Regional Anesthesia

Program Director, Dr. Javier Cubillos, MD

Welcome to the Regional Anesthesia Fellowship at the Department of Anesthesia and Perioperative Medicine of Schulich School of Medicine & Dentistry of Western University!

Prepare to embark on an exhilarating journey that will transform you into a top-tier regional anesthesiologist. Our fellowship is meticulously designed to empower you with unparalleled skills and knowledge, ensuring you excel in all aspects of perioperative management for patients receiving neuraxial or peripheral nerve blocks.

In this page: Program highlights Eligibility Requirements Fellowship Structure Goals and Objectives Assessment

Here’s what awaits you:

Mastering Ultrasound-Guided Techniques

Dive into the world of regional anesthesia and become an expert in performing common upper and lower limb, truncal, and neuraxial blocks for a wide variety of surgical procedures and subspecialties. Immerse yourself in the detailed anatomy and sono-anatomy relevant to regional anesthesia and analgesia.

Gain hands-on experience in our four state-of-the-art block rooms across the city. With our capacity to perform over 8,000 blocks annually, your training will be comprehensive and robust.

By the end of your fellowship, you will be proficient and precise in providing safe and effective single-shot and catheter techniques, ready to excel in your career as a regional anesthesiologist.

Comprehensive and Complex Pain Management

Elevate your expertise in conducting thorough, personalized perioperative pain management assessments to ensure that every patient receives the highest standard of care, reflecting the cutting-edge philosophy of precision medicine. Learn to tailor multimodal analgesia to each individual patient.

Master the use of parenteral opioid techniques, including infusions of lidocaine and ketamine, and expertly select the most appropriate blocks for each patient.

Develop resourceful troubleshooting skills for continuous peripheral and neuraxial nerve blocks, ensuring seamless postoperative care.

Rise to the challenge of assessing and managing opioid-dependent patients and those with complex pain issues.

Collaborate with our acute and chronic pain management teams, who will provide unwavering support in demanding cases requiring optimal solutions.

Shine as a consultant to anesthesiologists, surgeons, nurses, and physiotherapists, offering your invaluable expertise and support.

Block Room Administration

Take charge and efficiently manage a block room, fostering effective communication with surgical and nursing staff. Gain the ability to establish a new Regional Anesthesiology and Acute Pain Medicine program in your future practice.

Research Opportunities

This fellowship not only aims to enhance your clinical skills but also to foster a strong foundation in academic and research excellence. If you have any specific research interests, the faculty will support you in exploring those to further their knowledge and contribute to the field of regional anesthesia and acute pain medicine.

You will have the chance to participate in ongoing research projects, develop your own research initiatives under the guidance of experienced mentors, present your findings at national and international conferences, and publish your research in reputable medical journals.

Leadership in Education

Lead the way in training future generations of generalists and subspecialists in Regional Anesthesiology and Acute Pain Medicine.

Provide visionary leadership in organizing and managing an acute pain medicine service within a hospital setting.

Develop your teaching skills by becoming a stellar educator, sharing this knowledge with other staff, residents, and medical students.

Become a beacon of knowledge, educating patients, family members, surgeons, PACU, and floor nurses about the management of nerve blocks.

Join us and become a trailblazer in the field of Regional Anesthesiology and Acute Pain Medicine!

In their words

“I recently completed my regional anesthesia and acute pain fellowship and this fellowship gave me a multi-layered experience both clinically and academically. The varied patient population between the three hospitals made sure the exposure to the different blocks and cases was vast and complete. It was a pleasure to work and learn with all the consultants who are approachable and proactive in teaching and who enable effective clinical and academic work. It was a constructive fellowship both professionally and personally.” - Dr. Niveditha Karuppiah, India

"I have recently completed my Regional Anesthesia Fellowship and I have learned a wide variety of traditional and novel truncal, upper limb and lower limb blocks, with excellent teaching from the staff anesthesiologists. I was also able to participate in cadaveric and ultrasound workshops for regional anesthesia. In addition to the large clinical volume of regional anesthesia, I maintained my skills in general anesthesia with a broad range of surgical lists. I also appreciated the opportunity to complete research during my fellowship." - Dr. Georgina Mahony, Australia

