Regional anaesthesia (RA) plays an important role in the success of most surgical procedures, providing multiple benefits.^{1 2} Its use is increasingly widespread, including outside the operating room.^{3 4} That is why RA is considered a core component of peri-operative care.^5-9

This importance of RA makes it essential for residents to complete their anaesthesiology training programme? by mastering the knowledge and skills surrounding ultrasound guided regional anaesthesia (UGRA). ^10-14 This proficiency enables them to perform the main blocks used in daily clinical practice¹⁵ with quality and security, from which the greatest number of patients can benefit.

Currently, there is no standardized educational approach to teaching UGRA in anaesthesiology training; only guidelines and recommendations are published in RA Fellowship programs.^{7 16} As UGRA and acute pain medicine are now considered essential knowledge and skills for anaesthesiologists, it is necessary to develop a standardized UGRA curriculum for residency training. This curriculum should be applicable to the majority of anaesthesiologists worldwide, improving the quality of training and nerve blocks for the benefit of patients.

The way of teaching has changed over the years. We have moved from an apprenticeship training model ^{17 - 19} based on ‘seeing and doing’ to directly performing the procedure on the patient in the clinical setting, often compromising patient safety. This traditional approach relied on time-based training without performance indicators and provided a limited number of procedure exposures. Additionally, the increased number of trainees has further challenged this model. Now, we are shifting towards a competency-based education (CBE) model.^18-23

CBE focuses on acquiring specific skills and competencies rather than completing a set number of hours. Trainees advance as they demonstrate mastery in key areas, allowing them to progress at their own pace and focus on areas that need improvement. Residency training programs worldwide are transitioning from time - or volume-based requirements to a CBE model with simulation-based education¹⁷.

The principles of a CBE in RA are focused on defining specific competencies, developing tailored learning pathways (individualized learning plans for residents) ²⁴ and competency-based assessment. ^{16 25 26}

The UGRA core competencies outlined by the ASRA-ESRA joint committee comprise six domains: patient care, medical knowledge, system-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism.¹⁷

The Dreyfus Model of Skill Acquisition is a framework that describes how learners progress through different stages of skill development, from novice to expert. This model is based on experiential learning, adaptation and judgment (figure 1). As residents gain experience, they advance through the different stages, becoming more adept at decision-making, problem-solving, and adapting to various clinical scenarios responding effectively.

In the context of RA, integrating the Dreyfus Model of Skill acquisition with competence-based education (CBE) principles can provide a structured and effective approach to training anaesthesiology residents in UGRA, resulting in (figure 2):

1. Progression learning through skill levels. Trainees advance from one step to the next after demonstrating the acquisition of specific competences according to defined objective proficiency benchmarks. Each step is accompanied by an assessment and feedback.

2. Development of structured curriculum with specific definitions of learning objectives related to RA and assessment to document achievement of competencies. It is necessary to provide a mix of didactic education, hands–on training, simulation exercises and clinical experiences to support residents’ development.

3. Continuous feedback and reflection on their performance, highlighting strengths and areas for improvement, as well as encouraging self–reflection and self–assessment to help residents monitor their progress and identify learning goals.

4. Mastery–based progression. Residents advance to the next stage of the Dreyfus Model and take more complex challenges in RA once they demonstrate mastery of competencies at each level through assessment.

Performance of successful UGRA requires theoretical knowledge and manual skills. According to CBE and Dreyfus integrated model, we can describe 4 stages of proficiency-based progression (PBP) training programme for UGRA during anaesthesiology residency. We describe competencies to achieve in the different stages/steps:

First step Competences: KNOWLEDGE

In this stage, didactic education should include: principles of ultrasonography, local anaesthetics, anatomy of peripheral nerve blocks (PNBs), applied anatomy to different surgery indications, understanding the role of RA as a core component of perioperative care and multimodal analgesia, indications and contraindications of common blocks, preparation for the block and management of RA complications.

Educational resources for knowledge are textbooks, e-learning methods like video materials, and e-learning text.

Tools for knowledge assessment: Multiple Choice Questions (MCQs), Short Answer Questions (SAQs), Case-Based Discussions (CBDs).

