St. Paul’s Hospital

St. Paul’s Hospital is a tertiary care teaching hospital serving British Columbia and the Yukon Territory. The regional anesthesia group at St Paul’s hospital is very active clinically, academically, and with resident and fellow education. Our regional anesthesiologists are all skilled in the field of ultrasound-guided regional anesthesia for both single injection and continuous techniques.

Clinically, we operate two out-of-OR nerve block rooms: One block room, serving a mixed in-patient/out-patient population, serves the main operating room1, while the other block room serves two specially designed and highly efficient ambulatory “swing” operating rooms2. Here, peripheral nerve blockade is used to provide surgical anesthesia for upper and lower limb procedures performed sequentially by a single surgical team, and with minimal turnover time between cases.

At St Paul’s Hospital, we perform more than 2500 single injection peripheral nerve blocks annually, including interscalene, supraclavicular, infraclavicular, axillary, popliteal-sciatic, sapheneous, TAP, and paraverterbral blocks. In addition we place approximately 400 in-patient perineural catheters annually. In 2012 we began a home peri-neural catheter program, in which ambulatory patients are discharged home with a perineural catheter in situ, as well as with an infusion of local anesthesia supplied by a portable, disposable pump.

In addition to our busy clinical practice, we are also active in the field of resident and fellow education. In 2009 we began what has become a very popular resident rotation in regional anesthesia, and in 2011 we developed a dedicated regional anesthesia fellowship. Since 2011 we have had 7 fellows complete their training with us. For further information regarding our regional anesthesia fellowship at St. Paul’s Hospital, please contact Dr. Steven Petrar (anesthesiafellowships@gmail.com).

Main OR Block Room:

Our main operating room block area is the centerpiece of our block program. This dedicated block room facilitates placement of both single-injection and continuous nerve block techniques, and provides service to orthopedic and plastic surgical teams. In addition to peripheral nerve blocks, our regional anesthesiologists also contribute to improved operating room efficiency through the placement of thoracic epidurals for general surgery cases as well. ¹

Home Catheter Program:

In 2012, regional anesthesiologists at St Paul’s Hospital began a program whereby selected outpatients are offered the option of having a perineural catheter placed for postoperative pain control following extremity orthopedic surgery. By sending patients home with a portable, disposable pump filled with dilute local anesthetic, the duration of pain relief following surgery can be prolonged from the usual 12 – 24 hours, to 3 or 4 days (and in certain situations, even longer). Such catheters are placed by our regional anesthesiologists in the St Paul’s Hospital nerve block room preoperatively, who then follow up the patients at home with a daily telephone call.

Surgical Procedures Room:

In 2008 St. Paul’s Hospital opened the doors of a new high efficiency operating suite that is known as the SPR (Surgical Procedures Room).² Its creation was a joint effort by the St. Paul’s Hospital department of anesthesiology together with the departments of surgery and nursing and St. Paul’s Hospital administration. The mission of this facility is to provide distal upper and lower limb ambulatory surgery to a select population of patients that can be admitted directly into a three bed block room, undergo peripheral nerve block anesthesia, then be transferred to one of two adjacent operating suites and then transferred back to the block room for prompt discharge from the hospital.

This high efficiency surgical model was designed to increase surgical throughput by having the surgeon rotate between the two OR suites with almost no “downtime” between cases. Our anesthetic model requires precise and dense surgical anesthesia of the operative limb with a minimum of sedation such that we can facilitate good operative conditions for the surgical team yet allow for timely discharge from the SPR.

The success of this program is largely attributed to the growth of ultrasound guided regional anesthesia as a sub-specialty practice by members of our department. The high success rate of our peripheral nerve blocks has been the cornerstone of our ability to anesthetize solely the operative limb and otherwise maintain the patient in a relatively normal physiologic state. Early discharge within 15-20 minutes is thus possible as the patients are largely free of the nausea and pain.

The SPR has become an important component of our training program for regional anesthesia residents and fellows, has been the subject of a national news article³, and also been the setting of some important research¹. Several peer reviewed publications related to operative efficiency (regarding surgical throughput, pain and nausea interventions and early discharge) have been published in the last few years.²

In 2014 we expanded the scope of surgical care in the SPR, and we now work with our vascular surgeons to provide tumescent local anesthesia for radiofrequency ablation of varicose veins.

References:
1) Mecereux P, Lee B, Head SJ, and Schwarz SKW. A regional anesthesia-based “swing” operating room reduces non-operative time in a mixed orthopedic inpatient/outpatient population. Canadian Journal of Anesthesia 2012; Vol 59;10:943-949
2) Head SJ, Seib R, Osborn JA, and Schwarz SKW. A “swing room” model based on regional anesthesia reduces turnover time and increases case throughput throughput. Canadian Journal of Anesthesia 2011; 58:725-732.
3) “How a Vancouver hospital drastically cut its wait times.” Rod Mickleburgh, The Globe and Mail, Aug. 23 2012

Vancouver General Hospital

Vancouver General Hospital is a tertiary referral and trauma center serving British Columbia. Trauma. Major surgery is performed at the Vancouver Acute (VA) site and more ambulatory surgery is performed at the University of British Columbia Hospital (UBCH). Major orthopedic joint reconstruction is also performed at UBCH.