Eligibility Requirements for Canadian and Foreign Medical Graduates

Candidates must possess a medical degree from a University recognized by the Medical Council of Canada (MCC)
Candidates must have completed an anesthesia residency that is recognized by the College of Physicians and Surgeons of Ontario (CPSO)
International Medical Graduates do not need to write additional exams, but must be approved by the PGE Office at Western University
English Language Requirement for IMGs: TOEFL-iBT required to achieve an overall score of no less than 93 with a minimum score of 24 in speaking; IELTS required to achieve a minimum score of 7 in each category.
All non-Canadian trained anesthesiologists will be required to pass an assessment period taking place over the first 4 - 8 weeks in order to continue with the fellowship (‘PEAP’ – Pre-entry assessment period).
Please refer to the Application and Requirements page for a more detailed description

Fellowship Structure

Duration: The fellowship training program will be undertaken over twelve consecutive months and includes four weeks of vacation time.
Number of fellowship positions: 2 to 4 per year
Location: Fellowship training will take place at St Joseph’s Healthcare London and London Health Sciences Center which includes University Hospital, Victoria Hospital and the LHSC Surgicenter. Subspecialty training will be roughly divided evenly between those locations, although this is flexible depending on clinical exposure attained.
Service commitment: 100 days per year (subject to change according to department fellowship policies). This service commitment may be in subspecialties unrelated to regional anesthesia. The remainder of the weekdays is subspecialty time. Academic time may be granted depending on the academic productivity of the fellow.
Call Commitment: Fellows will be expected to be available out of hours (evenings, nights and weekends) to troubleshoot blocks, and follow up blocks sited. Coverage will vary dependent on number of fellows. On most of the occasions, troubleshooting would be possible via telephone. The fellow would also be expected to run the acute pain service rounds at weekends once in every 4 weeks.
Regional technique exposure: You will have the opportunity to learn and practice across four different block rooms in the city, allowing fellows to gain proficiency in a diverse array of ultrasound-guided procedures. These include neuraxial techniques (such as spinal, epidural, and combined spinal-epidural procedures of varying complexity), as well as single-shot blocks and peripheral nerve catheters for the upper limb, lower limb, and trunk.

Research

Research is an important and expected component of the fellowship. Fellows are expected to spearhead at least one original research project, including protocol creation, research grant application, ethics approval submission, and participant recruitment.
Attendance of at least one major conference (CAS, ASRA or ASA) is highly encouraged with presentation of an abstract if available.

Education

Regional anesthesia specific education will be ongoing throughout the subspecialty and take the following forms:

Clinical education: During subspecialty training days, fellows will work under the direct supervision of an experienced regional anesthetist. They will have the opportunity to enhance their recognition of sonoanatomy, refine their block selection and needling skills, and perform both single-shot and catheter blocks. An essential focus of this training component will be the follow-up and post-procedure management of nerve blocks.
Regional Anesthesia Journal club: Journal club will be held between 2 and 4 times per month for the duration of the fellowship. Relevant articles will be presented and analysed. Fellows will be expected to present regularly (at least monthly) at these rounds and supervise presenting residents.
Anatomy lab: The anatomy lab will be held one to two times per year and will be attended by both residents and fellows. Initially, fellows will participate as students, gaining valuable insights from cadaveric models. They will have the opportunity to correlate 3D anatomy with ultrasound imaging and understand spatial relationships through needle handling in cadaveric specimens. As the fellowship progresses, fellows will transition to the roles of teachers and demonstrators in subsequent labs.