Second Step Competences: SKILLS.

Technical skills acquisition is very important in UGRA, and together with the vigilance of the anaesthesiologist, they are probably the most important component of patient safety during RA. In addition, high skill acquisition (proficiency) is associated with better outcomes. The specific interrelated skills required to perform UGRA are image acquistion, anatomical interpretation ²⁸, hand-needle-eye coordination for precise alignment of the needle and ultrasound beam and accurate needle placement. Deliberate practice of component skills with feedback may accelerate the rate of skill acquisition.^{18 29}

The most common errors made by residents during the learning of UGRA are related to skills acquisition. The first is the advancement of the needle when the tip is not visualized, followed by unintentional probe movement associated with poor ergonomics,³⁰ and failures in identifying the incorrect spread of local anaesthetic.²⁷

It is recommended that these skills be acquired first in a simulation environment before being applied in clinical practice.^{17 29}

Third and fourth Step: CLINICAL PRACTICE.

The final step involves performing UGRA blocks in the clinical environment, on patients, under supervision and feedback. Supervision will gradually decrease until residents demonstrate, after assessment, the acquisition of all competencies in the clinical practice.

Other tasks and skills can be learned through clinical experience, such as using an aseptic technique, marking of block site, monitoring of vital signs and patient comfort, providing informed consent, management of complex patients or complications, explaining post-procedure care and multidisciplinary of postoperative care.

A key aspect of PBP programs is assessment to demonstrate competency in the curricular goals, although there is no standard tool for assessing UGRA competency.^{21,31,23,32,33,21,28,34,35,36,37,38,39} Task-specific checklists are the most reliable form of assessment and can be used in simulation and clinical settings. Example checklist tasks include ¹¹: visualizing key landmarks, identifying nerves/plexus, confirming normal anatomy or recognizing variations, maintaining an aseptic technique, following the needle in real time, identifying the correct pattern of local anaesthetic spread and following safety guidelines. Other assessment tools include: Global Rating Scores, Quality-compromising behaviours (QCB), Direct observation of procedural skills (DOPS), Cumulative sum scoring (CUSUM), Key Performance Indicators (KPIs) or new technologies like tracking motion devices (digits/arms/eye gaz ⁴⁰ , 360-degree video, augmented and virtual reality.

Simulation-based education and training (SBET) ^{17,41,42,43,44,45} is an essential component of an UGRA teaching curriculum and plays a primary role in competency-based learning in the preclinical phase^16,35, although it is only partially or poorly implemented in many countries, including Europe⁴². Simulation is useful for training both technical (understanding devices operations, imagine optimization, image interpretation, visualization of needle insertion and of LA.) and non-technical skills (leadership, communication, team working, situation awareness and decision-making). SBET offers several advantages over traditional training methods: it allows safe and ethical learning without risk or consequences for patients. This provides the opportunity for repetitive practice in a safe environment, creates low-stress learning conditions without time pressure. Additionally, it offers individualized expert feedback, increases trainees’ self-confidence (which improves problem solving in the clinical practice and reduces the likelihood of complications), shortens the learning curve and achieves long-term retention of skills. All of these benefits ultimately improve clinical competency, block success, and patient safety. Debriefing and feedback have been identified as the most important aspects of simulation-based learning.

There are diverse simulation modalities with different applications in regional anaesthesia training (table 1).

Simulation, artificial intelligence and new technologies³⁵ play an increasingly important role in the field of RA.⁴⁶

There are several high-quality websites and online resources dedicated to teaching regional anaesthesia, each offering a range of educational materials, including tutorials, videos, guidelines, applications and interactive modules to enhance knowledge and skills in regional anaesthesia.

Machine learning systems for RA have been incorporated in recent years as artificial intelligence-based devices for ultrasound image interpretation^{18,47,48,49,50}, and other wearable devices for needle tasking⁴⁷, virtual^35,51 and augmented reality⁵²,⁵³. Randomized control trials are still missing for application of AI-guided UGRA in clinical anaesthetic practice^47,54.

