesthesia.
 If the block is established, let the OR staff know that they can start the prep. If
you are not absolutely convinced that the block is working but believe that it is
something that can be handled by the surgeon placing local anesthetic, let the
surgeon know this.
 If the patient prefers to be “asleep” during surgery, make sure you adequately
sedate the patient prior to the start of surgery. Propofol with or without ketamine
will produce an acceptable level of sedation and still allow rapid recovery.
 Vigilance is crucial. You must keep your eyes on both the surgeon and the patient
when the first incision is made and throughout the case. Be prepared to take rapid
action in the event that the block is not providing adequate surgical anesthesia.
 Begin thinking about and preparing for the next case. Ideally, you should place
the block for the next patient 45-60 min before the anticipated surgical start. This
will require you to prepare up to 1.5 hours in advance. This includes
communicating with the front desk to make sure the patient is brought back in a
timely manner. The patient should be ready for you at least one hour before the
surgical start.
 Your faculty can help facilitate this process by calling someone to get you out of
the room to perform the block. People that may be available for this include the
residents in the pre-op clinic and the PACU resident. In addition, your faculty



may call the person running the board in the main OR to locate a “free” body to
facilitate.
Talk with the surgeon about the next case and any special needs they have.
Titrate sedation so the patient is only slightly sedated at the end of the case. This
may require discontinuing intravenous sedation prior to placement of the dressing
and splint. This will facilitate a timely discharge from the PACU.
Complete post-op orders. If the patient had a lower extremity peripheral nerve
block, remember to include: “Patient to be non-weight bearing on operated limb
for 24 hours.” You may also need to order a sling for upper extremity cases or a
knee immobilizer for lower extremity cases.
Postoperative/Follow-up
 Follow-up forms are available at the front desk. Ideally, these should be started in
the OR with a description of the block performed, local anesthetic used, and time
of block placement.
 Each patient should receive a phone call the next day to assess their
perioperative experience, the time the block wore off, the time of first required
analgesic, and any problems or complications. The follow-up form provides a
means of recording this information. The completed follow-up forms should be
given to Dr. Mariano or placed in his mailbox. This is an essential element of
regional anesthesia. Performing a procedure that has a long duration extends your
care of that patient. It is vital that you follow-up each patient who undergoes a
regional anesthetic. The information gained from this experience will give you a
better understanding of the risks and benefits of regional anesthesia and allow you
to provide your future patients with more accurate information.
 If the patient had any problems or complications, please inform your attending as
soon as possible.