ABSTRACT
Ultrasound is increasingly used in anesthesia and intensive care medicine for procedural guidance and patient assessment. However, training and formal skills assessment vary, and there is limited knowledge about current ultrasound practices in the Nordic countries. This study aims to survey the availability, daily clinical use, and current state of ultrasound training and skills assessment among anesthesiologists across the Nordic countries. An online cross‐sectional survey, designed according to the Consensus‐Based Checklist for Reporting of Survey Studies (CROSS) guidelines was distributed as a convenience sample across anesthesiology departments in Denmark, Finland, Iceland, Norway, and Sweden, covering a range of hospital types, including regional and university hospitals. The survey consisted of three sections: demographics, ultrasound availability, and procedural use, including skills development and assessment. Key measures included the frequency of ultrasound use, types of procedures where ultrasound was employed, training methods, self‐assessed proficiency, and the frequency of formal skills assessments. An overall response rate of 38% (n = 412) was obtained. Ultrasound was used daily or weekly by 96% of respondents, and procedures where ultrasound was most frequently used were vascular access (97%) and peripheral nerve blocks (83%). Practical training was primarily acquired through clinical use under supervision from colleagues, with limited use of simulation‐based training. Few respondents (27% across procedures) reported formal skills assessments, and self‐assessed proficiency varied, with intermediate and beginner levels being the most common. Retention of skills was rarely assessed, with an average of 8% across procedures. Ultrasound is used almost daily by most anesthesiologists in the Nordic region, with equipment readily available in the departments. Despite its frequent use, training and skills assessments vary with limited focus on ensuring skills retention.
Editorial Comment
This article presents the results of a survey on ultrasound availability, usage and training for anesthesiologists working in the Nordic countries. Keeping in mind responder bias, the availability and usage is high, but there is a low level of reported formal training and skills assessment. This highlights a need for structured training and competency assessment for ultrasound, that could be offered via nordic collaboration.
1. Introduction
Ultrasound is increasingly becoming an important adjunct in anesthesia and intensive care, offering a noninvasive method for patient assessment and procedural guidance across a broad spectrum of patients, from those undergoing elective surgery to critically ill patients [1, 2, 3]. The portability and real‐time imaging capabilities support rapid point‐of‐care evaluation, enhancing assessment of hemodynamic and respiratory conditions, and improving the accuracy and safety of invasive procedures [4, 5, 6, 7].
However, despite its expanding role, training and skills assessment in ultrasound for anesthesiologists often remain inconsistent [8, 9]. The availability of structured training programs is limited, and there is no international consensus on the training and evaluation of anesthesiologists in ultrasound use [10, 11]. Inconsistent education and lack of structured training programs may compromise the ability to interpret images sufficiently, potentially affecting clinical decisions and patient outcomes [12].
International studies highlight significant variations in ultrasound training and utilization across countries [13, 14, 15, 16]. In the United States, less than half of the pediatric anesthesia programs provide formal ultrasound education despite program leaders recognizing its value [9]. Barriers, such as limited financing, sparse training opportunities, and a shortage of qualified instructors, contribute to this challenge [16].
The Nordic countries may be well‐positioned to overcome these barriers with their well‐financed, technologically advanced healthcare systems and strong tradition of medical education. Accessibility to ultrasound equipment is unlikely to be a limiting factor, making the region well‐suited for exploring whether training and skill development keep pace with technological availability. However, to our knowledge, no previous studies have mapped the daily use of ultrasound and skills development among anesthesiologists in the Nordic countries.
To address this, we aim to survey the availability, clinical use, and current state of ultrasound training and assessment among anesthesiologists across the Nordic region.
2. Methods
2.1. Study Design
This study was designed as an online cross‐sectional survey, following the Consensus‐Based Checklist for Reporting of Survey Studies (CROSS) guidelines [17]. The study protocol was published in a peer‐reviewed journal prior to data collection [18].