To sum up, the ASRA-ESRA-UK guidelines suggest the implementation of a PBP training and assessment in UGRA to enhance quality of training and quality of nerve blocks, thereby improving patient outcomes^20,17. Through a combination of didactic education, hands-on clinical experience and continuous assessment, residents can achieve proficiency and confidence in UGRA, an essential area of anaesthesiology.

Foundation training should be aimed at the learning and deliberate practice of a small number of versatile techniques that cover the vast majority of surgical procedures ^26,28 (Plan A ¹⁵ : interscalene, axillary, femoral, adductor canal, sciatic in the popliteal fossa, erector spinae plane and rectus sheath blocks). This approach ensures patient access to reliable and safe RA. Competence in more advanced blocks should be acquired during an advanced fellowship in regional anaesthesia.

Training to competence in the preclinical setting using simulation has become and essential part of the learning process, as well as the continuous assessment of competence acquisition rather than the volume of practice. Residents will require more than the established minimum number to become proficient in regional anaesthesia and periodic retraining is necessary to consolidate and maintain proficiency in technical skills introduced during training^17,55.

Certainly, it’s imperative to be familiar with all the educational sources and evaluation tools. Based on our resources, we should prioritize those that are most reproducible in our environment, utilizing a competence-based model of teaching.

There continues to be controversial issues such as curricular goals (like which peripheral blocks and how many), universal assessment tools for achieving competences in UGRA, limited access to simulation to train in preclinical setting, and understanding if knowledge and technical skills are transferable.

Future work should focus on standardizing the UGRA curriculum and determining the most effective teaching and assessment methodologies for achieving competencies in UGRA. Additionally, there should be increased investment in expanding access to simulation and research for new technologies applied to RA educational practices.

• Download figure
• Open in new tab
• Download powerpoint

Abstract H22 Figure 1

Dryfus Model of skill acquisition

• Download figure
• Open in new tab
• Download powerpoint

Abstract H22 Figure 2

CBE for UGRA training in anesthesiology residency

References

1. Hong B, Bang S, Chung W, Yoo S, Chung J, Kim S. Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study. Korean J Pain. 2019;32(3):206-214. doi:10.3344/kjp.2019.32.3.206

2. Manhai G, Wei W, Xiaolu H, Juan W. Bibliometrics and knowledge map analysis of ultrasound-guided regional anesthesia. 2023.

3. Wolmarans M, Albrecht E. Regional anesthesia in the emergency department outside the operating theatre. Curr Opin Anaesthesiol. 2023;36(4):447-451. doi:10.1097/ACO.0000000000001281

4. Bröking K and RW. How to Teach Regional Anesthesia.; 2006.

5. Boselli E, Hopkins P, Lamperti M, et al. European Society of Anaesthesiology and Intensive Care Guidelines on Peri-Operative Use of Ultrasound for Regional Anaesthesia (PERSEUS Regional Anesthesia) Peripheral Nerves Blocks and Neuraxial Anaesthesia. 2021;38. doi:10.1097/EJA.0000000000001383

6. El-Boghdadly K, Wolmarans M, Stengel AD, et al. Standardizing nomenclature in regional anesthesia: An ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks. Reg Anesth Pain Med. 2021;46(7):571-580. doi:10.1136/rapm-2020-102451

7. Harmon DJ, Boscardin CK, Cohen NH, Braehler MR. The efficacy of an anatomy and ultrasonography workshop on improving residents’ confidence and knowledge in regional anesthesia. BMC Med Educ. 2023;23(1). doi:10.1186/s12909-023-04653-y

8. Matyal R, Mitchell JD, Mahmood F, et al. Faculty-Focused Perioperative Ultrasound Training Program: A Single-Center Experience. J Cardiothorac Vasc Anesth. 2019;33(4):1037-1043. doi:10.1053/j.jvca.2018.12.003

9. Cai N, Wang G, Xu L, et al. Examining the impact perceptual learning artificial-intelligence-based on the incidence of paresthesia when performing the ultrasound-guided popliteal sciatic block: simulation-based randomized study. BMC Anesthesiol. 2022;22(1). doi:10.1186/s12871-022-01937-6

