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REGIONAL ANESTHESIA: Edited by Admir Hadzic

Education and training in ultrasound-guided regional anaesthesia and pain medicine

Chuan, Alwin

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Current Opinion in Anaesthesiology: October 2020 - Volume 33 - Issue 5 - p 674-684
doi: 10.1097/ACO.0000000000000908
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The use of ultrasound in regional anaesthesia (UGRA) procedures is relatively recent, but has arguably become the standard of care for regional anaesthesia when performed by anaesthesiologists and pain medicine physicians. Evidence-based reviews of clinical outcomes for UGRA peripheral and neuraxial blocks have concluded that ultrasound-guidance provides benefit of increased block success rates, faster block onset, shorter block performance times, reduction in needle passes, and is at least noninferior to other nerve localizing modalities with respect to neurological complications [1–4].

Gaining proficiency in the technical and nontechnical skill sets required for efficacious and safe UGRA performance is thus necessary. This has prompted a search for evidence-based medical education to inform all aspects of curriculum development, motor skills training, design of in-vitro models, teaching methodology, and competency assessment. The first review was performed in 2013 by Nix et al.[5] on the evidence-base for UGRA education and training, whereas more recently a focus has been on simulation-based education in regional anaesthesia [6,7,8▪] as well as in broader anaesthesia training [9]. This has merit as several previous meta-analyses have shown that a curriculum that incorporates simulation-based medical education, especially with deliberate practice, confers multiple advantages beyond didactic teaching and traditional experiential clinical placements [10,11]. Other reviews relevant to regional anaesthesia training have focused on the role of competency-based assessment and its impact on how physicians gain knowledge and skills [12,13].

This narrative review provides an update of regional anaesthesia education and training articles in literature from 2018 to 2020. To organize the discussion, studies will be categorized by themes previously defined in an international Delphi consensus survey of research priorities in regional anaesthesia education and training [14▪]. These are curriculum design; equipment and benchtop part-task trainer models; regional anaesthesia assessment; knowledge translation from training to clinical practice; methodology and conduct of regional anaesthesia education research; and motor skills training. 

Box 1
Box 1:
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The following search parameter was used to identify potential articles of interest in PubMed and via Google search: ‘regional anaesthesia’ or ‘regional anesthesia’ or ‘nerve block’, and ‘simulation’ or ‘training’ or ‘education’. Limits were placed on year of publication, full text available, and English language. References were hand searched to identify other articles meeting the above criteria.


The PRISMA flow diagram is in Fig. 1. Twenty-two articles were identified. Seventeen articles were clinical studies (Table 1  ), with five articles on curriculum or equipment; three articles on knowledge translation, assessment, or methodology; and two articles on motor skills (articles may have more than one theme). Five articles were review articles and editorials (Table 2), of which three were on curriculum and one each on research methodology and equipment. Table 3 reorganizes the articles by aligning study aims against the top-ranked topics by research priority. Of the 13 top-ranked topics [14▪], only four topics were not specifically investigated by the 22 articles in this review.

PRISMA flow diagram. RA, regional anaesthesia.
Table 1
Table 1:
Summary of clinical research articles, organized by year of publication
Table 1 (Continued)
Table 1 (Continued):
Summary of clinical research articles, organized by year of publication
Table 1 (Continued)
Table 1 (Continued):
Summary of clinical research articles, organized by year of publication
Table 2
Table 2:
Summary of review articles and editorials, organized by year of publication
Table 3
Table 3:
Research topics by priority as ranked in an international Delphi consensus survey [14▪], and articles in this review addressing each topic

Curriculum design

Two small, proof-of-concept randomized control trials (RCTs) investigated traditional versus simulation teaching. In Nixon et al.[15], 12 anaesthesiology residents underwent prerotation training in obstetric epidural blocks using an online multimedia package. Photos and videos augmented didactic information on patient assessment, medications, procedural tasks, and postblock follow-up. In Mladenovic et al.[16▪], 22 dental students received training in inferior alveolar nerve blockade with the assistance of augmented reality goggles. These goggles superimpose computer generated imagery onto the visual field view of the wearer. In both instances, simulation training was beneficial with faster and higher quality of performance of regional anaesthesia. Another study that used an online multimedia learning package was by Muriel-Fernandez et al.[17] of 53 different peripheral and truncal blocks, and pain procedures. This study was however primarily descriptive, and evaluation of learning outcomes was not performed.

