Anaesthesia 2021, 76 (Suppl. 1), 53–64 doi:10.1111/anae.

15244

Review Article

Contemporary training methods in regional anaesthesia:

fundamentals and innovations
R. R. Ramlogan,1 A. Chuan2 and E. R. Mariano3,4

1 Assistant Professor, Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, The Ottawa
Hospital, University of Ottawa, Ottawa, ON, Canada
2 Associate Professor, Department of Anaesthesia, Liverpool Hospital, South Western Sydney Clinical School, University
of New South Wales, Sydney, NSW, Australia
3 Professor, Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine,
Stanford, CA, USA
4 Chief, Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA,
USA

Summary
Over the past two decades, regional anaesthesia and medical education as a whole have undergone a
renaissance. Significant changes in our teaching methods and clinical practice have been influenced by
improvements in our theoretical understanding as well as by technological innovations. More recently, there
has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on
how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and
innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training,
specifically the current state of simulation-based education, deliberate practice and curriculum design based
on competency-based progression. Moving into the future, we present the latest innovations in web-based
learning, emerging technologies for teaching and assessment and new developments in alternate reality
learning systems.

.................................................................................................................................................................
Correspondence to: E. R. Mariano
Email: emariano@stanford.edu
Accepted: 20 July 2020
Keywords: artificial intelligence; competency-based training; medical education; regional anaesthesia; simulation;
technology
Twitter: @RevaRamlogan; @AlwinChuan; @EMarianoMD

Introduction foundational education principles to teach regional

Over the past two decades, regional anaesthesia and anaesthesia, and the evidence for how to best teach and
medical education as a whole have undergone a assess trainees is growing.
renaissance. The way we teach, in as much as the way we While regional anaesthesia training has made
practise, has been influenced by innovations in technology. tremendous progress, it is wise to remember the words of
Specialised training in regional anaesthesia has evolved Greek philosopher Heraclitus: “Change is the only
from apprenticeships to established programmes in constant.” The global pandemic of coronavirus disease
graduate medical education. “See one, do one, teach one” 2019 (COVID-19) has touched all aspects of life and forces
is no longer acceptable as a model for regional anaesthesia us to think of new ways to deliver education. The old ways of
training. More recently, there has been a focus on using teaching regional anaesthesia with in-person didactics in

