ASRA Pain Medicine Update

Cite as: Myhre C, Ip V, Kalagara H. Learning POCUS, part 2: training for anesthesiologists and our future generations. ASRA Pain Medicine News 2024;49. https://doi.org/10.52211/asra050124.011.

Introduction

With expertise in intensive care, obstetrics, airway management, and regional anesthesia, along with both acute and chronic pain management, anesthesiologists are uniquely positioned to oversee patient safety for a diverse patient population across the continuum of the perioperative period.¹ Point-of-Care ultrasound (POCUS) is a cost-effective, efficient, and non-invasive bedside tool to enhance the anesthesiologist’s ability to uphold those perioperative responsibilities.² POCUS is a useful diagnostic tool perioperatively, informing anesthesiologists on the patient’s hemodynamic status, cardiac function, gastric contents, presence of lung pathologies, and more. When patient care decisions are based on accurate image interpretation, a provider’s competence using POCUS as a diagnostic tool is critical. Nonetheless, training in POCUS for practicing physicians remains ambiguous and inconsistent. Some may attend a weekend course organized locally or a more formal course organized by societies such as ASRA Pain Medicine whereby pre-course education materials are available to consolidate background knowledge before the hands-on workshop for better understanding and knowledge retention. Implementation of pre-and post-course tests will further enable physicians to identify strengths and knowledge gaps and may help to direct future POCUS curriculum development. 

The Evolution of Ultrasound as the Anesthesiologist’s Friend

Historically, the use of ultrasound has been the domain of radiologists, gynecologists, and cardiologists.² Today, modern ultrasound offers portability and accessibility with an increasingly improved image quality. In the early 2000s, ultrasound-guided vascular access and its use to guide vascular placement was explored.³ Cadavers were utilized for learning sonoanatomy and fine-tuning ultrasound-guided regional techniques.⁴ In the mid 2000s, ultrasound-guided regional nerve blocks became popular; however, the ultrasound machines available to anesthesiologists did not offer good image quality, making image interpretation challenging. As technology advanced, the ultrasound image quality improved drastically, making ultrasound-guided nerve blocks and vascular access a routine standard of practice. An increasing number of trainees would further their education by pursuing a fellowship to master their skills in ultrasound-guided regional anesthesia. During the last decade, there was an increasing interest in expanding the use of ultrasound beyond regional anesthesia for anesthesiologists in the perioperative arena.⁵ Much effort was invested in gastric ultrasound,⁶ focused assessment of transthoracic echocardiography (FATE),⁷ airway ultrasound, and focused assessment with sonography for trauma (FAST) scan.⁸ The continual developments of technology in ultrasound with artificial intelligence technology will only make ultrasound-guided diagnostic and therapeutic interventions easier to learn and flatten the learning curve for various POCUS techniques. Further, the recent surge in the usage of glucagon-like-peptide-1 agonist drugs for obesity and diabetes increased concern about delayed gastric emptying and increased aspiration risks. The American Society of Anesthesiologists (ASA) has since issued guidance on the usage of gastric ultrasound in these patient populations,⁹ which is a testament for why anesthesiologists need to be familiar with the growing need and usage of POCUS to improve patient safety.

Implementation of pre-and post-course tests will further enable physicians to identify strengths and knowledge gaps and may help to direct future POCUS curriculum development.

Competency Among Anesthesiologists

As the anesthesiologist’s role expands to include that of the perioperative physician, the utilization of POCUS also shifts. As previously mentioned, POCUS is becoming a key tool for both initial assessments and for guiding the care of patients through their perioperative journey.¹⁰ ASRA Pain Medicine is leading knowledge dissemination by having regular POCUS courses and workshops catered to delegates at different levels of their learning and enabling participants to earn a basic FATE certificate. ASRA Pain Medicine is the first subspecialty in anesthesiology that has published expert panel recommendations on education and training for POCUS, and these highlight the pathways to achieve competencies in various POCUS elements.^2,11 There are regular POCUS Spotlight articles in each issue of ASRA Pain Medicine News, featuring high quality images and videos from experts all over the world to help readers appreciate the sonoanatomy and provide tips and clinical pearls to improve scanning techniques. These articles are quite popular, supporting the fact that there is a demand to learn these skills. POCUS Spotlight will continue to be a regular feature in ASRA Pain Medicine News, and some articles are even translated into Spanish–thanks to leadership from Dr. Hari Kalagara and his ASRA Pain Medicine POCUS special interest group.

Training and Assessment for Future Generations

As ultrasound becomes more accessible, various specialties have integrated formal POCUS training within their residency programs, implementing standard of care credentials and guidelines, such as the American College of Emergency Physicians and the Society of Critical Care Medicine.^11,12 These programs have acted in accordance with the American Medical Association, which recommends that POCUS usage and privileges be based on the medical specialty’s standards and training in ultrasound.^2,13 Despite the anesthesiology being at the forefront of the subspecialties significantly benefited by POCUS, Canadian anesthesiology POCUS training standards have not been formalized.²

Within the National Curriculum for Canadian Anesthesiology Residency, The Royal College of Physician and Surgeons describes POCUS as a necessary tool of the anesthesiologist with three overarching perioperative applications; resuscitative/diagnostic, monitoring, and procedural guidance.¹⁴ The curriculum details various POCUS competencies to be met by the anesthesiology resident with the training methods and assessment of such at the discretion of the individual residency program. As identified in a study surveying anesthesiology residency program directors across Canada, the most frequently reported teaching method is informal bedside teaching.¹⁵ As a result, POCUS training may be highly variable for residents, not only between Canadian programs, but within.¹⁵ Formal guidelines are well established for the anesthesiologist performing transesophageal echocardiography and ultrasound for procedural guidance, and in support of the evolving use of POCUS, ASA has recently released expert panel recommendations for diagnostic POCUS.^12,16,17 Given the anesthesiologist’s expanding role as a perioperative physician, diagnostic-specific POCUS training is an opportunity for improvement in Canadian and American anesthesia residency programs.¹⁵

In the United States at the University of California, Irvine, whole-body diagnostic POCUS training has been successfully incorporated into anesthesiology residency training.¹⁸ POCUS examination was determined to change care management in 76% of cases, and clinical examinations demonstrated an increase in new pathology detection at 31%.¹⁸ As such, there is growing support to incorporate whole-body diagnostic ultrasound into anesthesiology residency training nationally. Further, some advocates of formalizing POCUS curriculum have identified that medical students have variable exposure to ultrasound during medical school, resulting in a discrepancy in POCUS skill between new residents.¹⁹ Accordingly, there is growing support for POCUS training to be standardized during medical school.²⁰

The American Board of Anesthesiology has introduced POCUS clinical testing scenarios into board exams, which has triggered mandatory training for most anesthesiology residencies in the United States. Yet, many programs still lack a robust curriculum in this regard. For most physicians interested in attaining competencies in POCUS, ASA has started a Diagnostic POCUS certificate, which has multiple steps involved in a systematic process. This ASA Diagnostic POCUS certificate is a step forward to attain the needed competencies and credentials for performing and billing POCUS in clinical practice with some quality assurance.

Conclusion

The anesthesiologist is uniquely positioned to lead a new frontier in patient care as the perioperative physician. Establishing competency requirements for POCUS as a diagnostic tool may serve to further establish the role of anesthesiologists as perioperative physicians.

Formal curriculum and national training standards, as well as assessment tools for POCUS education amongst anesthesiology residencies, and even in medical schools, enables future anesthesiologists to gain competency and establish a standard more readily. The time has come to embrace POCUS in anesthesiology training programs and clinical practice.

References

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