2.2. Data Collection Methods
2.2.1. Development
A literature search was conducted to identify existing surveys on ultrasound use among anesthesiologists in the Nordic countries; none were found. Consequently, a formative model was employed to develop the questionnaire, incorporating an unbiased and precise vocabulary, clearly defined response anchors and options, dichotomous answers where appropriate, and a mix of closed‐ and open‐ended questions.
2.2.2. Description of Survey
The survey (Supporting Information: Appendix 1) was based on a conceptual model with three main sections: (1) demographics (five questions), (2) ultrasound machine and accessibility (four questions), and (3) procedural use, skills development, and assessment (the number of questions varied). It was designed to be concise, with a maximum completion time of 10 min.
The first section collected respondents' characteristics (country, years as physicians, years in anesthesia, subspeciality, and department size). These were core questions for the respondents. In the second part, core questions on the number of ultrasound machines in the department, availability when needed, and the type(s) of machines and probes were collected. In the third part, respondents were asked which procedures they used ultrasound for in their daily clinical work. This section used branching logic based on respondents' reports to ensure follow‐up questions on training and skills assessment in each procedure used. Finally, an open free‐text section was provided at the end of the survey for additional comments.
2.2.3. Target Population
The target population comprised physicians in anesthesia and intensive care in Denmark (including Greenland and the Faroe Islands), Finland, Iceland, Norway, and Sweden.
2.2.4. Pretesting
Pilot testing was conducted once in each Nordic country, with one anesthesiologist per country participating (i.e., a total of five participants) representing varying levels of experience, including specialists, trainees in residency, and trainees in introductory positions. Both genders were represented, and participants covered a broad age range. Written feedback was collected and used to revise the questionnaire, ensuring clarity and relevance in each setting. This process aimed to optimize the survey to ensure in‐depth responses aligned with the study aim and with pretesting participants closely resembling the target survey population.
2.3. Sample Characteristics
The survey aimed to gather responses from a diverse group of anesthesiologists representing various department sizes, including regional and university hospitals, and anesthesiologists with varying levels of experience. No specific exclusion criteria were set.
2.4. Sampling Technique
The sampling technique was based on convenience sampling, relying on voluntary participation. Local contacts in each country assisted with distribution to maximize reach and participation.
2.5. Survey Administration
The survey was distributed via email and facilitated by local contacts (1–2 per country) connected through previous research networks, an approach deliberately chosen in the hope of maximizing participation. An online platform (REDCap) hosted the survey, ensuring secure storage for the data collection [19]. One reminder email was sent 14 days after the initial invitation to further encourage responses.
The timeline for survey distribution was as follows:
Inclusion period: January to April 2025
Active recruitment: 4 weeks
Reminder emails: After 14 days
2.6. Ethical Considerations
Ethical approval was obtained from the Regional Scientific Ethics Committee in the Region of Southern Denmark, which deemed the study exempt (case number S‐20242000‐87). The project was registered in the Internal Research Register in the Region of Southern Denmark (case number 24/22467). Participation was voluntary and submitting the survey implied consent for data processing. Responses were anonymized and stored securely on a server hosted by a research support unit, the Open Patient data Explorative Network (OPEN). MSN had access to the server, and logins were tracked and supervised.
2.7. Statistical Analysis
Data were analyzed using R and RStudio version 2025.05.1 + 513 (R Foundation for Statistical Computing, Vienna, Austria) [20]. A nonparametric descriptive approach summarized results as counts and percentages. Missing data were handled descriptively, with incomplete responses included in the analysis where feasible.
3. Results
3.1. Respondent Characteristics
A total of 412 anesthesiologists participated in the survey, and the overall response rate was 38%. Figure 1 outlines the number of respondents at each stage of the study, including overall and country‐specific response rates.
FIGURE 1.
Flowchart for survey responses.
Table 1 presents the respondents' characteristics. The majority had between 6 and 20 years of experience in anesthesia (47%) or more than 20 years (29%). Respondents worked across multiple subspecialties, with 87% working with anesthesia and 71% working with intensive care medicine, indicating that many were engaged in both areas (Table 1). Respondents worked in departments of varying sizes, with 19% having more than 50 specialist‐trained anesthesiologists in the department and 10% having fewer than 10, representing both regional and university hospitals (Table 1). To preserve participant anonymity, city‐ or hospital details were not provided.