© 2021 Association of Anaesthetists 53


Anaesthesia 2021, 76 (Suppl. 1), 53–64
tightly packed lecture halls, formaldehyde-infused cadaver
anatomy labs and workshops limited to specific sites with
minimal protective equipment may no longer apply.
This article will review fundamentals (“Where have we
been?”) and discuss innovations (“Where are we going?”) in
regional anaesthesia training. In the first section on training
fundamentals, we present the current state of simulation-
based education, deliberate practice and curriculum design
based on competency-based progression. In the second
section on innovations, we explore the latest developments
in web-based learning, emerging technologies for teaching
and assessment and alternate reality learning systems.
Fundamentals of regional anaesthesia
training
Simulation-based education
Simulation allows participants to perform aspects of
necessary procedural and non-technical skills within a safe
environment (e.g. simulation centre) and without putting
patients at risk. This ability to replicate clinical tasks,
combined with an opportunity to practise, has multiple
advantages. Simulation allows mastery of skills through trial
and error; permits expert feedback; creates space for
participant reflection; and may be used to demonstrate
satisfactory achievement of competency before
progressing to patient care [1].
A meta-analysis of simulation vs. non-simulation
training by Cook et al. [2] showed improvement in all
measurable learning outcomes such as time taken;
procedural flow; and successful task completion. The best
use of simulation was found for technical and professional
skillsets, as opposed to improving theoretical knowledge.
As simulation training is often considered more expensive
and resource-intensive than didactic teaching, a curriculum
blending both types of educational modalities may provide
the best balance of effectiveness vs. cost.
In regional anaesthesia training, simulation may
describe in-vitro models to practise ultrasound-guided
needling skills; technological aids such as web-based
multimedia learning or virtual reality/haptic trainers; or full
team-based simulation of local anaesthetic systemic toxicity
crisis management with sophisticated manikins. Recent
qualitative systematic reviews have confirmed the
usefulness of simulation when integrated into regional
anaesthesia teaching [3–5]. Further refinements in the use of
simulation in regional anaesthesia should aim to define cost
effectiveness of specific types of simulation, which includes
translation into measurable improvements in patient safety
and clinical outcomes. Heterogeneity in our education
methodology hampers generalisation, and Chen et al.
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Ramlogan et al. | Training methods in regional anaesthesia
argued that the regional anaesthesia community should
commit to a core set of standardised assessment tools and
educational outcomes for future studies [5].
Deliberate practice
Deliberate practice is part of an educational framework
postulating that expertise is gained through structured
training in the multiple part-tasks of a more complex
procedural skill [6]. It emphasises individualised teaching
provided by expert faculty, setting specific learning
goals and cycles of repetition of the task combined with
feedback [7].
Most regional anaesthesia studies have confirmed an
educational benefit of deliberate practice compared with
discovery learning [8–10], although one study did not [11].
Importantly, deliberate practice is only as good as the
expert faculty [12]; quality of feedback is more influential
than simulator fidelity [13]; and how well the faculty has
been trained can influence the outcome [14]. One method
to assist faculty may be using assessment tools to frame the
feedback, as done by Ahmed et al. [8] and de Olivera Filho
et al. [9]. Termed formative assessment, or assessment for
learning, feedback is structured by the individual items in a
checklist or global rating scale. This allows faculty to provide
a granular discussion of successes and opportunities for
improvement based on the trainee’s performance.
Part-task trainers
Available models span a continuum of fidelity, from home-
made gelatin/agar constructs to fresh frozen cadavers.
Recent innovations include three-dimensional (3D) printing
of skeletal structures that are anatomically accurate for
neuraxial blocks [15] and the use of Thiel method cadavers
that are flexible, soft-embalmed cadavers with acoustic and
hydrodissection characteristics observed in vivo, yet are
more durable than fresh cadavers [16]. In a randomised trial,
a meat-based phantom provided equivalent effectiveness
to fresh frozen cadavers when used for teaching novices
ultrasound-guided needling skills [17], suggesting that
cheaper models may effectively substitute for expensive
alternatives for teaching certain tasks.
Competency-based education
The rapid evolution of regional anaesthesia training is
occurring within a broader shift towards competency-based
medical education [18–20]. Tangible changes as part of this
shift include simulation and deliberate practice, as
described above, and the concept of longitudinal
assessment throughout training compared with traditional
final examinations. Recently, national accreditation of 1-year
© 2021 Association of Anaesthetists

