Dartmouth-Hitchcock Medical Center

Education in Regional Anesthesia and Pain Medicine

Dartmouth-Hitchcock Medical Center is a leader in graduate medical education for regional anesthesia and pain medicine. Residents and fellows experience learning within an integrated regional anesthesia and acute pain medicine service. Our fully on-line and interactive curriculum is supplemented by a busy regional anesthesia practice that is performing approximately 4000 peripheral nerve blocks per year. Our residents and fellows actively engage in cadaveric dissections to improve their anatomical knowledge and procedural skills. Residents and fellows get a unique experience learning how to place non-obstetrical epidurals under fluoroscopic guidance. We have created a dedicated APS fluoroscopy suite attached to the operating room. With strategic image guidance and direction of epidural catheters to pre-established neuraxial locations, we have essentially eliminated mal-positioned epidural catheters as a clinical phenomenon. Additionally, our APS team is medically managing complex acute on chronic pain patients with state of the art protocols and tools ranging from ketamine infusions to cognitive-behavioral therapy.

Research Programs

Health Services Research

Based on our close relationship with The Dartmouth Institute, the Department of Anesthesiology has developed a comprehensive Health Services Research arm. With regards to perioperative medicine, we are actively examining how people get access to health care, how expensive that care costs, and identifying whether or not outcomes actually improve. The main goals of this line of research are to identify the most effective and cost-efficient clinical behaviors, reduce medical errors, and improve patient safety. To achieve these ends, our Department through its internal resources and external relationships has expertise and analyzing population health level data including the NHANES, Medical Expenditure Panel Survey, Premier Research, Medicare, SEER, NSQIP, PRAN, and IRORA. Examples of areas of active investigation include:

  1. Does regional anesthesia improve perioperative outcomes after total shoulder arthroplasty?
  2. Is sleep apnea associated with serious adverse outcomes and increased costs after routine shoulder arthroscopy?
  3. Is chronic opioid therapy associated with the increased risk of developing cancer?
  4. Does the presence of mental illness influence how opioids are prescribed in the US?
  5. On a national level, do new opioid users demonstrate improvements in health and disability metrics?

Basic Science

Our main area of basic science investigation centers around generating new insights into the adaptive, pro-inflammatory effects of glucocorticoids. Cortisol is a prototypical human stress hormone that is widely understood to suppress inflammation and immunity. Recent research reveals a role for cortisol in the stress response that also includes delayed, adaptive effects that manifest as immune stimulation. Based on multiple clinical studies that we, and others, have reported we recently identified a surprisingly robust pro-inflammatory synergism between the stress hormone cortisol and the immune stimulating cytokine IFN-ϒ. The results support a physiologic model with an adaptive role for cortisol whereby acute release of cortisol suppresses early pro-inflammatory responses but also primes monocytes for an augmented response to a subsequent immune challenge. The latter effect has been interpreted as an adaptive response to repeated stress such as a post-injury infection. Although the immediate clinical application of these findings is as yet unknown the potential for clinical relevance has two important implications. First, the data strongly suggest that future research should not presuppose GCs effects on inflammation to be exclusively anti-inflammatory. Second, the reproducibility and robustness of the results suggest clinical applications should be explored in situations where enhancement of immune responses (e.g., immediately after surgery or vaccination) is important. Our work also creates an experimental framework to examine individual differences, mechanisms and translational implications of cortisol-enhanced immune responses in humans.

Quality Improvement

The Department of Anesthesiology has been involved in systems level research focused on critical patient safety issues for over a decade. One particular area of interest has been on Failure to rescue (FTR), defined as death in the inpatient setting following a complication, a leading driver of inpatient mortality. In recognition of the need to address FTR, the Department of Anesthesiology established the Dartmouth-Hitchcock Patient Safety Learning Laboratory, supported by the Agency for Healthcare Quality and Research. The Laboratory brings together multidisciplinary teams (including engineers, clinicians and data analysts) to analyze, redesign, implement and test early detection and rescue systems. Our current research is organized into three general areas: technology based interventions such as surveillance monitoring; team and individual behaviors such as hand-overs and patient assessment; and systems integration where we address socio-technical issues related to rescue systems. Our research methods include evidence-based gap analysis of causes of FTR, systems-level intervention design, rapid prototyping and measurement of solutions, and full-scale integration and implementation. Recent efforts resulted in successful implementation of surveillance monitoring in general care units, device integration and mobile continuous patient monitoring, EMR-based patient state alerts, communication and shared mental model training, and simulation-based response training. Additionally, we have partnered with the High Value Collaborative (www.highvaluehealthcare.org) which provides care to over 80 million Americans. This collaborative utilizes member submitted and CMS health data to identify variation and opportunities for improvement for major health issues such as sepsis by uniquely combining data analysis with frontline clinical changes.

Clinical Trials

We are actively participating in international clinical trials, such as the GAS study that evaluates the impact of anesthesia at an early sage on neurodevelopmental outcomes, and national trials, such as the multi-center RCT examining possible regional anesthesia factors contributing to the development of fistulas after hypospadias repair. We have built a relationship with the University of Vermont as well as the Department of Education in the states of New Hampshire and Vermont to measure the effect of early anesthesia on school testing scores.

Pain Medicine Research

Our research efforts in pain medicine have focused on reviewing commonly prescribed medications and therapies for pain as well as investigating novel approaches, medications, and interventional pain therapies to help reduce opioid usage and improve patient function. Regarding commonly prescribed medications, we are evaluating whether the use of an oral steroid taper can predict success for the subsequent use of steroid injected in the epidural space for patients having radicular leg pain. As medical cannabis use increases as a possible pain therapy, we are investigating whether this may improve patients' perceived quality of life. We are also evaluating, in the perioperative domain, if cognitive behavioral therapy may decrease pain catastrophizing and opioid use for patients undergoing total knee arthroplasty. Currently we are using a psychoneuroimmunologic paradigm to evaluate chronic pain and conducting research on the use of microglial attenuating medications that may decrease neural inflammation and improve chronic pain conditions. In terms of novel interventional therapies, we are evaluating the use of peripheral nerve stimulation and radiofrequency ablation for patients with a variety of chronic pain conditions.