TABLE 1.
Respondents' baseline demographics.
| Baseline demographics | % |
|---|---|
| Country a | |
| Denmark | 38 |
| Finland | 25 |
| Iceland | 7 |
| Norway | 19 |
| Sweden | 11 |
| Years as physician b | |
| 1–9 years | 26 |
| 10–19 years | 37 |
| 20–29 years | 25 |
| 30 or more years | 12 |
| Years of experience in anesthesia c | |
| < 2 | 9 |
| 2–5 | 16 |
| 6–20 | 47 |
| > 20 | 29 |
| Participants' subspecialties (multiple answers possible) d | |
| Anesthesia | 87 |
| Intensive care medicine | 71 |
| Prehospital care | 17 |
| Pain and palliation | 11 |
| Trained anesthesiologists in respondents' department e | |
| < 10 | 10 |
| 10–30 | 46 |
| 31–50 | 25 |
| > 50 | 19 |
401 answers.
361 answers.
404 answers.
400 answers.
402 answers.
3.2. Availability and Type of Ultrasound Machines and Probes
The number of ultrasound machines varied across departments. In departments with fewer than 10 anesthesiologists, the majority (84%) reported having fewer than five ultrasound machines, followed by a smaller group (8%) reporting 6–10 machines. Departments with 10–30 anesthesiologists mostly had 6–10 machines (56%), followed by fewer than five machines (27%). In departments with 31–50 anesthesiologists, the most frequent responses were 6–10 machines (46%) and 11–20 machines (39%). Among the largest departments with more than 50 anesthesiologists, the two most common responses were 11–20 machines (47%) and more than 20 machines (35%).
The majority of respondents (68%) reported that ultrasound machines were available when needed, while 31% stated that the machines were often available. Only 0.3% noted that machines were infrequently available when needed.
Nearly all respondents' departments (97%) had portable ultrasound machines (mobile devices with wheels), and 38% also had handheld machines (pocket‐sized devices) available. Regarding probe types, anesthesiologists primarily used linear array probes (99%) in their daily clinical life, followed by phased array probes (74%), convex array probes (73%), and other types (9%). Other mentioned probe types included transoesophageal echo probes, hockey stick probes, and micro convex probes.
3.3. Daily Clinical Use
Most respondents (51%) reported using ultrasound daily, while 45% used it weekly. Smaller proportions used ultrasound monthly (3%), less than monthly (0.3%), or never (0.5%).
Ultrasound was widely utilized by the respondents, with its most common applications being for vascular access (97%), peripheral nerve blocks (83%), lung (70%), and cardiac assessments (68%). While less frequent, ultrasound was also employed in assisted or guided neuraxial access (25%), evaluation for deep venous thrombosis (20%), and gastric assessments (15%). Airway assessment was the least common indication of use, at 8%. Furthermore, 9% reported using ultrasound for other procedures, primarily including the focused assessment with sonography for trauma (FAST) protocol and transcranial Doppler. Figure 2 illustrates the specific procedures where ultrasound was utilized overall and for each country.
FIGURE 2.
Country‐specific distribution of ultrasound utilization in clinical procedures [1]. Distribution of ultrasound use across different procedures overall and within each country. A few responses indicated that ultrasound was not used for any of the listed procedures (n = 4 in Iceland, n = 1 in Finland, and n = 1 in Sweden).
3.4. Skills Training and Assessment
The respondents primarily acquired theoretical knowledge from colleagues, in‐person courses, or online resources, while practical skills were mainly learned through clinical training, with or without supervision (Table 2). Simulation training was less common but was notably used by 30% for lung ultrasound (Table 3).
TABLE 2.