Ramlogan et al. | Training methods in regional anaesthesia
regional anaesthesia fellowship programmes in the USA has
been based on trainees’ achieving learning outcomes and
meeting competency milestones consistently during
training [21]. Guidelines similarly exist for other national
fellowship programmes, such as in Australia and New
Zealand [22]. The establishment of a standardised
curriculum for regional anaesthesia fellowships represents
one step towards the aspirational goals of equality in
education and improvements in patient care throughout a
country by providing benchmarks for volumes of practice,
expected levels of professional performance and a
definition for quality among the teaching faculty [23].
As an example of applying a competency-based
curriculum, it is possible to link granting of trainees’
privileges to the demonstration of competency within a
simulation environment; such a system has been proposed
in anaesthesia [24] and surgery [25]. A trainee may only
progress to ultrasound-guided needling practice on a
phantom if satisfactory sonoanatomical knowledge has
been established using a multiple-choice question
assessment. Other researchers are developing entrustable
professional activities, emphasising progressive
achievement of unsupervised practice through discrete
clinical tasks [26, 27]. Both types of competency-based
progression are complementary, as they assess the trainee
during simulation and in the clinical environment.
This translation of performance benefit during
simulation to clinical practice remains a high-priority
research area in regional anaesthesia education [28]. Not all
anaesthesia trainees will pursue a regional anaesthesia
fellowship. To maximise impact on clinical care and ensure
the greatest number of patients have access to regional
anaesthesia, standardised high-impact regional
anaesthesia training should be integrated into core
anaesthesia training and continuing professional
development. Compared with fellowship training which has
the goal of producing experts, core residency training in
regional anaesthesia should emphasise achieving
competency in a smaller number of blocks with well-
established techniques and common surgical indications
[23]. By limiting this ‘basic blocks package’ to the most high-
impact blocks, there is greater likelihood of training more
general anaesthetists in regional anaesthesia and ensuring
beneficial regional anaesthesia outcomes.
A number of studies have attempted to associate
retention of knowledge/skills and patient benefits after a
regional anaesthesia educational intervention [29–31].
Unfortunately, methodological issues have limited the
strength of the evidence to date. Ultimately, the effects of
our interventions on patient-oriented outcomes matter
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Anaesthesia 2021, 76 (Suppl. 1), 53–64
most, and much more research is needed. Translational
research comes in two types: (1) translation of basic science
research results into potential human application; and (2)
translation of human subjects’ research results into routine
clinical practice [32]. For regional anaesthesia education
research, more type two translation is needed with
subsequent demonstration of improvement in patients’
quality of recovery, pain trajectory, functional outcomes and
reduction in opioid use.
Innovations in regional anaesthesia
training
Web-based learning
The world wide web is 30 years old and web-based learning
is now ubiquitous in Western undergraduate and
postgraduate medical programmes. It has been espoused
to enhance learning because it can provide a wealth of
engaging activity to stimulate the learner, and it is available
from almost anywhere at any time. Although modern end-
users may prefer web-based learning formats, it has not
been demonstrated to be better than traditional teaching
methods in terms of knowledge acquisition [33].
The diversity of variables involved in web-based
learning (Table 1) necessitates that educators carefully
consider their learners and learning context to determine
the most effective components [34]. Features of web-based
learning that have been found most beneficial to
knowledge acquisition include high interactivity (e.g.
questions; self-assessments) and detailed feedback [35].
Several web-based learning studies have assessed
knowledge improvement based on the theme of ‘spacing’
vs. ‘repetition’ [35]. Spacing refers to distributing small
amounts of learning activities over an extended period of
time. Repetition refers to repeating the same task or
instructions multiple times during the same learning
module. There may be some benefit of repetition over
spacing although the effect-size is small [35]. Similarly,
massed vs. distributive practice has not been found to lead
to significant differences in learning sonographic skills for
axillary block [36]. Notably, online discussions and audio
tutorials have not been associated with improvement in
knowledge acquisition but receive high satisfaction scores
by healthcare learners using web-based learning [35].
Educators need evidence-based guidance on how to
develop effective web-based learning [35]. Research into
the effective designs of web-based learning in regional
anaesthesia is sparse. Kopp and Smith investigated whether
module design and learner preferences played a role in
web-based learning for anaesthesia residents [37]. The
investigators postulated that residents would perform
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Anaesthesia 2021, 76 (Suppl. 1), 53–64 Ramlogan et al. | Training methods in regional anaesthesia

Table 1 Categories of learning tools used in website designs in web-based courses for health professionals [34].
Category Examples
Configuration • Multimedia
• Videoconferencing
• Discussion boards
• Slideshows
• Virtual patients
Instructional methods • Practise exercises
• Self-assessments
• Feedback
• Patient cases
• Adaptation (tailoring of course content based on learner responses)
Presentation • Animations
• Audio
• Hyperlinks