The impact of an ultrasound teaching curriculum was examined by Matyal et al.[18] in their institution. All cardiothoracic point of care applications including echocardiography were included, with a smaller UGRA component. The curriculum was based on elements of proficiency-based progression, such as regular self-assessments and an observed structured clinical examination at the conclusion of knowledge training. In the next phase, expert faculty provided feedback to trainees in a clinical setting. However, these assessments were done only for cardiothoracic ultrasound applications, and not specifically for UGRA knowledge and clinical skills.

Kim and Tsui's [8▪] review article on simulation-based UGRA teaching summarized important topics of knowledge and motor skills training, and competency-based assessment. Importantly, the authors addressed nontechnical skills in UGRA competency such as teamwork and management of complications. Of interest is the concept of gamification, which aims to reward friendly competitive behaviour through conceits such as earning of points and proficiency leaderboards. However, no studies have yet been reported in the context of regional anaesthesia simulation.

Two editorials addressed broader curriculum issues. Turbitt et al.[19▪] argued that better patient care is achieved if anaesthesiologists adopted ‘widespread competence in performing a small number of nerve blocks which cover the vast majority of surgical procedures’. This would mean identifying those blocks of greatest value on evidence-base of efficacy and safety. Based on anatomical locations, a simpler range of basic ‘Plan A’ blocks complemented with backup ‘Plan B’ advanced blocks was proposed. A flow-on benefit of a standardized curriculum is easier national implementation and simplified simulation training. However, follow-up correspondence has highlighted that the numbers and expertise of current teaching faculty is currently insufficient even for Plan A blocks [20]. Mariano and Rosenquist [21] described the background and process of regional anaesthesia and pain medicine fellowships gaining accreditation from the Accreditation Council for Graduate Medical Education in 2017. Successful accreditation brings benefits in training quality and promotes standards in education.

Equipment used for education and training

O’Donnell and Loughnane [22] reviewed features of ultrasound machines and needle enhancement technology that have improved sonographic image quality and real-time visualization of needles. Other advances including magnetized needles, ultra-high-frequency transducers, and three-dimensional/four-dimensional ultrasound were also reviewed but uptake is currently limited. The authors noted that the risk of intraneural injection is clinically important, and described the possibility of using elastography and optical pressure sensors to detect inadvertent intraneural needle placement.

These emerging technologies were investigated by the research group in the University of Dundee, UK, with two studies using fusion-elastography [23▪▪] and piezoelectric crystals embedded in the needletip [24]. In the former study, the visual perceptive ability of anaesthesiologists was greater using elastography, allowing easier detection of inappropriate perineural spread as well as recognizing intraneural injection when compared with B-mode ultrasound. In the latter study, while there were statistical improvements on some metrics, the use of a tip-tracking needle did not change the overall success and error rates when novices performed sciatic nerve blocks on soft embalmed cadavers. Further studies to explore their utility are warranted.

While cadavers provide the highest fidelity in-vitro model, animal-based benchtop models provide a lower cost and more accessible alternative. Naraghi et al. described the use of transglutaminase (meat glue) to allow different pieces of meat to be assembled together to mimic muscle groups seen with ultrasonography. This have the interesting side-effect of recreating hyperechoic fascial planes observed in vivo, and allows an expanding space when performing hydrolocation [25].

Three-dimensional printing allows clinicians to create relatively low cost, bespoke, and easily shared equipment useful for regional anaesthesia. Johnson et al.[26] and Bortman et al.[27] both produced three-dimensional-printed neuraxial spine part-task trainers to teach thoracic epidurals. Neice and Forton [28] used three-dimensional additive manufacturing to create a needle guide to assist in out-of-plane approaches for UGRA.