10. Narouze SN, Provenzano D, Peng P, et al. The American society of regional anesthesia and pain medicine, the European society of regional anaesthesia and pain therapy, and the Asian Australasian federation of pain societies joint committee recommendations for education and training in ultrasound-. Reg Anesth Pain Med. 2012;37(6):657-664. doi:10.1097/AAP.0b013e318269c189

11. Sites BD, Chan VW, Neal JM, et al. The American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy joint committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2009;34(1):40-46. doi:10.1097/AAP.0b013e3181926779

12. Villalonga Vadell R, Cobo Castro T, Guillén Antón J, et al. New training program in Anesthesiology. Update for the Challenges of Anesthesiology of the XXI Century. Rev Esp Anestesiol Reanim. 2021;68(1):5-9. doi:10.1016/j.redar.2020.08.003

13. Cho NR, Cha JH, Park JJ, Kim YH, Ko DS. Reliability and quality of youtube videos on ultrasound-guided brachial plexus block: a programmatical review. Healthc. 2021;9(8). doi:10.3390/healthcare9081083

14. Chuan A, Ramlogan R. Research priorities in regional anaesthesia education and training: an international Delphi consensus survey. BMJ Open. 2019;9(6):1-8. doi:10.1136/bmjopen-2019-030376

15. Turbitt LR, Mariano ER, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia. 2020;75(3):293-297. doi:10.1111/anae.14768

16. Chuan A, Jeyaratnam B, Fathil S, et al. Non-Fellowship regional anesthesia training and assessment: an international Delphi study on a consensus curriculum. Reg Anesth Pain Med. 2021;46(10):867-873. doi:10.1136/rapm-2021-102934

17. Kim TE, Tsui BCH. Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents. Korean J Anesthesiol. 2019;72(1):13-23. doi:10.4097/kja.d.18.00317

18. Ramlogan RR, Chuan A, Mariano ER. Contemporary training methods in regional anaesthesia: fundamentals and innovations. Anaesthesia. 2021;76(S1):53-64. doi:10.1111/anae.15244

19. Niazi AU, Peng PW, Ho M, Tiwari A, Chan VW. L’avenir de la formation en anesthésie régionale: leçons à tirer de la spécialité chirurgicale. Can J Anesth. 2016;63(8):966-972. doi:10.1007/s12630-016-0653-7

20. Buléon C, Eng R, Rudolph JW, Minehart RD. First steps towards international competency goals for residency training: a qualitative comparison of 3 regional standards in anesthesiology. BMC Med Educ. 2021;21(1). doi:10.1186/s12909-021-03007-w

21. Kallidaikurichi Srinivasan K, Gallagher A, O’Brien N, et al. Proficiency-based progression training: An end to end’ model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study. BMJ Open. 2018;8(10). doi:10.1136/bmjopen-2017-020099

22. McCarthy N, Neville K, Pope A, Barry L, Livingstone V. Effectiveness of a proficiency-based progression e-learning approach to training in communication in the context of clinically deteriorating patients: a multi-arm randomised controlled trial. BMJ Open. 2023;13(8). doi:10.1136/bmjopen-2023-072488

23. Chuan A, Wan AS, Royse CF, Forrest K. Competency-based assessment tools for regional anaesthesia: a narrative review. Br J Anaesth. 2018;120(2):264-273. doi:10.1016/j.bja.2017.09.007

24. Fuller Skylar L, Ambardekar Aditee P, Diachun Carol Ann B, Kearney, Matthew D, Long Timothy R, Miller Juve Amy K, Mitchell, John D. Woodworth GEM. ORIGINAL RESEARCH REPORTS: ORIGINAL CLINICAL RESEARCH REPORT Competency-Based Time-Variable Anesthesiology Residency Training: Identification of Problems and Solutions Fuller, Skylar L. MD*; Ambardekar, Aditee P. MD, MSEd†; Diachun, Carol Ann B. MD, MSEd‡. Anesth Analg. 2024;138(4):848-855.