better using interactive case-based material compared with group, but hands-on ultrasound interpretation skills were
an online traditional textbook format. To the contrary, post- the same in both groups.
test scores were the same regardless of the learning module Niazi et al. developed an online neuraxial ultrasound
design. The majority of the surveyed residents believed that model to provide residents with interactive teaching on
interactive web-based learning should be a component of lumbar spine anatomy and sonoanatomy and allow the user
all anaesthesia rotations but not replace didactic lectures. to practise virtual transducer movements to view the
Surprisingly, residents rated themselves as primarily visual interlaminar spaces and perform landmarking (http://
learners as opposed to verbal learners, yet the results usra.ca/virtual-spine/vspine.php) [39]. This free web-based
indicated that they perform equally well regardless of the learning tool has been shown to significantly improve
modality. The investigators suggested that anaesthesia residents’ knowledge of spine anatomy and sonoanatomy
residents are high-functioning learners, who can acquire [40]. Furthermore, this interactive virtual spine model has
knowledge from different formats, despite their personal also been found to improve pre-puncture neuraxial
learning preferences. scanning to identify the L3–4 interspace and depth to the
Teaching the modern learner in regional anaesthesia ligamentum flavum [39]. This is one of the few web-based
requires not only imparting knowledge, but also learning tools to show a transfer of knowledge to the clinical
specialised development of peripheral nerve and setting.
musculoskeletal ultrasonography skills. With the Translating sonography and anatomical knowledge
advancement of webpage programming and into practical procedural performance remains a challenge,
microprocessor speeds, online simulators that emulate and this is where deliberate practice may play an important
live sonograms have been developed. Woodworth et al. role [6]. While the knowledge aspects of regional
conducted a study to determine the effectiveness of a anaesthesia (e.g. anatomy; pharmacology) appear to be
web-based sciatic nerve-block interactive simulation and amenable to self-paced web-based learning, the
video, in teaching ultrasound image acquisition and development of procedural skills is limited by the need for
interpretation [38]. The video presented anatomy of the practice [6], specific feedback [6] and self-reflection of how
posterior thigh, and the computer-based simulation cognitive knowledge is incorporated into learning motor
involved sliding a virtual ultrasound transducer along the skills [41, 42]. It is likely that the virtual spine model
popliteal-fossa to the gluteal area and viewing the demonstrated improved clinical performance [39] because
corresponding magnetic resonance imaging and residents had ongoing access to it for 2 weeks before
sonography. The control group did not have access to testing, compared with only 5 min for the sciatic model [38].
the web-based learning resources, but both groups had Thus, we can speculate that residents require an ample
the opportunity to practise scanning on live models. The opportunity for repetition and reflection of the relationship
experimental group had the opportunity to use the virtual between anatomy and sonography.
simulator for 5 min. Interestingly, knowledge Financially constrained educators need not invest in
improvement was higher in the web-based learning developing all of their own web-based learning tools as