Motor skills in regional anaesthesia and pain medicine

There were two RCTs comparing deliberate practice versus self-directed learning. Deliberate practice is a teaching method that emphasizes individualized training with concrete learning goals achieved through a cycle of repetition and feedback [29]. In the first study by Ahmed et al.[30] novices in the deliberate practice group received feedback based around a 15-item checklist and nine-item error assessment tool. They found that novices with this intervention were more successful and had less errors performing a needling task. This is an example of formative assessment, also termed ‘assessment for learning’, a process by which an expert trainer can provide feedback of both strengths and deficiencies of a trainee's skill set [31]. de Oliveira Filho and Mettrau [32] similarly used deliberate practice (which the authors termed as high-frequency feedback in their study) anchored by a checklist, finding benefits of accelerated performance and steeper learning curves in novices taught a UGRA needling task.

Knowledge translation from simulation to clinical practice

Linking simulation training to clinical performance has been previously identified as the second highest priority topic for regional anaesthesia education research [14▪], and the following three studies are to be commended for investigating this issue. As previously described in the study by Nixon et al.[15] the researchers taught residents obstetric epidurals with a multimedia package and also assessed their clinical performance with a 49-item checklist. Similarly, Bortman et al.[27] taught thoracic epidurals with a three-dimensional-printed model and assessed residents’ success and need for supervision in their clinical performance. A critical limitation of both studies is that outcomes were measured only in the resident's first procedure, rather than over several clinical interactions. Shaylor et al.[33] attempted to follow-up at 3 and 6 months the extent of skills retention by physicians who attended a neuraxial UGRA workshop. This study has multiple limitations including low response rates, confounding with previous experiences, and skills decay was variable between physicians as all had different opportunities for training and clinical usage after the workshop. It highlights difficulties in designing feasible studies to measure skills retention and attrition after simulation.

Knowledge and skills assessment

Two studies performed psychometric evaluation of assessment tools for UGRA. McLeod et al.[34] provided initial confirmation of content and construct validity of a 30-item checklist, in turn designed using a methodological framework analysis from expert regional anaesthesiologists. Secondary outcomes include eye-tracking metrics, which is covered in detail in the next section. A limitation of this new tool is validation is currently restricted to interscalene blocks.

A block-generic workplace-assessment tool was investigated by Shafqat et al.[35]. This tool is a combined checklist and global rating scale [36], which is believed to be most appropriate when assessing medical procedural skills [31]. This study revalidated and confirmed reliability using 21 anaesthesiologists as they performed their next UGRA procedure (peripheral nerve and truncal blocks). A block-generic tool would improve feasibility and help standardize assessment of procedural skills in both clinical and research contexts. However, one limitation of this tool is a focus on technical skills only, instead of holistic patient-centred and team-based care. Regional anaesthesiologists also require competency in nontechnical skills such as pre and postprocedure steps, communication, team work, risk management, and insight into safe practices [37].

Methodology of research

Eye-tracking (or eye-gaze) technology uses infrared light from head-worn goggles to track the movement of the wearer's pupils and correlate direction and duration of gaze with the wearer's visual field. This may provide data including which object draws immediate visual attention, subsequent order of visual attention, and duration of gazing. Practical applications have included marketing surveys, augmented reality, and electronic assisted control and communication by individuals with severe physical disabilities. When used in research, multiple objective endpoints may be defined such as areas of interest as a ‘heatmap’ (direction or frequency of gazing at a specific visual point), gaze time, time taken to fixate, and number of glances.

Eye-tracking has only recently been investigated for use in regional anaesthesia simulation, with the majority of studies within the time period of this review. Appropriately, these initial studies sought to validate some endpoints provided by eye-tracking software. A small study was performed by Borg et al.[38] comparing five novices and five expert regional anaesthesiologists on gaze time both in the area of interest and outside the area of interest, and time taken to fixate. These endpoints were measured when participants were shown static sonoanatomy images and asked to identify relevant structures. Some metrics were possibly useful, with experts faster at correct fixation and less likely to be distracted away from the area of interest.

The interesting study by Mustafa et al.[23▪▪] compared the visual salience of novices versus experts, using fusion-elastography to provide visual clues of appropriate perineural spread of injectate. Experts are known to have automated pattern recognition of relevant (target) and irrelevant (distractor) sonoanatomical structures, informed by their greater knowledge and experience. An explicit rationale for this study was to build a body of work that complements eye-tracking technology as a means to objectively describe UGRA learning curves.

