REVIEW

C URRENT
OPINION A modern roadmap for the use of simulation in
regional anesthesiology training
Amanda H. Kumar a, Ellile Sultan b, Edward R. Mariano b,c
and Ankeet D. Udani a
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Purpose of review
A variety of educational modalities are used to teach regional anesthesia. Simulation is an educational tool
that facilitates hands-on learning in a well tolerated, reproducible environment, eliminating potential harm
to patients during the process of learning. Available literature and expert consensus statements support
customizing simulation programs according to the level of training and experience of the learners.
Recent findings
Simulation is useful for learners of all levels of expertise, though the application and frequency of simulation
must be adapted to meet the learners’ objectives.
Summary
This review presents recommendations for the use of simulation for residents, fellows, practicing
anesthesiologists without formal training in regional anesthesia, and practicing anesthesiologists with
regional anesthesia expertise. Passports and portfolio programs that include simulation can be used to
verify training. Virtual applications of simulation are growing, expanding the scope of regional anesthesia
simulation and increasing access to lower resource areas.
Keywords
anesthesiology, continuing medical education, crisis resource management, medical education, nerve block,
regional anesthesia, simulation, task trainer

INTRODUCTION model scanning, simulated patient encounters, and

The field of regional anesthesia has witnessed rapid
evolution in recent decades with the increased uti-
lization of ultrasound and explosion of new ultra-
sound-guided techniques. It is crucial to match the
pace of this expansion with advances in training.
Incorporation of foundational education principles
has led to the evolution of ‘see one, do one’ appren-
ticeship-style training to competency-based curric-
ula that include both traditional and innovative
&&
training modalities [1 ]. These may include lectures,
problem-based learning discussions, online resour-
ces, and simulation [2]. This article will focus on
the use of simulation for contemporary training in
regional anesthesia.
Simulation represents a range of educational
tools that permit hands-on experience in a well
tolerated setting that eliminates potential harm to
patients and the anxiety of teaching and learning in
the presence patients and families. Educational
tools commonly used in a simulated environment
include part-task trainers or cadaveric models for
procedural task training, high-fidelity models, live
crisis resource management-simulated scenarios.
The simulated environment allows for repetition
of procedural skills, self-reflection, timely targeted
feedback, and observation of others.
SIMULATION FOR SKILL ACQUISITION
AND CRISIS RESOURCE MANAGEMENT
Development of technical skills in regional anesthe-
sia follows a steep learning curve. Novice trainees
a
Department of Anesthesiology, Duke University Medical Center, Dur-
ham, North Carolina, bDepartment of Anesthesiology, Perioperative and
Pain Medicine, Stanford University School of Medicine, Stanford and
c
Anesthesiology and Perioperative Care Service, Veterans Affairs Palo
Alto Healthcare System, Palo Alto, California, USA
Correspondence to Edward R. Mariano, MD, MAS, FASA, Anesthesi-
ology and Perioperative Care Service, VA Palo Alto Healthcare System,
3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA.
Tel: +1 650 849 0254; fax: +1 650 852 3423;
e-mail: emariano@stanford.edu
Curr Opin Anesthesiol 2022, 35:654–659
DOI:10.1097/ACO.0000000000001179

www.co-anesthesiology.com Volume 35  Number 5  October 2022

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

 Use of simulation in regional anesthesiology training Kumar et al.
KEY POINTS
 Regional anesthesia is rapidly evolving, and simulation
is a useful educational tool to teach both trainees and
practicing anesthesiologists.
 Simulation should be used at regular intervals, though
the frequency and objectives of simulation must evolve
to meet the needs of the learner.
 Technological advancement has improved the realism
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of simulation and allows for virtual teaching, reducing
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the need for physical space and expanding the reach.
may require 28 trials of a single nerve block proce-
dure, with iterative practice guided by feedback
from skilled faculty, to attain competency [3]. How-
ever, skills gained from learning one type of nerve
block procedure may not easily translate to another.