The regional anesthesia group at VGH is very active clinically and academically. The patient population at both sites provides opportunities for the use of regional anesthesia techniques on a wide spectrum of patients from outpatients to critically ill patients. A variety of upper and lower limb regional blocks are routinely performed and perineural catheters are utilized to manage acute postoperative pain, particularly those with chronic pain and/or opioid tolerance. All members of the team are skilled at ultrasound guided regional anesthesia and it is the preferred technique taught to residents and fellows.

The regional anesthesia research team (RART) at VGH is particularly active and provides prospective fellows many opportunities for research. Fellows involved with RART have had publications in the areas of education, novel uses of ultrasonography, new technology, and neuraxial anesthesia. Their work has been presented nationally and internationally and our fellows have won multiple awards. Many of these publications are collaborative efforts with other departments such as anatomical pathology, surgery, and dentistry. We are continually looking for new ideas and are currently expanding our collaborative efforts with radiology and biomedical engineering. Interested applicants should apply at our website: http://apt.ubc.ca/hospital-sites/vancouver-general-hospital/
fellowships.

Recent Publications:
Peter Rose, Kathryn Dawson, Ian Mowat, Andrew Sawka, Himat Vaghadia, Raymond Tang. Pre-procedural
ultrasonography and marking for neuraxial anesthesia: an observational study (letter). Can J Anesth
2016; DOI: 10.1007/s12630-016-0607-0.

Jacques Smit, Raymond Tang, Andrew Sawka, Himat Vaghadia. The ultrasound guided retroclavicular
block: comparison to a novel subpectoral approach (letter). Reg Anesth Pain Med 2016; 41 (2): 290.

Ian Mowat, Raymond Tang, Himat Vaghadia, Claudia Krebs, William Henderson, Andrew Sawka. Epidural
distribution of dye administered via an epidural catheter in a porcine model. Br J Anaesth 2016;
116 (2): 277-81.

Peter Rose, Jenni Sakai, Ruth Argue, Kevin Froehlich, Raymond Tang. Opioid information pamphlet
increases postoperative opioid disposal rates: a before versus after quality improvement study. Can
J Anesth 2016; 63 (1): 31-7.

Andrew Sawka, Raymond Tang, Himat Vaghadia. Sonographically guided superior laryngeal nerve block
during awake fiberoptic intubation: case series. Anesth Analg Case
Rep 2015; 4 (8):107-10.

Lions Gate Hospital

"The Department of Anesthesia at Lions Gate Hospital has taken great strides in establishing a successful Regional Anesthesia Program. An out-of-OR Block Room was created in 2011 in conjunction with the hiring of our department’s first Anesthesia Assistant (AA). We have quickly integrated the techniques of ultrasound guidance and the use of continuous perineural catheters for anesthesia and multi-modal analgesia in our specific patient population. All of our department members are skilled at performing peripheral nerve blocks and a number of them have participated as educators in ultrasound-guided regional anesthesia workshops throughout the province.

The majority of our blocks are done pre-operatively in the Block Room by a dedicated “out-of-OR” anesthesiologist with the help of an Anesthesia Assistant. All of our blocks are performed under ultrasound guidance. We perform over 400 peripheral nerve blocks per year, of which 10-15% are continuous perineural catheters. For the in-hospital patients with continuous perineural infusions, we have two dedicated CADD Solis pumps. We provide follow-up care to all of our blocked patients through our Acute Pain Service while in hospital. Upon discharge, each patient may receive a series of follow-up telephone calls. Our focus is on providing enhanced perioperative pain relief for all the patients that flow through our service.

We have had an inaugural patient go home under our "At-Home Continuous Perineural Catheter Program”; however, growth of the service has been limited by the fact that we are unable to send patients home with volumes greater than 200 ml of local anesthetic infusate. As such, we require our patients to return to hospital every 24 hours to have their local anesthetic solution replaced and their catheter assessed.

Currently, the Department of Anesthesia at LGH is in the process of creating a dedicated perioperative care team (Peri-operative Anesthesiologist and Anesthesia Assistant) who would be responsible for regional anesthesia services as well as the placement of selected pre-operative lines, neuraxial anesthesia and analgesia, and Point-of-Care-Ultrasonography.”