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Ramlogan et al. | Training methods in regional anaesthesia
many online resources are available for free or at nominal
cost (Table 2). The Anesthesia Education Toolbox was
initially developed by five academic departments in the USA
to house learning material for regional anaesthesia. This
collaborative educational platform has expanded into a
variety of anaesthesia subspecialties and is maintained by
over 45 anaesthesia departments globally. The site hosts a
broad array of educational materials including e-learning
modules; test questions; problem-based learning
discussions; podcasts; simulation scripts; procedural skills
training guides; a video/image library; and competency
assessment tools [43].
Emerging technology: artificial intelligence, wearable
devices and eye-tracking
We use machine-learning systems on a daily basis in our
electronic devices to identify faces and objects in
images; convert speech into text; select products of
interests for purchase; and find relevant results of a
literature search [44]. Machine learning is the foundation
for artificial intelligence. Historically, artificial intelligence
technology was limited by the need for raw data to be
entered. Representation learning is a method of machine
learning that enables the machine to use raw data to
discover the representations required for detection or
classification [44]. Deep learning uses the raw data and
transforms it to create multiple different levels of
representation. It is analogous to multiple layers of
neurons that make up a neural network, allowing the
system to learn functions as complex as autonomous
driving [44, 45]. Deep learning has produced artificial
intelligence systems capable of matching or
outperforming humans in image recognition of skin
cancers and diabetic retinopathy [45].
A recent scoping review [46] to assess the breadth of
artificial intelligence research in anaesthesia revealed 173
studies, involving primarily risk prediction, depth of
anaesthesia monitoring and control of anaesthesia delivery.
There were 11 studies describing the use of artificial
intelligence techniques to assist in the performance of
ultrasound-based procedures. The authors found that
neural networks have been trained to identify and
differentiate blood vessels in ultrasound images, as well as
assist in identification of intervertebral level and lamina for
epidural placement. Artificial intelligence systems have the
potential to predict the outcome of a procedure by using a
machine-learning algorithm to analyse multiple data
sources [47]. One of the advantages of machine learning is
its ability to continuously adapt as more data become
available [46].
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Many data sources for machine learning are already
available and being used to innovate within other fields of
medical education [48–50]. Wearable recording devices are
typically small portable electronic monitors worn by a
person to collect data without impeding the task [51]. First-
person perspective wearable recording devices (e.g. LED
daylite NanoCam HD, Google Glass and GoPro) can be
used to record tasks, which can then be reviewed by the
trainee for reflection and self-assessment of performance
[49, 51, 52]. Google Glass (Alphabet Inc., Mountain View,
CA, USA) also has voice-controlled communication features
and broadcast features via Bluetooth technology,
potentially allowing an instructor to teach trainees or
practicing physicians, in real-time, even when not in the
same room or same city [48].
Another type of wearable device is the head-mounted
display device, which allows for super-imposing ultrasound
screen images onto eye-glasses. The device may attach to
pre-existing eye-glasses or may take the form of standard
eye-glasses with digital input. A number of studies have
assessed the feasibility of these devices for ultrasound-
guided regional anaesthesia training in performing a
simulated needling task [53–55]. Head-mounted displays
have been found to reduce needling time [54, 55]; improve
needle viewing [54, 55]; reduce unintentional transducer
movements [54]; and reduce head movements [53, 54]. It
would appear that head-mounted displays may improve
efficiency and help reduce the frequency of some of the
quality-compromising manoeuvres that Sites et al.
identified in novices, specifically poor ergonomics (head
turning > 45°) and unintentional probe movements [56].
Head-mounted displays likely affect these novice
behaviours because the operator does not need to adjust
head position when viewing both the ultrasound image and
the procedural site simultaneously.
Eye-tracking technology has been used as a means of
improving training, as well as providing feedback and
assessment in the fields of surgery, radiology and pathology
[57]. Eye-tracking identifies gaze fixations and measures eye
movements of a user while performing a task and can be
used to determine a user’s focus of attention [57]. This
technology has been used to assess medical image
interpretation [58] as well as performance of medical
procedures [59] and thus it may lend itself well to
ultrasound-guided regional anaesthesia training.
Compared with novices, experts tend to fixate their gaze on
the target for a longer period of time before a critical
movement (Fig. 1) [60]. This has been referred to as the
‘quiet-eye period’. Longer duration quiet-eye is associated
with a cognitive process, akin to focusing on the task, as
57
 Table 2 Examples of web-based learning sites with varying multi-media platforms and their target end-user. £ = < 100 GBP; ££ = 100–500 GBP; £££ = 500–1000 GBP; £

58
£££ = > 1000 GBP.
Name Web address Features Cost Target audience
Anaesthesia Tutorial of the Week www.wfsahq.org • Various anaesthesia topics including No cost Anaesthetists, trainees
regional anaesthesia
• Downloadable files with images
• Knowledge tests
Anesthesia Toolbox www.anesthesiatoolbox.com • Interactive learning modules for various Variable Trainees
anaesthesia topics
• Problem-based learning cases
• Test questions
• Discussion board
Block Jocks www.blockjocks.com Educational videos ££ annually; Anaesthetists, trainees
Anaesthesia 2021, 76 (Suppl. 1), 53–64