Residents in programs accredited by the Accredita-
tion Council for Graduate Medical Education
(ACGME) are required to document 40 patient-care
experiences where ‘peripheral nerve blocks are used
as part of the anesthetic technique or perioperative
analgesic management’ [4]. However, one study
showed that after performing at least 60 supervised
nerve blocks during a regional rotation, residents
still make an average of 2.8 errors per block [5]. The
most common error is advancing the needle with-
out visualization; others include poor transducer
handling and malposition of the target during ultra-
sound imaging. These error types are all amenable to
correction via simulation training.
It is challenging to evaluate the true effective-
ness of simulation. Training programs often intro-
duce a bundle of interventions as part of a
comprehensive curriculum (e.g. lectures, online
resources). Many studies lack a proper control
group, prioritizing the education of learners over
research methodology. Establishing incremental
effectiveness of a simulation-based teaching strategy
may, thus, be arduous [6]. Several studies to date
have attempted to justify the value of resource-
intensive simulation in a training curriculum. A
meta-analysis revealed that simulation training
led to improvements in all measurable learning out-
comes, including knowledge acquisition, proce-
dural flow, and successful task completion [7].
Successful training in the simulation laboratory
can translate to a more successful nerve block per-
formance in the actual clinical setting [8]. Further-
more, simulation appears to be dose-dependent;
learners who practice more simulation may be more
procedurally efficient with fewer technical errors [9].
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Admittedly, not every learner will have routine
access to simulation, and resources can be a major
limitation. Fortunately, trainees who practice pro-
cedural tasks on either a low-fidelity model or high-
fidelity simulator demonstrate similar clinical per-
formance [10]. Potential barriers to implementing
simulation are faculty and staff time to teach and
develop a curriculum, cost of equipment and per-
sonnel, and simulator availability [11]. Ways to
mitigate these challenges include self-directed sim-
ulation-based learning, mobile simulators, and low
cost or even disposable simulators. Regardless, given
that simulation is generally more resource-intensive
than didactic teaching, a blended curriculum that
supports both simulation and traditional methods
may represent an ideal balance of benefit and cost
&&
[1 ].
High-fidelity simulation has a specific role in
learning crisis resource management. Anesthesiol-
ogists serve as expert consultants in managing
acute perioperative pain and unexpected compli-
cations. High-fidelity simulation allows learners to
simultaneously practice managing the patient and
environment at large, with emphasis on rare critical
situations that trainees may not otherwise experi-
ence (e.g. local anesthestic systemic toxicity,
wrong-sided block). Simulation is well established
in resuscitation training, and its repeated use is
associated with skill and knowledge retention
[12]. Importantly, crisis resource management
training focuses on nontechnical skills, such as
situational awareness, communication, and team-
work.
SIMULATION FOR DIFFERING TRAINING
PATHWAYS
Simulation can be helpful for learners of all skill
levels. However, the application, utility, and fre-
quency of simulation must adapt with varying levels
of expertise to best fit the needs of the learner.
The American Society of Regional Anesthesia
and Pain Medicine (ASRA) and the European Society
of Regional Anaesthesia and Pain Therapy (ESRA)
published joint committee recommendations for
education in ultrasound-guided regional anesthesia
(UGRA) in 2009, establishing two pathways differ-
entiating residents from postgraduate anesthesiolo-
gists [13]. Subspecialty training in regional
anesthesiology and acute pain medicine (RAAPM)
has expanded over the past decade, with an increas-
ing number of fellowship programs, leading to large
variation in regional anesthesia experience and
expertise. Here we propose suggestions for the use
of simulation for learners of different levels (Fig. 1).
www.co-anesthesiology.com 655
 Regional anesthesia
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FIGURE 1. A modern roadmap with recommendations for integrated simulation training applicable to learners of differing skill
levels and career stages.