Resources

Fellows will have access to the following resources:

Department Anesthesia Library
The Western University Library online resources, providing access to the majority of significant anesthesia journals
Department librarian assistance

Goals and Objectives

Medical Expert

Be able to provide acute pain management and medical consultation for the full spectrum of injuries, medical etiologies, and surgical and other invasive procedures that produce acute pain in the hospital setting
When indicated, safely and effectively perform and troubleshoot a comprehensive range of advanced regional anesthesiology procedures for appropriate indications, in a safe, consistent, and reliable manner, understanding the individual risks and benefits, indications and contraindications of each.
Specific Requirements for Medical Knowledge

Nerve Anatomy
- Discuss the anatomy of neurons
- Describe the differences between motor and sensory nerves
- Describe the microanatomy of the nerve cell.
Local Anesthetics
- Describe the pharmacology of local anesthetics, including new liposomal formulations with respect to mechanism of action, physicochemical properties, comparative attributes, and appropriate dosing for single injection or continuous infusion
- Determine the selection and dose of local anesthetics as indicated for specific medical conditions
- Compare the dosing, advantages, and disadvantages of local anesthetic adjuvants
- Understand signs, symptoms, and treatment of local anesthetic systemic toxicity or neurotoxicity of local anesthetics
- Neuraxial and Systemic Opioids, Nonsteroidal Anti-inflammatory Medications, and Non-opioid Adjuvants for Analgesia
Neuraxial Opioids
- Describe indications/contraindications, mechanism of action, physicochemical properties, effective dosing, and duration of action of neuraxial opioids
- Recognize complications and adverse effects, including related monitoring, prevention, and therapy
- Differentiate intrathecal versus epidural administration relative to dose, effect, and adverse effects
Systemic Opioids
- Discuss the pharmacokinetics of opioid analgesics: bioavailability, absorption, distribution, metabolism, and excretion
- Discuss the site and mechanism of action of opioids
- Discuss the differences in chemical structure of the various opioids
- Describe the mechanisms, uses, and contraindications for opioid agonists, opioid antagonists, and mixed agents
- Describe challenges of post-procedure analgesic management in the patient with chronic pain and/or opioid-induced hyperalgesia
- Describe how to manage acute or chronic pain in the opioid-tolerant patient
Non-Opioid Analgesics
- Describe the concept of multimodal analgesia and its impact on recovery after surgery
- Differentiate the pharmacology of acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors ,N-methyl-D-aspartic acid antagonists, α2agonists, and γ-aminobutyricacid–pentanoidagents with respect to optimizing postoperative analgesia
Regional Anesthesia Techniques:
- Nerve Localization Techniques
  - Explain principles, operation, advantages, and limitations of the peripheral nerve stimulator to localize and anesthetize peripheral nerves.
  - Describe principles of paresthesia-seeking perivascular or transvascular approaches to nerve localization.
  - Explain principles, operation, advantages, and limitations of ultrasound to localize and anesthetize peripheral nerves.
- Spinal Anesthesia
  - Describe the anatomy of the neuraxis.
  - Describe the indications, contraindications, adverse effects, complications, and management of spinal anesthesia.
  - Recognize the cardiovascular and pulmonary physiologic effects of spinal anesthesia.
  - Describe common mechanisms for failed spinal anesthetics.
  - Compare local anesthetics for intrathecal use: agents, dosage, surgical and total duration of action,and adjuvants.
  - Explain the relative importance of factors affecting intensity, extent, and duration of block such as patient position, dose, volume, and baricity of injectate.
  - Define meningeal puncture headache and describe symptoms, etiology, risk factors, and treatment.
  - Differentiate advantages and disadvantages of continuous spinal anesthesia.
- Epidural Anesthesia (Lumbar and Thoracic)
  - Describe the indications, contraindications, adverse effects, complications, and management of epidural anesthesia and analgesia.
  - Compare the local anesthetics available for epidural use: agents, dosage, adjuvants, and duration of action.
  - Differentiate between spinal and epidural anesthesia with regard to reliability, latency, duration, and segmental limitations.
  - Explain the value and techniques of test dosing to minimize certain complications of epidural anesthesia and analgesia.