• Procedural videos monthly

• Lectures subscription
• Live Webcasts also available
• Some free videos
•
E-Learning Anaesthesia www.tutle.courses • Peer-reviewed and written by experts at the £ per module Trainees
Royal College of Anaesthetists
• Various interactive modules
• Knowledge tests
Gulf Coast Ultrasound Institute www.gcus.com • Video lectures ££ annually Anaesthetists
• Scanning demonstrations
• Course handouts
• Interactive components
• Knowledge tests
Masters in Principles of Regional Anaesthesia www.uea.ac.uk • Online Masters programme through ££££ Anaesthetists, regional
University of East Anglia anaesthesia fellows
• Six 16-week modules
NYSORA Regional Anesthesia Learning System www.nysoralms.com • Interactive platform featuring a variety of £ annually Anaesthetists
courses on specific blocks and regional
anaesthesia topics
• Downloadable high-resolution graphics for
personal presentations
• Discussion board
Oregon Health and Science University www.ohsu.com • Interactive course modules ££ annually Anaesthetists, trainees,
Ultrasound-Guided Regional Anesthesia Training • Companion e-book students, other
• Ultrasound clips physicians and allied
• Guided practice for needling on a phantom health professionals
• Knowledge tests
Ultrasound for Regional Anesthesia www.usra.ca • Comprehensive review of blocks No cost Anaesthetists, trainees
• Videos, images
• Paid workshops also available

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Ramlogan et al. | Training methods in regional anaesthesia
opposed to a slowing of motor movements of the hand [60].
Harrison et al. examined the gaze pattern of a novice
compared with an expert performing an ultrasound-guided
paravertebral block on a part-task trainer using the Tobii Pro
Glasses 2 (Tobii Pro AB, Stockholm, Sweden) eye-tracking
head-mounted glasses [61]. Similar to other fields, the
ultrasound-guided regional anaesthesia expert spent more
time gazing at the area of interest (the needle tip) whereas
the novice’s gaze was scattered throughout the sonogram,
particularly when trying to locate the needle. The expert was
also noted to briefly gaze at the skin before needle insertion,
whereas the novice had multiple points of fixation on the
skin and transducer before needle insertion. Quiet-eye
training and the fixation points of experts have both been
employed to refine the skills of trainees in surgical
procedures [57]. Harrison et al. postulate that eye-tracking
can be used to establish benchmarks for metrics in
performing ultrasound-guided regional anaesthesia;
compare the effectiveness of different teaching
interventions; and assess the acquisition of competence
[61].
Machine learning algorithms have been applied to
radiologists’ gaze patterns and cognitive opinions in
predicting diagnostic errors reading mammograms [62].
Shorten et al. make a compelling argument for the use of
this technology to improve training in ultrasound-guided
regional anaesthesia [47]. They suggest that the same data
used to teach artificial intelligence systems can be used to
assess and improve the performance of trainees. With
enough data sources (e.g. video; ultrasound; eye-tracking),
it is conceivable that a machine-learning system can
discover which ultrasound-guided regional anaesthesia
behaviours, manoeuvres and gaze patterns are predictive of
Figure 1 An eye-tracking heatmap demonstrating the gaze fixations of an expert identifying the target site for a supraclavicular
block. The majority of gaze fixations are concentrated on the ‘corner pocket’ and the divisions of the brachial plexus. A,
subclavian artery; R, first rib.
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Anaesthesia 2021, 76 (Suppl. 1), 53–64
a successful outcome. The same data sources can also be
used to design a guidance system to assist the trainee
during clinical performance of ultrasound-guided regional
anaesthesia. Employing such a guidance system, the trainee
could receive real-time feedback on optimal patient
positioning, ultrasound image interpretation, needle
positioning and suggested targets for injection [47] akin to
deliberate practice. Guidance system feedback may be
even more favourable to the practicing anaesthetist who no
longer has the benefit of being supervised by a consultant
regional anaesthetist.
Alternate reality learning systems
Alternate reality simulators have been used for training and
education in the airline industry for many decades. It has
made its way into a variety of applications for medical
education from undergraduate anatomy [63] to surgical
training [64]. The three categories of alternate reality
technologies are summarised in Table 3. Evidence for the
use of this technology as an educational tool for practising
and improving procedural skills is mounting. Virtual reality
and augmented reality technology have the potential to
bridge the gap between hospital productivity, resident
work-hour limitations and the need for clinical experience to
gain technical skills. Learners have found that virtual reality
learning systems are engaging which increases motivation
to learn and allows students to explore at their own pace
[64]. When orthopaedic surgery residents were trained to
perform anterior hip arthroplasty using a competency-
based simulation curriculum using immersive virtual reality,
they were able to significantly reduce the number of errors
the need for assistive prompts and procedural duration [65].
In a physical world assessment, the residents matched their
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Anaesthesia 2021, 76 (Suppl. 1), 53–64 Ramlogan et al. | Training methods in regional anaesthesia