25. Gwynne-Jones DP, Martin G, Crane C. Enhanced recovery after surgery for hip and knee replacements. Orthop Nurs. 2017. doi:10.1097/NOR.0000000000000351

26. Woodworth G, Maniker RB, Spofford CM, et al. Anesthesia residency training in regional anesthesiology and acute pain medicine: a competency-based model curriculum. Reg Anesth Pain Med. 2020;45(8):660-667. doi:10.1136/rapm-2020-101480

27. Sites BD, Spence BC, Gallagher JD, Wiley CW, Bertrand ML, Blike GT. Characterizing Novice Behavior Associated With Learning Ultrasound-Guided Peripheral Regional Anesthesia. Reg Anesth Pain Med. 2007;32(2):107-115. doi:10.1016/j.rapm.2006.11.006

28. Bowness JS, Pawa A, Turbitt L, et al. International consensus on anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2022;47(2):106-112. doi:10.1136/rapm-2021-103004

29. Barrington MJ, Wong DM, Slater B, Ivanusic JJ, Ovens M. Ultrasound-guided regional anesthesia: How much practice do novices require before achieving competency in ultrasound needle visualization using a cadaver model. Reg Anesth Pain Med. 2012;37(3):334-339. doi:10.1097/AAP.0b013e3182475fba

30. Fathil SM, Ghani MRA, Chen KY, Lee P, Hou J De, Lin JA. Physical ergonomics in peripheral nerve block. Appl Sci. 2021;11(20). doi:10.3390/app11209736

31. Allen BFS, McEvoy MD. Competency Assessment in Regional Anesthesia: Quantity Today, Quality Tomorrow. Reg Anesth Pain Med. 2017;42(4):429-431. doi:10.1097/AAP.0000000000000626

32. Ahmed OM, O’donnell BD, Gallagher AG, Shorten GD. Development of performance and error metrics for ultrasound-guided axillary brachial plexus block. Adv Med Educ Pract. 2017;8:257-263. doi:10.2147/AMEP.S128963

33. Holtmannspötter M, Crossley RA, Liebig T, Gallagher AG. Metric-Based Simulation Training to Proficiency for Endovascular Thrombectomy in Ischemic Stroke. Front Neurol. 2022;13. doi:10.3389/fneur.2022.742263

34. Ahmed OMA, Niessen T, O’Donnell BD, et al. The effect of metrics-based feedback on acquisition of sonographic skills relevant to performance of ultrasound-guided axillary brachial plexus block. Anaesthesia. 2017;72(9):1117-1124. doi:10.1111/anae.13968

35. Chuan A, Qian J, Bogdanovych A, Kumar A, McKendrick M, McLeod G. Design and validation of a virtual reality trainer for ultrasound-guided regional anaesthesia. Anaesthesia. 2023;78(6):739-746. doi:10.1111/anae.16015

36. Cheung JJH, Chen EW, Darani R, McCartney CJL, Dubrowski A, Awad IT. The creation of an objective assessment tool for ultrasound-guided regional anesthesia using the delphi method. Reg Anesth Pain Med. 2012;37(3):329-333. doi:10.1097/AAP.0b013e318246f63c

37. Ruiz MG, Tou S, Gallagher AG, Cagigas Fernández C, Cristobal Poch L, Matzel KE. Intraoperative robotic-assisted low anterior rectal resection performance assessment using procedure-specific binary metrics and a global rating scale. BJS Open. 2022;6(3). doi:10.1093/bjsopen/zrac041

38. A Kollmann-Camaiora NBEAFG. Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block. Rev Esp Anestesiol Reanim . 2017;64(8):453-459.

39. MJ Watson, DM Wong, R Kluger, A Chuan, MD Herrich, Castanelli, Lin, Lansdown B. Psychometric evaluation of a direct observation of procedural skills assessment tool for ultrasound-guided regional anaesthesia.

