Within six short years in the dynamic field of regional anesthesia and acute pain management, Dr. Christian Horazeck has already amassed a wealth of experience and insight. In this Member Spotlight, Dr. Horazeck highlights innovative strategies that improve patient care and outcomes, such as optimizing post-cesarean opioid prescribing, and discusses his research on nerve blocks for outpatient knee arthroplasty. He also shares his approach to educating future anesthesiologists, encouraging them to consider themselves "expert consultants.”
Could you describe a particularly challenging case from your experience in regional anesthesia and acute pain medicine? What did you learn, both personally and professionally?
I very vividly remember a pediatric case that benefited from my knowledge in regional anesthesia. A six-year-old was undergoing a major resection of an aggressive osteosarcoma of his femur. He had been hospitalized twice in the past year for painful procedures. During each hospitalization he performed poorly on systemic opioids. His parents reported horrible nausea and a scary event during which he became apneic with an opioid overdose, while pain management was moderate at best.
They were considerably worried given the major surgery he faced now. We discussed the option of an opioid-free, regionally based anesthetic with the parents early and explained how we could utilize nerve blocks for most of his analgesia and supplement with NSAIDs and low dose ketamine for any sympathetically mediated breakthrough pain. We managed his pain with femoral and sciatic nerve block catheters, which we kept in place for the full six-day hospitalization. He ended up never requiring the ketamine and stayed opioid-free not only during the hospitalization, but also at home.
While this obviously isn’t a brand-new technique never described before, even well-known nerve blocks often get omitted in the pediatric theatre due to fear of side effects, intolerance, or systemic toxicity. All these issues, however, can be dispelled by consulting with a true expert in the field of regional anesthesia.
Personally, as a father of two, the case touched me as a parent, and I could truly understand the parents’ worry. Seeing a child suffer bad side effects from medications that end up failing to treat the issue would be frustrating and worrisome to witness. Seeing him pain-free and his parents worry-free was a wonderful experience, particularly in a specialty in which we don’t often follow our patients for an extended period of time.
Professionally, it demonstrated the continued need for well-trained regional anesthesiologists, who can consult on acute pain management issues and can advise on matters that change the entire outcome for a patient and their family.
As medical director of an inpatient pain service, what strategies have you implemented to enhance the quality of care and patient outcomes? Could you share an example of a successful protocol or quality improvement initiative you've led?
Directing my first inpatient pain service was a humbling experience. I came into the position fresh out of fellowship at a facility that never had a protocolized pain service. They had good follow-up on nerve block catheters and post C-section patients, but there was minimal use of continuing ERAS protocols on the floor or consulting on chronic pain patients.
To slowly expand and professionalize the service, I employed a mix of education for non-anesthesia providers and demonstrated financial success to the hospital administration. Education for non-anesthesia providers included starting an educational lunch lecture series for medicine and surgery residents, med-surg RNs, and NPs, aka the future customers of the service. We needed to let them know what conditions we could help treat, what services we could provide, and probably most importantly, what services we could not.
Showcasing financial success to hospital administrators is an underappreciated skill among physicians. In the end, hospitals will support a financially sound service with a business plan much more readily than a service that may provide amazing medical help but meets undefined business needs.
An example of the success of our education series was changing post-cesarean opioid use for a busy obstetric service. Residents were prescribing the somewhat standard ten days of continued opioids for all patients to take home. A quick phone survey of 20 recently discharged patients showed that most of these patients used three or less opioid doses total. By engaging OBGYN residents in open lunch discussions, we were able not only to teach them about the risks of excessive opioid prescribing, but also gain an understanding of the analgesic needs of these patients. The residents were worried that pain wouldn’t be appropriately addressed, and our service was able to help them write non-opioid analgesic protocols for discharge.
You’re also very interested in clinical and basic science research, could you elaborate on a recent study you were involved in? What were the key findings or implications for clinical practice?
My most recent study, which is still being written up in development prior to publication, involves the assessment of optimal nerve block strategies following outpatient total knee arthroplasty. With different protocols available that are usually based on academic settings, we wanted to find the ideal pain management for our outpatient private practice location.
We worked in tandem with our orthopedic surgeons and developed a protocol that involved multimodal analgesics, along with adductor canal, genicular, and iPACK blocks, as well as mepivacaine spinals. We compared outcome measures such as PACU opioid use, calls for rescue opioids at home, time in PACU, time to first PT ambulation, and time to discharge to our prior protocol and found improvement in all categories. We are excited about these results, because we feel that most of our protocol is easy to replicate even in a fast-paced environment.
In your role as an educator, what are some of the key principles or skills you emphasize to prepare future anesthesiologists for clinical practice?
One of the key principles I like to convey to residents is to build a reputation as an expert consultant, not just the proverbial “gas passer” or “block jock.” Just because a surgeon believes a patient needs to be optimized for surgery doesn’t mean you have to perform an anesthetic. Review every patient’s chart, check for imaging studies yourself, read the labs, and don’t rely on the internist note—they have a very different focus from us in anesthesia. Talk on equal terms with our surgical colleagues, explain your reasoning, and be ready to challenge and be challenged.
The same is true for nerve blocks. Almost any patient can receive a nerve block. True experts, however, evaluate the patient, weigh risks and benefits, and perform the nerve block most suited for the patient and the expected pain. Never decide on an anesthetic because “it’s always done this way.”.That devalues your own education, as well as our specialty.
Is there is anything you would like to talk about that we haven’t touched on?
A current project in which I am involved is the development of an AI-supported software that will aid practitioners around the world in the research-based evaluation and treatment of pain. Medicine can be slow to adapt to technology, which is sometimes based on merited concerns but other times just a matter of convenience. I am working with a team of medical students and a few programmers to utilize AI on this. Our thought is that pain affects every human being during their life. The balance between undertreatment and overprescribing opioids is a fine line. We want to give medical personnel the tools to handle pain with the same comfort level as they handle hypertension or a physical exam.
Christian Horazeck is a board-certified anesthesiologist with fellowship training in regional anesthesiology and acute pain medicine, specializing in both ambulatory and inpatient surgical anesthesia. He earned his medical degree from Duke University School of Medicine, following his undergraduate studies at Duke University, where he double-majored in cellular and molecular biology and neuroscience. Dr. Horazeck is also actively involved in research and medical education, advancing the field through the planning and evaluation of clinical studies and teaching medical students in workshops and year-long courses.
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