The same research group included eye-tracking as secondary endpoints in their other studies; the primary outcomes have been described earlier in this review [24,34]. Of the data from eye-tracking, McLeod et al.[24] did not find effective discrimination, whereas McLeod et al.[34] did find results supporting its use to stratify proceduralists based on expertise. Conclusions from the results of all available studies are limited as methodologies are dissimilar, the sample sizes are small, and validation of eye-tracking was not the primary aim in the majority of studies. A possible advantage of eye-tracking is allowing longer term follow-up of knowledge translation after simulation, as it provides an objective tool to assess training outcomes in the laboratory and later in clinical environments.

Chuan and Ramlogan [14▪] performed a structured prospective electronic Delphi international survey of 38 experts in regional anaesthesia, to identify and rank education and training topics in order of research priority. Conducted over three rounds, the expert panel ranked 82 topics. Based on a-priori thresholds, a consensus was reached on 13 top-ranked topics (Table 3). The primary aim of the study was to describe the breadth of research activities in regional anaesthesia education, and to inform researchers on which topics to target based on importance to our subspecialty.

A review of competency-based assessment tools used in regional anaesthesia was performed by Chuan et al.[39]. This review provided a statistical framework to evaluate the psychometric properties of an assessment tool, or commonly called ‘assessing the assessment tool’. These are dependent on measuring the validity (content, construct, and face validity) as well as the reliability (external and internal) of the tool. Having robust testing of psychometric properties is required so that all stakeholders have confidence in the results gained from assessment. The review covered different types of statistical tests, including commonly encountered tests such as Cronbach's alpha, Cohen's kappa, and intraclass correlation coefficient, as well as uncommon but robust tests such as generalizability theory and Rasch item-response theory.


The current review described the 22 recent articles pertaining to education and training in regional anaesthesia and pain medicine. The themes and topics of these articles were varied. Performing research in regional anaesthesia education is difficult due to diversity of topics, feasibility to recruit and logistics, smaller sample sizes, linking interventions to improved patient care, and large interindividual differences in learning. Encouragingly, the majority of recent research output specifically addressed nine of the top concerns identified in our subspecialty, and continues to add information to a maturing evidence-base.



Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:

1. Choi S, McCartney C. Evidence base for the use of ultrasound for upper extremity blocks: 2014 update. Reg Anesth Pain Med 2016; 41:242250.
2. Salinas F. Evidence basis for ultrasound guidance for lower-extremity peripheral nerve block: update 2016. Reg Anesth Pain Med 2016; 41:261274.
3. Abrahams M, Derby R, Horn J. Update on ultrasound for truncal blocks: a review of the evidence. Reg Anesth Pain Med 2016; 41:275288.
4. Perlas A, Chaparro L, Chin K. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med 2016; 41:251260.
5. Nix C, Margarido C, Awad I, et al. A scoping review of the evidence for teaching ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2013; 38:471480.
6. Chen X, Trivedi V, Al Saflan A, et al. Ultrasound-guided regional anesthesia simulation training: a systematic review. Reg Anesth Pain Med 2017; 42:741750.
7. Udani A, Kim T, Howard S, Mariano E. Simulation in teaching regional anesthesia: current perspectives. Local Reg Anesth 2015; 8:3343.
8▪. Kim T, Tsui B. Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents. Korean J Anesthesiol 2019; 72:1323.
9. Ross A, Kodate N, Anderson J, et al. Review of simulation studies in anaesthesia journals, 2001–2010: mapping and content analysis. Br J Anaesth 2012; 109:99109.
10. McGaghie W, Issenberg S, Cohen E, et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med 2011; 86:706711.
11. Cook D, Brydges R, Hamstra S, et al. Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simul Healthc 2012; 7:308320.
12. Ilgen J, Ma I, Hatala R, Cook D. A systematic review of validity evidence for checklists versus global rating scales in simulation-based assessment. Med Educ 2015; 49:161173.
13. Miller A, Archer J. Impact of workplace based assessment on doctors’ education and performance: a systematic review. BMJ 2010; 341:c5064.
14▪. Chuan A, Ramlogan R. Research priorities in regional anaesthesia education and training: an international Delphi consensus survey. BMJ Open 2019; 9:e030376.
15. Nixon H, Stariha J, Farrer J, et al. Resident competency and proficiency in combined spinal-epidural catheter placement is improved using a computer-enhanced visual learning program: a randomized controlled trial. Anesth Analg 2019; 128:9991004.
16▪. Mladenovic R, Pereira L, Mladenovic K, et al. Effectiveness of augmented reality mobile simulator in teaching local anesthesia of inferior alveolar nerve block. J Dent Educ 2019; 83:423428.
17. Muriel-Fernandez J, Alonso C, Lopez-Valverde N, et al. Results of the use of a simulator for training in anesthesia and regional analgesia guided by ultrasound. J Med Syst 2019; 43:79.
18. Matyal R, Mitchell J, Mahmood F, et al. Faculty-focused perioperative ultrasound training program: a single-center experience. J Cardiothorac Vasc Anesth 2019; 33:10371043.
19▪. Turbitt L, Mariano E, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia 2020; 75:293297.
20. Ashken T, Thompson M. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia 2020; 75:554.
21. Mariano E, Rosenquist R. The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine. Curr Opin Anaesthesiol 2018; 31:643648.
22. O’Donnell B, Loughnane F. Novel nerve imaging and regional anesthesia, bio-impedance and the future. Best Pract Res Clin Anaesthesiol 2019; 33:2335.
23▪▪. Mustafa A, Seeley J, Munirama S, et al. Investigation into the visual perceptive ability of anaesthetists during ultrasound-guided interscalene and femoral blocks conducted on soft embalmed cadavers: a randomised single-blind study. Br J Anaesth 2018; 120:854859.
24. McLeod G, McKendrick M, Taylor A, et al. An initial evaluation of the effect of a novel regional block needle with tip-tracking technology on the novice performance of cadaveric ultrasound-guided sciatic nerve block. Anaesthesia 2020; 75:8088.
25. Naraghi L, Lin J, Odashima K, et al. Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models. BMC Med Educ 2019; 19:145.
26. Johnson M, Portnova S, Lester M. Three-dimensional thoracic epidural educational model. Reg Anesth Pain Med 2018; 43:100101.
27. Bortman J, Baribeau Y, Jeganathan J, et al. Improving clinical proficiency using a 3-dimensionally printed and patient-specific thoracic spine model as a haptic task trainer. Reg Anesth Pain Med 2018; 43:819824.
28. Neice A, Forton C. Evaluation of a novel out-of-plane needle guide. J Ultrasound Med 2018; 37:543549.
29. Ericsson K. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79:S70S81.
30. Ahmed O, Azher I, Gallagher A, et al. Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting. J Clin Anesth 2018; 48:2227.
31. Bould M, Crabtree N, Naik V. Assessment of procedural skills in anaesthesia. Br J Anaesth 2009; 103:472483.
32. de Oliveira Filho G, Mettrau F. The effect of high-frequency, structured expert feedback on the learning curves of basic interventional ultrasound skills applied to regional anesthesia. Anesth Analg 2018; 126:10281034.
33. Shaylor R, Halpern S, Carvalho J, Weiniger C. An observational study of skill retention and practice adoption after a workshop on ultrasound-guided neuraxial anaesthesia. Eur J Anaesthesiol 2018; 35:801803.
34. McLeod G, McKendrick M, Taylor A, et al. Validity and reliability of metrics for translation of regional anaesthesia performance from cadavers to patients. Br J Anaesth 2019; 123:368377.
35. Shafqat A, Rafi M, Thanawala V, et al. Validity and reliability of an objective structured assessment tool for performance of ultrasound-guided regional anaesthesia. Br J Anaesth 2018; 121:867875.
36. Cheung J, Chen E, Darani R, et al. The creation of an objective assessment tool for ultrasound-guided regional anesthesia using the Delphi method. Reg Anesth Pain Med 2012; 37:329333.
37. Smith A, Pope C, Goodwin D, Mort M. What defines expertise in regional anaesthesia? An observational analysis of practice. Br J Anaesth 2006; 97:401407.
38. Borg L, Harrison T, Kou A, et al. Preliminary experience using eye-tracking technology to differentiate novice and expert image interpretation for ultrasound-guided regional anesthesia. J Ultrasound Med 2018; 37:329336.
39. Chuan A, Wan A, Royse C, Forrest K. Competency-based assessment tools for regional anaesthesia: a narrative review. Br J Anaesth 2018; 120:264273.

medical education; regional anaesthesia; simulation; training; ultrasound

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