Theoretical training for those trained in each procedure. Multiple answers were possible for each respondent.
| Type of theoretical training | |||||||
|---|---|---|---|---|---|---|---|
| Ultrasound procedure | At a congress, n (%) | E‐learning, n (%) | From a colleague, n (%) | In‐person course, n (%) | Online materials, e.g., Youtube, n (%) | Printed or online literature, n (%) | Other, n (%) |
| Guided regional peripheral nerve block (n = 411) | 65 (16) | 129 (31) | 257 (63) | 170 (41) | 208 (50.6) | 160 (39) | 4 (1) |
| Guided vascular access (n = 352) | 31 (9) | 94 (27) | 287 (82) | 142 (41) | 170 (48) | 109 (31) | 12 (3) |
| Lung (n = 256) | 34 (13) | 139 (54) | 176 (69) | 161 (63) | 119 (46) | 107 (42) | 7 (3) |
| Cardiac (n = 248) | 51 (21) | 128 (52) | 182 (73) | 183 (74) | 114 (46) | 119 (48) | 15 (6) |
| Assisted or guided neuraxial access (n = 89) | 21 (24) | 30 (34) | 62 (70) | 42 (47) | 58 (65) | 44 (49) | 1 (1) |
| Deep venous thrombosis (n = 71) | 2 (3) | 19 (26) | 42 (58) | 33 (45) | 37 (51) | 25 (34) | 0 (0) |
| Gastric (n = 53) | 3 (6) | 29 (55) | 31 (59) | 24 (45) | 22 (42) | 13 (25) | 2 (4) |
| Assisted airway assessment (n = 31) | 2 (7) | 10 (32) | 12 (39) | 12 (39) | 18 (58) | 10 (32) | 1 (3) |
TABLE 3.
Hands‐on training for those trained in each procedure. Multiple answers were possible for each respondent.
| Type of hands‐on training a | ||||
|---|---|---|---|---|
| Ultrasound procedure | Clinical experience without a colleague, n (%) | Clinical experience under the supervision of a colleague, n (%) | Simulation‐based course, n (%) | Other, n (%) |
| Guided regional peripheral nerve block (n = 411) | 158 (38) | 280 (68) | 70 (17) | 8 (2) |
| Guided vascular access (n = 350) | 252 (72) | 269 (77) | 52 (15) | 5 (1) |
| Lung (n = 257) | 167 (65) | 198 (77) | 77 (30) | 6 (2) |
| Cardiac (n = 247) | 35 (65) | 37 (69) | 7 (13) | 1 (2) |
| Assisted or guided neuraxial access (n = 89) | 58 (65) | 66 (74) | 17 (19) | 2 (2) |
| Deep venous thrombosis (n = 73) | 56 (77) | 33 (45) | 7 (10) | 1 (1) |
| Gastric (n = 54) | 35 (65) | 37 (69) | 7 (13) | 1 (2) |
| Assisted airway assessment (n = 32) | 22 (69) | 16 (50) | 5 (16) | 2 (6) |
Multiple answers are possible for each respondent.
Few respondents reported undergoing skills assessments, but among those who did, cardiac ultrasound had the highest reporting rate (37%) and deep venous ultrasound the lowest (18%). Assessments were typically conducted by colleagues in clinical settings (Table 4). Long‐term skill retention requirements were rare, ranging from 0% for deep venous ultrasound to 14% for ultrasound‐assisted or ‐guided neuraxial access, averaging 8% across all procedures (Table 4).
TABLE 4.
Skills assessment and retention for each procedure.