consultants in all but one of the metrics. The authors
attributed the lack of haptic feedback in virtual reality
environments for this shortfall, and this will also be a
limitation if applied to regional anaesthesia. Mixed reality
environments may provide some haptic feedback through
the use of manikins. Educators have used the HoloLens
(Microsoft Inc., Redmond, WA, USA) to augment cardiac
ultrasonography by overlaying virtual anatomical
perspectives onto a transoesophageal and transthoracic
echocardiography manikin-based simulator [66]. Similarly,
an ultrasound-guided regional anaesthesia learner could
correlate the two-dimensional (2D) ultrasound image with
the 3D anatomical hologram on a physical manikin,
potentially improving the learning curve of grasping
ultrasonography skills.
A virtual reality simulator for regional anaesthesia was
developed more than a decade ago for practicing inguinal
region nerve blocks using 3D imaging based on magnetic
resonance imaging and angiography data from five
subjects, thereby allowing for variation in anatomy [67, 68].
This virtual reality simulator integrates a haptic feedback
device for steering a virtual needle as well as force feedback
when virtual tissue contact occurs. The prototype was later
updated to incorporate ultrasonography. Coined the
RASimAs, it also includes a software ‘assistant’ that can
identify structures when scanning the inguinal region for a
femoral nerve block [69].
Most virtual reality studies have used commercial
haptic devices due to cost-benefit considerations [70].
Although these devices are capable of producing force
feedback when a virtual needle makes contact with tissue,
the ergonomics and bulk of the haptic device can be a
limiting factor for training in ultrasound-guided regional
anaesthesia. With the advent of 3D printing, prototypes
have been developed to modify the commercial devices
and incorporate real needle hubs to improve the face
validity of the virtual environment [71, 72]. Apart from
hardware interface limitations, studies in virtual reality
education have identified four other concerns including:
overhead costs related to equipment and training; usability
of hardware and software; lack of feedback; and lack of
engagement [64]. Learners have also reported side-effects
such as headache, dizziness and blurred vision [63].
There is a vast amount of ongoing research in this
technology for medical applications [70, 73], and it is likely
only a matter of time before commercial devices are readily
available for ultrasound-guided regional anaesthesia
training.
Putting it all together
The use of phantoms to simulate ultrasound-guided
peripheral nerve blocks allows for safe practice and
improvement of needling skills, particularly when expert
feedback is provided for deliberate practice. Cost-efficient
meat-based phantoms have proven to be just as effective as
more expensive models for teaching novices.
Understandably, simulation in ultrasound-guided regional
anaesthesia is commonly used for teaching procedural,
professional and communication skills, as opposed to
knowledge. However, there is increasing use of simulation
in the form of objective structured clinical exams for
assessment of trainees during uncommon or challenging
clinical scenarios in regional anaesthesia [74]. Debriefing
after these sessions allows for reflection and education.
These pedagogical methods are complementary for
trainees to demonstrate achievement of milestones towards
competence and independent practice. However, robust
evidence for transfer of skills from simulation to clinical
practice in regional anaesthesia is pending. Within the
regional anaesthesia competency-based medical
education framework, it is imperative to develop curricula
focusing on blocks that are proven effective, clinically

Table 3 Categories of alternate reality learning systems.