Simulation for trainees in anesthesiology
residency: the `basic trainee'
Core residency training should be the primary means
for establishing basic competency in regional anes-
thesia. Residents must complete a minimum number
of clinical experiences to showcase adequate depth
and breadth of training. Program requirements
for ACGME-accredited programs include dedicated
experiences in regional anesthesia, acute periopera-
tive pain management, and the management of
&
patients with chronic or cancer-related pain [14 ].
Despite these ‘experience-based’ requirements,
there is a wide variation in actual resident peripheral
nerve block volume [15]. Rapid growth in the use of
UGRA techniques, particularly with the emergence
of fascial plane blockade, signals the importance of a
competency-based educational model that does not
rely on experience-based metrics. Simulation offers
the means to apply this model to the learning
curriculum.
An international Delphi consensus study sur-
veyed directors of regional anesthesia training and
experts to design a nonfellowship curriculum for
&&
residency training [16 ]. Suprisingly, many items
that are often considered best practices in the edu-
cation literature did not reach strong consensus,
including the use of part-task trainers (simulation
trainers designed to focus on a single task like a
nerve block) and high-fidelity simulation. Feedback
suggested that cost, equipment accessibility, and
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limited number of teaching faculty may be barriers.
Thus, although it may not be feasible to have a
uniform simulation requirement as part of every
regional anesthesia curriculum, it should ideally
be incorporated whenever possible.
The ACGME requires that anesthesiology resi-
dents participate in at least one simulated intraoper-
ative clinical experience each year. In programs where
simulation is available, we recommend that residents
participate in one regional anesthesia and acute pain
simulation scenario per year. These sessions should
focus on objectives appropriate for a basic trainee
(Fig. 1). We recommend the use of part-task trainers
for preclinical development of needle visualization
skills early in the regional anesthesia rotation. These
trainers are commercially available but can also be
‘homemade’ using easily accessible materials [17,18].
Simulation for trainees in regional
anesthesiology and acute pain medicine
fellowship: the `advanced trainee'
Subspecialty fellowship education promotes exper-
tise, creating leaders in patient care, research, edu-
cation, and innovation. RAAPM fellowship training
programs became eligible to apply for accreditation
by the ACGME in 2016. Though all fellowship train-
ing programs follow guidelines on the organization
of the educational program and evaluation process
[19], accreditation comes with formal curricular
Volume 35  Number 5  October 2022
 Use of simulation in regional anesthesiology training Kumar et al.
requirements, external review, integration of com-
petency milestones, and benchmarks for practice
volumes to ensure that each program provides an
exceptional training experience [4]. In fact, select
procedures may only be recommended for advanced
trainees [20]. Part-task trainers can be used to hone
technical ultrasound and needling skills for more
advanced blocks that are encountered less often
clinically, such as paravertebral blocks [21]. Consis-
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tent and regular use of advanced models may dem-
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onstrate the progress of the fellow from the start to
the end of fellowship.
We also recommend that fellows participate in
at least one RAAPM high-fidelity simulation during
the fellowship year. This simulation should focus on
more complex objectives that an individual trainee
may not personally experience during standard clin-
ical training (Fig. 1). For fellows who just completed
residency, a fellowship year represents dedicated
time when RAAPM expertise is gained, but comfort
with general anesthesia emergencies may wane.
Simulation can also be used to maintain those skills.
The simulation environment also offers a low-pres-
sure setting to provide training in nontechnical
skills. Use of high-fidelity mannequin simulators
voiced by a simulationist or standardized patient
actors can present trainees with the opportunity to
work on interpersonal communication.
Simulation for the practicing
anesthesiologist with no formal regional
anesthesia training
The use of ultrasound has markedly increased over
the past decade. However, amongst practicing anes-
thesiologists, the most frequently cited reason for
not practicing UGRA is lack of training [22].