| Ultrasound procedure | Assessment, n (%) | If yes, how? n (% of yes) | Ongoing requirements to ensure skills retention, n (%) | |||||
|---|---|---|---|---|---|---|---|---|
| Yes | No | Assessment by colleague in a clinical setting | Assessment in a simulation‐based setting | Other | N/A | Yes | No | |
| Guided regional peripheral nerve block | 140 (34) | 271 (66) | 108 (77) | 9 (6) | 11 (9) | 12 (9) | 39 (10) | 372 (91) |
| Guided vascular access | 97 (28) | 254 (72) | 74 (76) | 7 (7) | 7 (7) | 9 (9) | 26 (7) | 351 (93) |
| Lung | 70 (27) | 187 (73) | 41 (59) | 22 (31) | 3 (4) | 4 (6) | 13 (5) | 244 (95) |
| Cardiac | 92 (37) | 156 (63) | 59 (64) | 21 (23) | 5 (5) | 7 (8) | 23 (9) | 225 (91) |
| Assisted or guided neuraxial access | 23 (26) | 66 (74) | 11 (48) | 3 (26) | 0 (0) | 9 (39) | 12 (14) | 77 (87) |
| Deep venous thrombosis | 13 (18) | 60 (82) | 7 (54) | 5 (39) | 0 (0) | 1 (8) | 0 (0) | 73 (100) |
| Gastric | 13 (24) | 41 (76) | 7 (54) | 3 (23) | 0 (0) | 3 (23) | 7 (13) | 47 (87) |
| Assisted airway assessment | 8 (26) | 23 (74) | 3 (38) | 3 (38) | 1 (13) | 1 (13) | 1 (3) | 30 (97) |
Self‐rated proficiency varied (Table 5). Most reported intermediate proficiency in lung ultrasound and neuraxial access, while vascular access was the procedure where most rated themselves as advanced (64%). For other procedures, beginner‐level self‐assessments were the most common.
TABLE 5.
Self‐reported proficiency for each procedure.
| Ultrasound procedure | Beginner, n (%) | Intermediate, n (%) | Advanced, n (%) | N/A, n (%) |
|---|---|---|---|---|
| Guided regional peripheral nerve | 35 (9) | 168 (41) | 95 (23) | 113 (28) |
| Guided vascular access | 9 (3) | 117 (33) | 223 (64) | 2 (1) |
| Lung | 95 (37) | 143 (56) | 15 (6) | 4 (2) |
| Cardiac | 116 (47) | 108 (44) | 20 (8) | 4 (2) |
| Assisted or guided neuraxial access | 34 (38) | 40 (45) | 13 (15) | 2 (2) |
| Deep venous thrombosis | 48 (66) | 19 (26) | 6 (8) | 0 (0) |
| Gastric | 33 (61) | 18 (33) | 1 (2) | 2 (4) |
| Assisted airway assessment | 15 (48) | 14 (45) | 0 (0) | 2 (7) |
3.5. Respondents' Comments on the Current Educational Structure
Respondents could provide final comments with free‐text responses. Only three comments addressed issues related to ultrasound training. Given the small number of substantive responses, a qualitative analysis was not considered.
“Sorry to say that we do not have any evaluation system in place…”
“There is a need for some accreditation process to confirm ultrasound knowledge.”
“I use ultrasound many times a week, and as such, I keep my skills in training. It would be nice to have simulation‐based touch‐ups even though…”
4. Discussion
This survey summarizes the clinical use of ultrasound among anesthesiologists in the Nordic countries. The results suggest consistency among anesthesiologists across countries, highlighting ultrasound as a widely used daily tool. Its constant availability and diverse selection of probes support its use in a broad range of procedures. Overall, there were limited requirements for skills assessment before clinical use, and ongoing assessment to secure retention of skills was even rarer.
4.1. Daily Clinical Use
Almost all respondents used ultrasound either daily or weekly (96%) for a wide range of procedures. More than half of the respondents employed it for both invasive guidance of nerve blocks and vascular access, as well as for assessments of the lungs and heart. These findings support the versatility of ultrasound in intensive care. Furthermore, ultrasound's ability to provide instant, goal‐directed assessments aligns with the anesthesiologist's need for quick, actionable answers in time‐critical situations; however, complex cases may still benefit from the expertise of radiologists, cardiologists, or other specialists [21, 22]. While ultrasound can be an efficient tool, determining the relevant procedures in each specialty is important. Mastering ultrasound is time‐consuming and resource‐intensive, and balancing adequate and excessive skill development can be challenging. For example, point‐of‐care ultrasound protocols, such as Focus‐Assessed Transthoracic Echocardiography (FATE), may be a valuable tool in anesthesia, whereas requiring all anesthesiologists to master complete echocardiography may be excessive [23].
