Orthopaedics, Plastics and Regional Anesthesiology Division

The Orthopaedics, Plastics and Regional Anesthesiology Division, also known as the “Regional Division,” has attracted multitalented individuals since its inception in 1998. Dr. Fran D’Ercole, the inaugural division chief, brought together a group that was committed to expanding the use of regional anesthetic techniques in order to improve patient outcomes. This is still the case today, as the division has continued to grow and expand under the past leadership of Dr. Gavin Martin. The division is currently led by Dr. Jeff Gadsden. As one of the premiere regional anesthesiology and acute pain medicine divisions in the country, the faculty continue to push the boundaries of the subspecialty with, as their mission statement reads, “sustained and dedicated engagement in clinical innovation, scholarship and extraordinary education.”

Duke Anesthesiology has long been associated with excellence in regional anesthesia and acute pain medicine, pioneering the use multiple nerve block techniques to keep patients comfortable and safe during and after surgery. Duke was one of the earliest centers to employ continuous perineural catheters to provide extended pain relief for several days following surgery, a technique that has been shown to significantly reduce or eliminate the need for opioids after many orthopaedic surgical procedures. The Regional Division at Duke has also been a leader in developing and popularizing the use of ultrasound guidance for nerve blocks, an innovation that has led to an explosion in the use of nerve and fascial plane blocks for perioperative pain control. All of the faculty in the Regional Division are highly skilled and experienced ultrasound experts who are not only innovators, but publish and teach internationally.

The Regional Division are leaders in creating pathways for Enhanced Recovery After Surgery (ERAS) for joint replacement surgery, and the innovations with multimodal analgesia and nerve block techniques have been shown to improve patient-related outcomes, such as pain control and satisfaction, as well as reduce length of stay and complications. Regional block techniques are now the core of similar clinical pathways for oncologic breast surgery and breast reconstruction, colorectal surgery, major urologic surgery, lower limb amputation, and others. Anesthesiologists from around the globe travel to visit the Regional Division and spend several days learning from their expert faculty.

As experts in the use of ultrasound, the Regional Division has advanced the use of Point of Care Ultrasound (POCUS) for perioperative patients at Duke, using bedside ultrasound to diagnose cardiac and pulmonary issues, evaluate patients’ volume status and effectiveness of preoperative fasting, and other applications. In 2016, Duke Anesthesiology’s Regional Division hosted the first POCUS workshop in the country aimed at perioperative physicians.

Duke Health is a global leader in hand transplantation, and under the leadership of Dr. Josh Dooley, these patients receive a carefully tailored anesthetic built around continuous brachial plexus block to not only provide excellent pain relief, but also to improve blood flow to the newly transplanted hand. Drs. Erin Manning and Neil Ray are anesthesiology co-directors of the Spine Co-Management group, who, along with their neurosurgical and orthopaedic colleagues, have kept spine surgery care at the forefront with advances in the use of multimodal analgesia, nerve blocks for spine surgery, and the development of spine-specific ERAS protocols.

Regional Anesthesiology & Acute Pain Medicine Fellowship

The Regional Anesthesiology and Acute Pain Medicine Fellowship has been a world-renowned leader in regional anesthesiology training for decades. In 2017, it became one of the first programs in the country to be an ACGME-accredited fellowship in regional anesthesiology and acute pain medicine. With a combination of extraordinary clinical experience, a structured educational program, mentoring by world experts, and a strong focus on fellow scholarship and inquiry, its fellows emerge prepared with the tools to make a profound impact at the patient, departmental, health system and national levels.

Fellows are assigned three clinical days/week in the operating room and two clinical days/week in the preoperative block area. Whether caring for elite athletes in the fast-paced ambulatory sports medicine rooms, placing multiple catheters for lower limb amputation, or choosing just the right combination of blocks for a patient undergoing mastectomy and reconstruction, one of the foundational goals of this fellowship is to ensure that there is no clinical scenario, technique or judgment call relating to regional anesthesiology and acute pain medicine that these fellows have not faced as they prepare for their roles as leaders in the field. Additional rotations include 12 weeks on the Inpatient Pain Service, managing acute postoperative pain using a variety of pharmacologic, non-pharmacologic and nerve block-based techniques and tools. And, two weeks seeing new consults for chronic nonmalignant and cancer pain and using many of the tools learned in the care of acute pain management to help ease the suffering of these patients.