Burnaby Hospital

The Burnaby Hospital Anesthesia Department has taken great strides in the last year to provide patients with options for regional anesthesia. We have acquired a second dedicated ultrasound machine which is routinely used for nerve blockade. We provide between 6 and 15 regional anesthetics a day for intra-operative anesthesia and post- operative analgesia for both elective and emergency cases. In 2015 we started a dedicated out-of-OR position to ensure adequate pain control of all surgical inpatients post-operatively on the Acute Pain Service, as well as to provide various peripheral nerve blocks for the operating room including: brachial plexus, paravertebral, truncal, femoral, adductor canal and sciatic blocks. Plans are currently underway to expand our program with a dedicated Pain Nurse and block room which will facilitate the growth of the program to provide continuous perineural catheters for inpatients and eventual home/outpatient program.

British Columbia Women’s Hospital

The Department of Anesthesia at BC Women’s Hospital prides itself on being a leader in obstetrical anesthetic care. When clinically indicated, we perform transversus abdominis plane (TAP) blocks for our patients under ultrasound guidance. We also have an Acute Pain Service that follows all postoperative patients, and identifies those who may benefit from a block post-operatively. Ultrasound has been adopted by the majority of our department, for both TAP blocks and for performing neuraxial techniques. Some of our staff and fellows have even functioned as educators in ultrasound workshops (especially in the areas of neuraxial ultrasound imaging), and we play a significant role in teaching trainees within the UBC residency program.

BC Childrens’ Hospital

The Department of Anesthesia at BC Children’s Hospital integrates the technique of ultrasound guidance with regional analgesia for children. We perform single shot and continuous perineural blocks mainly for children undergoing orthopedic and plastic surgery. We provide follow-up care to all of our inpatients with regional techniques through our Acute Pain Service. Most of our department members are skilled at performing peripheral nerve blocks in children and some of them have participated as
educators in ultrasound-guided regional anesthesia workshops. With our restructuring
into the new children’s hospital in 2016 we hope to develop this regional anesthesia
service further with a dedicated block room and more outpatient focused care and follow
up.

Victoria General Hospital and the Royal Jubilee Hospital, Victoria

"The Department of Anesthesiology, Pain and Perioperative Medicine in Victoria provides care at the Royal Jubilee Hospital and Victoria General Hospital and all surgical specialties are represented. There are numerous procedures that benefit from regional anesthesia, including Orthopedics (total joint replacements, trauma, upper and lower limb procedures), Plastics (hand surgery), Vascular (AV fistulas, amputations, lower limb revascularization, open AAA repair), Thoracics (thoracotomy), and abdominal surgery. We also have a busy Dedicated Obstetrical Anesthesia service. Some of the regional procedures that we perform include neuraxial anesthesia/analgesia, interscalene, supraclavicular, infraclavicular, femoral, adductor canal and popliteal sciatic nerve blocks. We perform peripheral nerve blocks in our operating rooms with the support of Anesthesia Assistants, and with the use of Ultrasound guidance and nerve stimulation. Most of the blocks are single shot injections, but occasionally we place perineural catheters. Approximately 10 members of our department have an interest in Regional Anesthesia. We do not have a block room or a dedicated Regional Anesthesiologist position yet, but we are striving to start these initiatives."

Nanaimo Regional General Hospital

The anesthesiologists at Nanaimo Regional General have 2 ultrasound machines and the benefit of support of two anesthesia assistants who assist with regional blocks. We primarily perform single shot analgesic blocks for orthopedic procedures and most are done under ultrasound guidance. Some of the common blocks we use here are femoral, adductor canal, interscalene, supraclavicular, and occasionally TAP blocks.

East Kootenay Regional Hospital (Cranbrook)

Several of the anesthesiologist at EKRH use regional anesthesia as a regular part of their
practice. Common blocks at our site are:
• interscalene blocks for shoulder surgery and upper arm trauma
• wrist blocks
• abdominal field blocks (TAP or rectus sheath)
• adductor canal blocks for TKR
• ankle blocks

Blocks are done preoperatively in the operating room, and the majority of blocks are US-
guided.

Vernon Jubilee Hospital

At Vernon Jubilee Hospital, we have 2 staff members who actively offer and provide the option of regional blocks to their patients. The blocks are exclusively of a "single shot" type: brachial plexus (interscalene, supra- and infraclavicular, and axillary approaches) for upper limb surgery; adductor canal blocks for total knee replacements. We also occasionally perform lower limb blocks (popliteal, femoral). Approximately 60% of the blocks are performed under continuous ultrasound guidance, and this number is increasing rapidly. We do not have a dedicated block room (procedures are typically performed pre-operatively in the OR, or post-operatively in Post Anesthesia Care Unit).

Prince George Regional Hospital

Several anesthesiologists at Prince George Regional Hospital have an interest in regional anesthesia, and perform a variety of ultrasound-guided peripheral nerve blocks, including supraclavicular/interscalene blocks for upper limb surgery, as well occasional lower limb blocks for foot and ankle surgery. At this time, regional anesthesia services are offered in the main operating rooms, without a dedicated block room.