40. Harrison TK, Kim TE, Kou A, Shum C, Mariano ER, Howard SK. Feasibility of eye-tracking technology to quantify expertise in ultrasound-guided regional anesthesia. J Anesth. 2016;30(3):530-533. doi:10.1007/s00540-016-2157-6

41. Niazi AU, Haldipur N, Prasad AG, Chan VW. Ultrasound-guided regional anesthesia performance in the early learning period: effect of simulation training. Reg Anesth Pain Med. 2012;37(1):51-54. doi:10.1097/AAP.0b013e31823dc340

42. Savoldelli GL, Burlacu CL, Lazarovici M, Matos FM, Østergaard D. Integration of simulation-based education in anaesthesiology specialist training: Synthesis of results from an Utstein Meeting. Eur J Anaesthesiol. 2024;41(1):43-54. doi:10.1097/EJA.0000000000001913

43. Torrano V, Zadek F, Bugada D, et al. Simulation-Based Medical Education and Training Enhance Anesthesia Residents’ Proficiency in Erector Spinae Plane Block. Front Med. 2022;9(April):1-5. doi:10.3389/fmed.2022.870372

44. Novak-Jankovič V. Simulation-Based Training of Regional Anesthesia Medical Simulation Center, University Medical Center Ljubljana, Slovenia. Acta Clin Croat. 2022;61:155-159. doi:10.20471/acc.2022.61.s2.21

45. Burnett GW, Shah AS, Katz DJ, Jeng CL. Survey of regional anesthesiology fellowship directors in the USA on the use of simulation in regional anesthesiology training. Reg Anesth Pain Med. 2019;44(11):986-989. doi:10.1136/rapm-2019-100719

46. Ali S, Athar M, Ahmed SM. Basics of CPB. Indian J Anaesth. 2019;49(4):257-262. doi:10.4103/ija.IJA

47. Bowness JS, El-Boghdadly K, Woodworth G, Noble JA, Higham H, Burckett-St Laurent D. Exploring the utility of assistive artificial intelligence for ultrasound scanning in regional anesthesia. Reg Anesth Pain Med. 2022;40:375-379. doi:10.1136/rapm-2021-103368

48. Koçer Tulgar Y, Tulgar S, Güven Köse S, et al. Anesthesiologists’ Perspective on the Use of Artificial Intelligence in Ultrasound-Guided Regional Anaesthesia in Terms of Medical Ethics and Medical Education: A Survey Study. Eurasian J Med. 2023;55(2):146-151. doi:10.5152/eurasianjmed.2023.22254

49. Bowness JS, Burckett-St Laurent D, Hernandez N, et al. Assistive artificial intelligence for ultrasound image interpretation in regional anaesthesia: an external validation study. Br J Anaesth. 2023;130(2):217-225. doi:10.1016/j.bja.2022.06.031

50. Viderman D, Dossov M, Seitenov S, Lee MH. Artificial intelligence in ultrasound-guided regional anesthesia: a scoping review. Front Med. 2022;9. doi:10.3389/fmed.2022.994805

51. Alaterre C, Duceau B, Tsai ES, et al. Virtual reality for peripheral regional anesthesia (VR-PERLA study). J Clin Med. 2020;9(1). doi:10.3390/jcm9010215

52. Jun EK, Lim S, Seo J, et al. Augmented Reality-Assisted Navigation System for Transforaminal Epidural Injection. J Pain Res. 2023;16(March):921-931. doi:10.2147/JPR.S400955

53. Shevlin SP, Turbitt L, Burckett-St.Laurent D, Macfarlane AJ, West S, Bowness JS. Augmented Reality in Ultrasound-Guided Regional Anaesthesia: An Exploratory Study on Models With Potential Implications for Training. Cureus. 2023;15(7):1-14. doi:10.7759/cureus.42346

54. Bowness JS, Metcalfe D, El-Boghdadly K, et al. Artificial intelligence for ultrasound scanning in regional anaesthesia: a scoping review of the evidence from multiple disciplines. Br J Anaesth. May 2024. doi:10.1016/j.bja.2024.01.036

55. Valdés-Vilches LF, Caballero-Domínguez M. Anestesia regional en el paciente bajo anestesia general: ¿es una práctica segura? Regional anesthesia in patients under general anesthesia. Is it a safe practice? Cir May Amb 2013. 2013;18(3):3. www.asecma.org.