Simulation is not a novel concept for the post-
graduate anesthesiologist. The American Board of
Anesthesiology (ABA) offers simulation as part of
the Maintenance of Certification in Anesthesiology
(MOCA) program. The ASRA–ESRA joint committee
recommendations suggest several possible avenues
for the practicing anesthesiologist to acquire regional
anesthesia skills [13]. Options include continuing
medical education (CME) simulation events as well
as self-directed practice on commercially produced or
‘homemade’ phantom models. These workshops
have been shown to improve participants’ confidence
levels in performing UGRA [23]. Practicing anesthesi-
ologists but novices in regional anesthesia improved
their skills after participating in part-task training and
high-fidelity simulation; however, the same cohort
did not show any improvement after didactic lecture
and hands-on ultrasound scanning alone [24]. Inter-
estingly, though skill acquisition increased after the
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1-day course, there was no change in the number
of clinical blocks performed or success rate in the
subsequent year posttraining. This highlights that a
1-day workshop, while it provides effective training,
may not be enough to change actual clinical practice.
Repeated education and simulation exposure may be
necessary but not sufficient, and barriers to the suc-
cessful implementation of regional anesthesia are
likely multifactorial [25].
For practicing anesthesiologists with no formal
regional anesthesia training, we recommend par-
ticipation in CME courses with a simulation com-
ponent every 6–12 months until the practitioner
self-reports competency or successfully completes a
formal portfolio program. The simulation compo-
nent should have incrementally complex objec-
tives (Fig. 1). The ASA has an UGRA portfolio
program that includes didactics, technical skills
workshops including simulation, an examination,
and a self-reported case log of clinical experiences.
The Australian and New Zealand College of Anaes-
thetists (ANZCA) has a similar training portfolio
system. The ESRA European Diploma in Regional
Anaesthesia and Acute Pain Management includes
an examintion that distinguishes individuals as
specialists in regional anesthesia and acute pain
management and requires specific practical work-
shops. A portfolio such as these can serve as a record
of professional development, including workplace-
based assessments and direct observational scores.
This can be used to market an individual’s skillset
for future job interviews, demonstrate clinical
experience, and document training completion
whenever applicable.
Simulation for the practicing
anesthesiologist with expertise in regional
anesthesia
ASRA and ESRA specifically acknowledge the expand-
ing scope of UGRA and encourage practitioners, both
trainees and physicians already in practice, to utilize
simulation-based programs. For regional anesthesia
experts, simulation-based training may not be neces-
sary for further skill development unless clinical prac-
tices and technology undergo major changes (Fig. 1).
To improve patient access to regional anesthesia, we
suggest that experts develop and teach simulation
courses, especially as new simulation-based ultra-
sound technology emerges. In addition, we encour-
age the advanced anesthesiologist to conduct
education research focused on the effectiveness of
UGRA training modalities. Simulation can also be
used to assess the teaching skills of faculty in a repro-
ducible environment, allowing for mentorship of
early career faculty.
www.co-anesthesiology.com 657
 Regional anesthesia
THE USE OF SIMULATION FOR SKILL
VERIFICATION
There is still much to be discovered about the sci-
ence of teaching and learning in medicine. There is
no magic number of minimum procedures or educa-
tional courses that will automatically translate to
mastery of UGRA. However, simulation will con-
tinue to be an integral part of the initial training and
ongoing education of anesthesiologists including
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One potential educational tool is a training pass-
port, which learners can use to demonstrate qual-
ifications. Validated simulation-based scenarios
have been used for summative assessment of train-
ees [26]. Assessment of performance within the
simulation environment is associated with clinical
competency [27]. During actual patient care, stand-
ardized assessment can also be accomplished using
validated tools such as the direct observation of
procedural skills [28,29]. These holistic rubrics can
also be used to assess cognitive and affective skills
[30]. A passport can be used to track achievement of
required skills including but not limited to: knowl-
edge of relevant sonoanatomy; identification of
nerve target and correct perineural injection; ability
to vary approach with anatomic differences; main-
tain aseptic technique; real-time needle visualiza-
tion; successful catheter insertion; and management
of potential complications [13].