Head-mounted
Modality Key elements device examples
Virtual reality • The user is visually separated from the real world using a head- • Oculus
mounted device • Samsung Gear
• The user can navigate through the virtual world and interact with • HTC Vive
virtual objects via a handheld controller • Google Cardboard
Augmented reality • Digital holographic objects are super-imposed on the real • Meta 2
world to create a composite view • Vuzix Blade
• Users can interact with both environments • Google Glass
Mixed reality • Similar to augmented reality, except that the computer- • Microsoft Hololens
generated objects can be manipulated and are made to appear
more real than augmented reality
• Nreal Light

60 © 2021 Association of Anaesthetists


Ramlogan et al. | Training methods in regional anaesthesia
Figure 2 The ultimate purpose of educational strategies and interventions in teaching regional anaesthesia is to improve
patient outcomes. Educators can select from a variety of fundamental approaches and innovations, based on their budget, to
meet this objective.
efficient and easily adoptable to any practice. This will have
the greatest potential to increase patient access to regional
anaesthesia and improve outcomes [23]. Ideally, this would
take the form of a standardised curriculum for regional
anaesthesia training.
Web-based learning provides for a variety of multi-
media options for learning the knowledge component of
regional anaesthesia, though there is some evidence that
virtual neuraxial scanning translates to clinical sonography
skills [39]. A profound benefit of web-based platforms is that
it facilitates ‘just-in-time learning’, that is, the information can
be reviewed just before it is required to perform a
procedure. Apart from knowledge testing with multiple
choice questions, a shortcoming of web-based learning is
the lack of immediate feedback. One consequence of
COVID-19 is the acceptance of learning at a distance such
as web-based learning and perhaps it will advance the
capabilities of this form of teaching. Platforms such as
Coursera (Coursera Inc., Mountain View, USA) and Udemy
(Udemy Inc., San Francisco, USA) provide a means of
hosting recorded lecture series for entire courses; while
Zoom (Zoom Video Communications Inc., San Jose, CA,
USA), Microsoft Teams (Microsoft Inc.) and Cisco WebEx
© 2021 Association of Anaesthetists
13652044, 2021, S1, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15244 by Turkey Cochrane Evidence Aid, Wiley Online Library on [11/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2021, 76 (Suppl. 1), 53–64
(Cisco Systems Inc., San Jose, CA, USA) provide a means of
discussion during live webcasts. It is conceivable that the
use of head-mounted devices to demonstrate performance
of a regional anaesthetic to a captive online audience may
be one of the next steps in facilitating distance learning.
Alternate reality learning systems can facilitate
repetition of procedural skills without incurring patient
harm, but cognitive skills such as knowing the next step in a
procedure; how to proceed in the face of challenging
anatomy; how to manage patient discomfort and adverse
events remains a limitation. Moreover, training faculty in
providing feedback will enhance learning more than the
fidelity of a simulator [13].
In summary, this review has examined the education
principles used to teach trainees during a dedicated
regional anaesthesia rotation, as well as innovations in
learning new techniques for the consultant or advanced
clinical fellow. Each provides benefit to learning, but it is
clear that no single modality is adequate on its own for the
variety of skills required in the performance and
management of regional anaesthesia. Thus, educators must
employ a balanced approach (Fig. 2) that takes into account
patient outcomes and the limits of their budget.
61

Anaesthesia 2021, 76 (Suppl. 1), 53–64
Acknowledgements
EM’s contribution to this material is the result of work
supported with resources and the use of facilities at the
Veterans Affairs Palo Alto Health Care System (Palo Alto,
CA, USA). The contents do not represent the views of the
Department of Veterans Affairs or the United States
Government. No external funding or competing interests
declared.
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