4.2. Theoretical and Practical Training
Respondents reported primarily relying on colleagues for both theoretical and practical skills development. While learning from colleagues can ensure context‐specific skills in patient cases, it may also lead to interindividual variability in the quality and quantity of education [24]. Notably, the limited number of respondents who regarded themselves as advanced in each procedure raises concerns that supervision may rely on colleagues without sufficient expertise, potentially affecting the quality of training for more novice learners.
Regarding theoretical learning, many participants reported using e‐learning resources. One possible reason for the widespread use of e‐learning could be the limited mandatory ultrasound training in the Nordic curricula for specialist training in anesthesiology. In Denmark, there is 1 day of compulsory ultrasound training; in Finland and Sweden, no minimum ultrasound training is mandated; in Iceland, all specialist training is completed abroad; and in Norway, a 2‐day course is required. The variation and overall scarcity of mandatory ultrasound training may encourage reliance on e‐learning as a flexible and accessible alternative.
Recent studies have shown that e‐learning is effective for acquiring theoretical knowledge in ultrasound and can even support distance learning of practical ultrasound skills [25, 26, 27]. However, a randomized trial from rheumatology found that e‐learning could not replace hands‐on training of novices acquiring practical ultrasound skills [28].
Despite its proven effectiveness in enhancing ultrasound skills through standardized training and assessment, simulation‐based training played a limited role in most procedures for respondents [29, 30, 31]. A reason for this could be limited accessibility. A survey on airway management skills involving 240 Danish anesthesiologists found that a majority wanted to participate in hands‐on workshops, but only a few did, confirming a significant gap between supply and demand [32]. Notably, access to simulation‐based training is considered a key factor in advancing ultrasound education for anesthesiologists in the United States [33]. Prioritizing simulation‐based training could support standardizing ultrasound training in the Nordic countries, though barriers such as high cost and instructor shortages should be considered [16].
4.3. Assessment
Few respondents in our study reported undergoing formal skills assessments, with cardiac ultrasound having the highest rate (37%) and deep venous ultrasound the lowest (18%). These assessments were typically conducted by colleagues in clinical settings, which may lead to inconsistencies in evaluation practices.
Self‐assessment of proficiency also showed considerable variability, with most respondents rating themselves as having intermediate proficiency in lung ultrasound and neuraxial access, while vascular access was the only procedure where many rated themselves as advanced. For other procedures, beginner‐level self‐assessments were most common. The limitations of self‐assessment are well‐established in medical education, as studies show that self‐assessed abilities often do not correlate with actual performance measures [34, 35]. A study comparing formal and informal training found that, despite formal training leading to a greater acquisition of knowledge and skills, participants with formal training reported similar levels of confidence in their ability to perform point‐of‐care ultrasound as those with only informal training [36]. Both groups felt equally comfortable using the technique in practice, but those with formal training were better equipped to perform it effectively [36]. This aligns with previous findings, where significant knowledge gaps in important areas of adult airway management were identified, with different findings from the subjective and objective assessments [37]. This underlines the importance of objective assessment to guide continuing education.
These discrepancies in self‐perceived competence underscore the difficulty in self‐assessing skills, as even well‐trained individuals may struggle to determine when it is appropriate to apply their skills in patient care. Previous research has shown that even without achieving full competency after completing several short ultrasound courses, physicians continued using ultrasound for clinical diagnosis without supervision [33]. This supports the need for ensuring high standards of competency with assessment, as lack of proper training could lead to potentially unsafe practices.
Previous studies examining learning curves of ultrasound skills highlight both interindividual and interprocedural variations in reaching a given plateau, with some individuals never achieving the desired skill [38, 39, 40, 41, 42]. This variation indicates that fixed thresholds, such as a set number of procedures or time, fail to account for individual differences in learning rates and skill acquisition [43]. A more flexible approach, such as mastery‐based training, could address this issue [44, 45]. By requiring trainees to meet predefined competency benchmarks before advancing, mastery‐based training ensures that all trainees reach the necessary level of competence while accommodating individual learning paces [46]. In line with these findings, a few participants in our survey expressed a desire for a more standardized approach to both initial training and ongoing skill maintenance. Respondents expressed concern over the absence of formal evaluation systems, which further emphasized the importance of accreditation to ensure competence.