Skill in the use of ultrasonography is acquired throughout the academic year. In addition to the techniques related to regional nerve blocks, fellows receive instruction in Point of Care Ultrasonography (POCUS), including trans-thoracic echocardiography, gastric, lung and IVC ultrasound, airway ultrasound, and abdominal/FAST exam. Fellows are also trained in research methodology, including the generation of a hypothesis, statistics and the creation of study design.

Faculty members in the Regional Division provide world-class education to medical students, residents and fellows, and consistently receive outstanding teaching accolades, with several faculty members receiving the annual Duke residency “Teacher of the Year” award in recent years.

The Regional Division is proud of the Regional Anesthesiology and Acute Pain Medicine (RAAPM) Fellowship. While regional anesthesia fellowship training has existed and flourished at Duke for more than 20 years, the fellowship was one of a handful to be the first ACGME-accredited fellowships in the country in 2017. The RAAPM Fellowship is highly competitive and is widely regarded as one of the best training programs in the country. Dr. Amanda Kumar is the associate program director for the fellowship, and Drs. Michael Bullock and Neil Ray are site directors for the Duke University Hospital and Inpatient Pain Service rotations.

Kumar is also highly involved with Duke’s Human Simulation and Patient Safety Center. She has expertise in simulation-based medical education and is interested in studying the role of simulation techniques to improve skill acquisition and retention in regional anesthesia procedures.

The Regional Division also has a track record of outstanding extramural education. The divisional faculty are invited to teach hands-on workshops every year at the ASA, ASRA, SCA, SAMBA and other meetings. The division has also hosted the first Point of Care Ultrasound (POCUS) workshop in the country aimed at perioperative physicians, an ongoing collaborative regional anesthesiology symposium and workshop in Tel Aviv, and co-hosted with UNC an annual regional anesthesiology and POCUS workshop provided free of charge to trainees around the country.

Anesthesiologists from around the globe travel to visit the Regional Division and spend several days learning from their expert faculty.

Dr. David MacLeod is member of the Regional Division and the director of the Human Pharmacology and Physiology Laboratory (HPPL) at Duke Anesthesiology, which has attracted dozens of governmental, industry and university grants in order to conduct clinical trials and other scientific studies. He is also the director of regional research for the division. MacLeod and the HPPL research unit utilizes healthy volunteers to investigate a broad range of topics relevant to anesthesiology and critical care, including:

• Phase 1 dose ascending studies in healthy volunteers to determine the safety, pharmacokinetic and pharmacodynamic effects of novel local anesthetics
• Evaluating the relationship between BIS and plasma drug concentrations using target controlled infusions of Propofol and remifentanil
• Comparison of skeletal muscle parameters from handheld ultrasound to CT imaging

The Regional Division is a highly-productive research division with interests in clinical, translational, education, and basic science research, including:

• The development and implementation of Enhanced Recovery After Surgery (ERAS) pathways for joint replacement
• The development of novel peripheral blocks for patients undergoing joint replacement
• Safety of nerve block procedure and prevention of injury during peripheral nerve blockade
• The role and impact of novel fascial plane blocks in reducing opioid use and pain experience for abdominal, pelvic and cardiac surgery
• The role of fascial plane blocks in accelerating recovery after Cesarean delivery
• The utility of 3D-guided needle tracking in nerve block performance
• Defining the anatomical spread of injectate during peripheral and fascial plane block models using cadaveric models
• Pharmacodynamics of local anesthetics and local anesthetic adjuvants
• The use of Point of Care Ultrasound (POCUS) to enhance perioperative decision-making

