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EDITORIAL Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 77-79
Ultrasound education in anaesthesia: Turning the tables on convention

Anaesthesia and Pain Management Research Unit, Department of Pharmacology, University of Melbourne, Victoria, Australia

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How to cite this article:
Royse C. Ultrasound education in anaesthesia: Turning the tables on convention. Ann Card Anaesth 2008;11:77-9

How to cite this URL:
Royse C. Ultrasound education in anaesthesia: Turning the tables on convention. Ann Card Anaesth [serial online] 2008 [cited 2022 Jan 20];11:77-9. Available from:

Echocardiography and surface ultrasound have been used in anaesthesia for the last 15 years. The initial phase of ultrasound use was restricted to cardiac anaesthesia and transoesophageal echocardiography. When I started using echocardiography in 1995, this practice was considered "somewhat strange", though there was considerable interest among colleagues. In 1995, there were no echocardiography education courses for anaesthetists, and there were very few texts on the use of transoesophageal echocardiography available. Most early practitioners were essentially self-taught. The use of transoesophageal echocardiography in cardiac anaesthesia required diagnostic-level skills, with an expectation of providing a cardiology-level service. Although this forced cardiac anaesthetists to gain those skills rapidly, the undesired consequence was to restrict echocardiography to cardiac anaesthesia practitioners only.

In more recent times, we have seen rapidly growing interest in surface ultrasound applications, including ultrasound-guided procedures (such as vascular access or nerve blocks) and limited transthoracic echocardiography. Other aligned speciality groups such as intensive care and emergency medicine have identified the need for both limited and diagnostic-level echocardiography in their practice. As cardiac anaesthetists well know, echocardiography changes the way we manage patients; and it is entirely logical that non-cardiac anaesthesia, intensive care, emergency specialists, and surgeons should embrace ultrasound and echocardiography. We are at the footsteps of a major evolution in clinical practice, where ultrasound will become such an integral part of our practice that it will be considered "ultrasound-assisted examination", rather than seen as a separate investigation.

Education is paramount in facilitating these developments. Although pioneers tend to practice first and catch up on education later, it is far better to educate first and practice later. Comprehensive education is also important for providing consistency in practice. The problem is that diagnostic echocardiography requires a long and considerable education process, which makes it difficult for many current practitioners to achieve the knowledge base and skills required. If we examine the utility of ultrasound in anaesthesia and critical care, it becomes obvious that haemodynamic state and basic assessment of valve function will provide most of the information that will guide management decisions in most patients. This level of knowledge base is substantially less than what is required for diagnostic practice. It is also possible to use transthoracic echocardiography in many patients in the operating room, preoperative clinic, or intensive care unit where there is no concurrent chest surgery.

In order to facilitate widespread use of ultrasound in anaesthesia, it is important to "turn the tables on convention" and view ultrasound education as a progressive knowledge base and skill set, rather than going first up for the full diagnostic training. Anaesthetists should start using surface ultrasound applications to guide nerve blocks or vascular access, then progress to limited transthoracic echocardiography, and finally (if required) progress to diagnostic-level education and the use of transoesophageal echocardiography. Although limited studies can be performed with transoesophageal echocardiography, there is a body of opinion that because it is an invasive procedure, full diagnostic studies should always be performed.

There are two components to ultrasound education: knowledge base and practical skills. Traditionally, anaesthetists have learned ultrasound through fellowships, supplemented by personal study. Whilst the traditional fellowship model provides excellent opportunity to acquire images, it is usually lacking in providing adequate knowledge base. The acquisition of images is actually not that difficult and can be achieved easily. What is difficult is the acquisition of knowledge base, particularly at the diagnostic level. It is the knowledge base that separates a highly skilled echocardiographer from an inadequate one. It is important, therefore, to change the traditional model and to provide educational opportunities for knowledge base separate from practice. With multimedia applications, it is easy to provide a knowledge base via a distance education model, supplemented by textbooks, [1] short courses, and workshops. The level of interactivity is ever growing, with practitioners now able to perform measurements on echocardiography images on their computers and build up a large body of experience of case reviews and the pathology, separate from acquiring the images. Practical skills are important to acquire, as the model in anaesthesia and intensive care is that the practitioner, rather than a technician, performs the echocardiography examination. The acquisition of skills can be taught at workshops, or on-the-job, supervised by trained colleagues.

What is important to appreciate is that the knowledge base and practical skills required to start using ultrasound are very achievable if the anaesthetist starts with surface ultrasound applications. At the University of Melbourne, for example, we have produced education packages for surface ultrasound uses that require about 40 hours of study, and attendance at a two-day hands-on workshop. For the limited transthoracic echocardiography examination (HEARTscan - haemodynamic echocardiography assessment in real time), the basics of haemodynamic state evaluation and basic valvular assessment using two-dimensional and colour flow Doppler imaging are taught over that time frame. We have previously determined that about 30 studies are required by a novice to reach agreement with an expert, for limited studies. [2] This level of education is achievable for most practitioners in anaesthesia and intensive care medicine. For those practitioners wishing to obtain diagnostic-level knowledge base, the level of commitment is substantially greater, as the knowledgebase is similar in magnitude to a second part examination for a speciality college. The University of Melbourne has produced a distance-based diploma course which can be completed over one or two years and is designed to provide diagnostic-level education and has now graduated over 250 students worldwide (see ).

Every country must work to find an acceptable solution to training both knowledge base and practical skills. There are now examinations available in the United States and the Europe to provide evidence of knowledge. The problem with examinations, however, is that they examine rather than teach, relying on the students to educate themselves. Training colleges, boards, societies, and hospitals will provide guidelines as to what level of training is sufficient to achieve accreditation at a local level. It is important not to confuse education with accreditation. Good graded education will facilitate the evolution of ultrasound used in our speciality, whereas accreditation will be a local decision on the minimum acceptable standard. These two processes tend to go hand in hand, although education will typically lead the process and accreditation will follow it.

When should ultrasound be taught? In the last few years, it has mostly been specialist anaesthetists learning echocardiography, but should it be integrated as part of the specialist training programmes? The evolution of ultrasound use is now of sufficient maturity that there is now a large enough pool of trained specialists to broaden the education programme to registrars. Limited transthoracic echocardiography (e.g., HEART scan) and ultrasound-guided nerve blocks and vascular access should now become core learning for specialists in training. Diagnostic echocardiography can become a vocational skill for those wishing to accomplish advanced knowledge.

The use of ultrasound is now well established in anaesthesia and critical care medicine. The challenge for the next decade is to provide sensible, graded, and consistent education to allow this important tool to become an everyday part of our clinical practice.

   References Top

1.Royse C, Donnan G, Royse A. Pocket guide to perioperative and critical care echocardiography. 1 st ed. Sydney: McGraw-Hill; 2006. p. 218.  Back to cited text no. 1    
2.Royse CF, Seah JL, Donelan L, Royse AG. Point of care ultrasound for basic haemodynamic assessment: Novice compared with an expert operator. Anaesthesia 2006;61:849-55.  Back to cited text no. 2    

Correspondence Address:
Colin Royse
Department of Pharmacology, Level 8, Medical Building, University of Melbourne, Victoria, 3010
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.41574

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