  - Interpret the volume-segment relationship and the effect of patient age, pregnancy, position, and site of injection on resultant block.
  - Differentiate combined spinal-epidural anesthesia from lumbar epidural anesthesia or analgesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications.
  - Categorize outcome benefits of thoracic epidural analgesia for thoracic and abdominal surgery and thoracic trauma.
  - Differentiate thoracic epidural anesthesia/analgesia from lumbar epidural anesthesia/analgesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications.
  - Explain the impact of antithrombotic and thrombolytic medications on neuraxial and peripheral anesthesia/analgesia with specific reference to the American Society of Regional Anesthesia and Pain Medicine guidelines: Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.
- Upper-Extremity Nerve Block
  - Describe the anatomy and sonoanatomy of the brachial plexus in relation to sensory and motor innervation.
  - Compare local anesthetics for brachial plexus block: agents, dose, duration of action, and adjuvants.
  - Explain the value and techniques of intravascular test dosing to minimize local anesthetic systemic toxicity associated with peripheral nerve block.
  - Differentiate the various brachial plexus (or terminal nerve) block sites including indications/ contraindications, advantages/disadvantages, complications, and management specific to each.
  - Contrast the indications and technique for cervical plexus, suprascapular, or intercostobrachial block as unique blocks or supplements to brachial plexus block.
  - Discuss the technical and nontechnical aspects unique to brachial plexus perineural catheter placement and management.
- Lower-Extremity Nerve Block
  - Describe anatomy and sonoanatomy of the lower extremity: sciatic, femoral, lateral femoral cutaneous, and obturator nerves, as well as the adductor canal and options for saphenous nerve blockade.
  - Compare local anesthetics for lower-extremity block: agents, dose, duration of action, and adjuvants.
  - Explain the value and techniques of intravascular test dosing to minimize local anesthetic systemic toxicity associated with peripheral nerve block.
  - Differentiate the various approaches to lower-extremity blockade, including indications / contraindications, side effects, complications, and management specific to each.
  - Discuss the technical and nontechnical aspects unique to lower-extremity perineural catheter placement and management.
- Truncal Block
  - Describe the relevant anatomy for intercostal, paravertebral, ilioinguinal-hypogastric, rectus sheath and transversus abdominis plane blocks.
  - Compare local anesthetics for truncal blockade: agents, dose, and duration of action.
  - Summarize the indications, contraindications, side effects, complications, and management of truncal blockade.
  - Discuss the technical and nontechnical aspects unique to continuous truncal catheter placement and management.
- Intravenous Regional Anesthesia
  - Review the mechanism of action, indications, contraindications, advantages and disadvantages, adverse effects, complications, and management of intravenous regional anesthesia.
  - Compare agents for intravenous regional anesthesia: local anesthetic choice, dosage, and use of adjuvants.
Complications of Regional Anesthesia and Acute Pain Medicine
- Discuss, recognize, and know how to manage complications specific to regional anesthesia and acute pain medicine practice. A partial list of these complications includes:
- Hemorrhagic complications in the patient receiving antithrombotic or thrombolytic agents.
- Infectious complications of neuraxial and peripheral blockade.
- Neurological complications of regional anesthesia and acute pain medicine.
- Knowledge and basic interpretation of tests recommended after plexus/nerve lesion such as electromyography, nerve conduction studies, somatosensory evoked potentials, and motor evoked potentials.
- Local anesthetic systemic toxicity.
- Opioid-induced respiratory depression.
Patient Care and Procedural Skills
- Describe rational selection of regional anesthesia and/or postoperative analgesic techniques for specific clinical situations. Such options include regional techniques, multimodal analgesia, and/or opioid and non-opioid pharmacological management.
- Debate the advantages/disadvantages of regional versus general anesthesia for various procedures and patients with regard to patient recovery, patient outcome, and operating room efficiency.
- Recognize and intervene to manage inadequate operative regional anesthetic and postoperative analgesic techniques with supplemental blockade, alternate approaches, and/or pharmacological intervention.