Admittedly, simulation carries significant bar-
riers, including limited availability, cost, time, and
loss of income when attending courses. Although it is
possible that ongoing professional practice evalua-
tions could be linked to regular demonstration of
competency within a simulated environment, there
is insufficient evidence to support any recommenda-
tions for credentialing or privileging [31]. A strict
simulation requirement with associated costs may
inadvertently lead practicing anesthesiologists, who
already apply their regional anesthesia skills, to aban-
don this practice. We wish to avoid unintended con-
sequences and encourage expansion of well tolerated
regional anesthesia utilization. Each institution must
determine the best way to judge competency and
grant privileges given the varied spectrum of practice
settings and the individualized needs of patients.
LESSONS LEARNED FROM THE
CORONAVIRUS DISEASE 2019 PANDEMIC
AND FUTURE DIRECTIONS FOR
SIMULATION
The coronavirus disease 2019 (COVID-19) pandemic
has required a dramatic shift in medical education.
One benefit of simulation training is that education
can still occur without dependence on clinical
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volume. Moreover, simulation is no longer restricted
to a physical center. Trigger videos can be used to
rouse discussion during virtual teaching, expanding
the audience nationally and internationally. Play-
back of recorded simulation sessions, involving the
learners themselves or not, is a particularly powerful
learning tool. This allows for thoughtful debriefs on
decision pathways and discussions of opportunities
to improve future clinical practice. Lower resource
areas of the world can implement simulation virtu-
ally, even using tele-mentoring with an international
proctor.
Future directions in simulation include the use
of three-dimensional printed models, augmented
and virtual reality, and mixed-reality simulators.
Three-dimensional printing can create mock ana-
tomical models and trainers based on actual patient
anatomy [32]. This can help with preoperative plan-
ning for challenging cases, allowing the practitioner
to practice manipulation of the needle around bony
protuberances, surgical hardware, or anatomical
abnormalities in advance. Three-dimensional print-
ing also allows programs or instructors to tailor the
models for specific learning objectives. Augmented
and virtual reality training simulators are newer
technology that can create realistic environments
and reproducible scenarios without a dedicated
facility [33]. These simulators allow for broad reach,
and updated technology has resulted in great
improvement in realism and even anatomic varia-
bility. We anticipate continued technological
advancement in these simulators, though at present
the haptic feedback is rudimentary. Mixed reality
simulators combine components of three-dimen-
sional printed models, augmented reality tracking
&&
simulators, and virtual anatomic models [34 ]. This
system can track the needle tip, automatically score,
and show replays for after-action review and feed-
back. These simulators are portable and designed for
use in austere environments. Although regional anes-
thesia applications are limited to thoracic paraverte-
bral and thoracic epidural procedures at present, this
mixed model amalgamates many of the advantages of
the individual components.
As the scope of simulation expands, future study
should aim to define the effectiveness of specific
types of simulation, including its translation to
measurable improvements in patient safety, clinical
&&
outcomes, and cost-effectiveness [1 ].
CONCLUSION
Anesthesiologists at all levels can and should utilize
simulation for regional anesthesia training, but rec-
ommendations for the application and frequency
of simulation vary based on the expertise of the
Volume 35  Number 5  October 2022
 Use of simulation in regional anesthesiology training Kumar et al.
learner. Repeated simulation exposure combined
with other tactics that address barriers to imple-
menting change may be the key to influencing
clinical practice. The ongoing pandemic has high-
lighted how simulation can be used virtually to
expand its educational reach.
Acknowledgements
This material has been, in part, supported with resources
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and the use of facilities at the Veterans Affairs Palo Alto
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Healthcare System (Palo Alto, California, USA). The
contents do not represent the views of VA or the United
States Government.
Financial support and sponsorship
None.
Conflicts of interest
A.H.K. has received research funding from Pacira Bio-
sciences. This company had no influence on the contents
of this article. None of the other authors has any finan-
cial conflicts of interest to disclose.
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