Representative Publications

1. Kumar L, Kumar AH, Grant SA, Gadsden J. Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty. Anesthesiol Clin. 2018 Sep;36(3):375-386. doi: 10.1016/j.anclin.2018.04.007. Epub 2018 Jul 11. PMID: 30092935.
2. Bain AR, Ainslie PN, Barak OF, Hoiland RL, Drvis I, Mijacika T, Bailey DM, Santoro A, DeMasi DK, Dujic Z, MacLeod DB. Hypercapnia is essential to reduce the cerebral oxidative metabolism during extreme apnea in humans. J Cereb Blood Flow Metab. 2017 Sep;37(9):3231-3242. doi: 10.1177/0271678X16686093. Epub 2017 Jan 10. PMID: 28071964; PMCID: PMC5584699.
3. Gadsden JC, Sata S, Bullock WM, Kumar AH, Grant SA, Dooley JR. The relative analgesic value of a femoral nerve block versus adductor canal block following total knee arthroplasty: a randomized, controlled, double-blinded study. Korean J Anesthesiol. 2020 Oct;73(5):417-424. doi: 10.4097/kja.20269. Epub 2020 Aug 26. PMID: 32842722; PMCID: PMC7533174.
4. Dooley J, Bullock WM, Kumar AH, MacLeod DB, Gadsden J. Systematic sonographic and evoked motor identification of the nerve to vastus medialis during adductor canal block. Reg Anesth Pain Med. 2020 Nov;45(11):937-938. doi: 10.1136/rapm-2019-101232. Epub 2020 May 19. PMID: 32434793.
5. Klement MR, Bullock WM, Nickel BT, Lampley AJ, Seyler TM, Green CL, Wellman SS, Bolognesi MP, Grant SA. Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty. Knee. 2019 Jun;26(3):679-686. doi: 10.1016/j.knee.2019.01.020. Epub 2019 Mar 20. PMID: 30904327.
6. Gadsden J. Enhanced Recovery for Orthopedic Surgery. Int Anesthesiol Clin. 2017 Fall;55(4):116-134. doi: 10.1097/AIA.0000000000000161. PMID: 28901986.
7. Gadsden J. Current devices used for the monitoring of injection pressure during peripheral nerve blocks. Expert Rev Med Devices. 2018 Aug;15(8):571-578. doi: 10.1080/17434440.2018.1507731. Epub 2018 Aug 7. PMID: 30079786.
8. Gadsden J, Orebaugh S. Targeted intracluster supraclavicular brachial plexus block: too close for comfort. Br J Anaesth. 2019 Jun;122(6):713-715. doi: 10.1016/j.bja.2019.02.020. Epub 2019 Mar 28. PMID: 30929761.

View the department’s competitive and non-competitive research grant awards by calendar year.

Duke Surgery – we work very closely with our surgical and other colleagues to achieve the best possible outcomes for our patients. Perioperative care involves a multidisciplinary team effort to optimize patients before surgery, help them recover from surgery as quickly as possible and return to their normal quality of life.

Inpatient Pain Service (IPS) – we implement multimodal and regional anesthesia techniques to minimize postoperative pain, and work closely with our colleagues in the IPS to provide a seamless transition in pain management from the operating rooms to the postoperative wards.

NYSORA – The New York School of Regional Anesthesia is a global leader in anesthesiology education, and the faculty of the Regional Division have a close collaboration with NYSORA, leading workshops and symposia, and contributing to textbooks and the online educational platform.

Belgium Regional Anesthesiology Fellowships – the Regional Division at Duke shares a collaborative educational exchange with two highly regarded European training programs. Each year, RAAPM fellows and faculty travel to Belgium and share clinical and research ideas with faculty and fellows from both KU Leuven and the Ziekenhuis Oost-Limburg’s Center for Research Education and Enhanced Recovery.

Block Nursing – the concept of a specialized perioperative nurse who works hand-in-hand with physicians performing regional block procedures was pioneered in the Regional Division at Duke. These nurses receive special training in pharmacology, block dynamics, resuscitation, and other skills in order to safely and efficiently care for patients undergoing nerve blocks. We are proud of our collaboration with this amazing team of nursing colleagues, some of whom have taught courses around the country on this nursing subspecialty.

Please contact the Orthopaedics, Plastics and Regional Anesthesiology Division’s staff assistant, Caroline Irish, at 919-681-6437 or caroline.irish@duke.edu with inquiries.