Communicator

Summarize information to the patient and family with respect to the options, alternatives, risks, and benefits of regional anesthesia and/or acute analgesic techniques in a manner that is clear, understandable, and ethical.
Develop effective listening skills and answer questions appropriately in the process of obtaining informed consent.
Develop communication strategies for coordinating a functioning block room in the peri-operative period.
Manage information related to efficient and safe flow of patients through the peri-operative course (SDCU- Block room- OR- PACU).

Collaborator

Operate effectively in a team environment and communicate and cooperate with surgeons, residents, nurses, pharmacists, physical therapists, and other members of the perioperative team. This requires the fellow to:
- Recognize the roles of all team members.
- Communicate clearly in a collegial manner that facilitates the achievement of care goals.
- Help other members of the team to enhance the sharing of important information.
- Formulate care plans that use the multidisciplinary team skills, such as a plan for facilitated recovery.
Act as a consultant to other anesthesiologists, surgeons, nurses, pharmacists, physical therapists, other medical professionals, operating room managers, hospital administrators, and other allied health providers.
Provide leadership in the organization and management of an acute pain medicine service within the hospital setting composed of a variety of specialists to provide comprehensive multimodal acute pain management
Train future generations of generalists and subspecialists in Regional Anesthesiology and Acute Pain Medicine.
Contribute to the mission of the department by facilitating both educational and research activity in the context of regional anesthesia.

Leader

Demonstrate the ability to direct the acute pain medicine service with attending supervision. Patient management will include multimodal analgesic techniques such as neuraxial and peripheral nerve catheters, local anesthetic and narcotic infusions, and nonnarcotic analgesic adjuvants.
Understand the need for perioperative efficiency and high-quality patient care. The fellow will effectively choose surgeons, patients, techniques, and approaches to achieve the best possible use of regional anesthesia and/or analgesia to improve patient outcomes.
Understand the interaction of the regional anesthesia and acute pain medicine service with other elements of the health care system, including primary surgical and medical teams, and other consultant, nursing, pharmacy, and physical therapy services.
Demonstrate awareness of health care costs and resource allocation and the impact of their choices on those costs and resources.

Health Advocate

Have the knowledge and skills required to establish a new Regional Anesthesiology program in his/her future practice and to adopt emerging knowledge and techniques for the acute pain management of patients whom he/she encounters.
Advocate for the patient and the family within the health care system and assist them in understanding and negotiating complexities in that system.
Advocate for the appropriate use of regional anesthesia in the peri-operative setting.

Scholar

Fellows are required to participate in research as a major activity of the fellowship.
Regularly present relevant articles at journal club, to other fellows, residents, medical students and staff.
Prepare resident education lectures and journal reviews for regional anesthesia and/or acute pain medicine subspecialty conferences.
Attend and subsequently teach at the cadaveric workshops.
Develop teaching techniques by instructing residents and/or medical students at the bedside under the supervision of faculty.
Review and enhance Web-based teaching resources such as resident teaching materials, curriculum documents and self-study and testing materials.
Evaluate and apply evidence from scientific studies, expert guidelines, and practice pathways to patient’s medical conditions.
Apply information technology to obtain and record patient information, access institutional and national policies and guidelines, and participate in self-education.
Analyze their own practice with respect to patient outcomes (especially success and complications from regional blockade) and compare with available literature.

Professional

Continuously conduct the practice of medicine with integrity, honesty, and accountability.
Demonstrate a commitment to lifelong learning and excellence in practice.
Practice consistent subjugation of self-interest to the good of the patient and the health care needs of society.
Demonstrate a commitment to ethical principles in providing care, obtaining informed consent, and maintaining patient confidentiality.

Assessment

360-degree appraisal from staff anesthetists, residents, medical students, surgeons, nurses (block and PACU nurses) after each block room rotation.
3 times yearly (post PEAP, mid fellowship, end fellowship) meeting with fellowship director.
Personal feedback as anatomy lab tutor.
Fellows are required to keep an up-to-date logbook of procedures performed.

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