4.4. Retention
Only a few respondents (8%) reported that their program required regular, standardized demonstration of ultrasound skills.
When acquiring technical skills, loss of retention is a recognized challenge [47, 48]. Various factors contribute to this loss of retention in ultrasound, including inadequate training with poor educational methodologies and a lack of continued practice [49]. However, studies have found that ultrasound skills can be retained, particularly when there is a well‐defined curriculum that includes integrated assessment and emphasises the rapid application of newly learned skills in clinical practice, ensuring longitudinal exposure [36, 50]. Additionally, participants' comments in the survey indicated that despite frequent clinical use, some participants noted that regular practice alone might not be sufficient to refine skills. In line with this, the European Society of Anesthesiology and Intensive Care Guidelines on perioperative use of ultrasound for regional anesthesia strongly recommend that the maintenance of competence in ultrasound‐guided regional anesthesia should rely solely on performance indicators, rather than the number of procedures performed [51].
4.5. Strengths and Limitations
Several limitations must be acknowledged. The reliance on convenience sampling introduces a potential selection bias, as anesthesiologists with a stronger interest or familiarity with ultrasound may have been more inclined to participate. This could result in an overestimation of ultrasound use or skill levels. Additionally, although the study achieved a moderate response rate, nonresponders might represent clinicians with different perspectives or less engagement in ultrasound practice, potentially skewing the results. Not every department in each country was invited to participate, which may affect the completeness of the regional overview. Another limitation to consider is that some countries may be underrepresented in the sample, which could influence the generalizability of the findings. The sample was not evenly distributed across countries, with Denmark being overrepresented and relatively few respondents from Sweden and Norway. This imbalance limits the external validity of the findings and must be acknowledged when interpreting country‐specific comparisons. The higher response rate in Denmark compared with other countries may reflect differences in local engagement or professional networks, but the exact reasons remain uncertain.
At the same time, this must also be interpreted in the context of differing population sizes and physician densities across the Nordic countries.
However, this study also has several strengths. It represents a comprehensive effort to capture the current state of ultrasound use and training among anesthesiologists across the Nordic countries. A key strength is the broad geographic coverage, including participants from Denmark (including Greenland and the Faroe Islands), Finland, Iceland, Norway, and Sweden. This ensures diverse representation across national healthcare systems, contributing to a more nuanced understanding of regional practices. Furthermore, the inclusion of anesthesiologists from departments of varying sizes and diverse experience levels enhances the generalizability of the findings.
4.6. Future Perspectives
This study highlights the widespread use of ultrasound among anesthesiologists in the Nordic region, underscoring both its integration into daily practice and the persistent gaps in structured training and skills assessment. The findings suggest a lack of standardized, competency‐based training programs and limited regular skills refreshers. Several factors may contribute to the absence of formal standards in the Nordic countries, including variations in hospital resources, differences in training structures, and a reliance on bedside supervision rather than formal certification pathways. Unlike in the United States, where certifications exist, for example, perioperative TEE, there are currently no formal certification pathways in the Nordic countries [52]. Collaborative efforts across the Nordic countries could foster a regional framework for ultrasound training and assessment, as few variations were observed among the countries. This study supports the potential role of the Scandinavian Society of Anesthesiology and Intensive Care Medicine (SSAI) in developing educational standards to enhance structured training, skills assessment, and competency maintenance for ultrasound in anesthesia and intensive care.
5. Conclusion
Ultrasound is used almost daily by most anesthesiologists in the Nordic region, with machines readily available in departments. It is primarily employed for vascular access, nerve blocks, and cardiac and pulmonary assessments. Despite its frequent use, training and skills assessments vary, with limited focus on ensuring competency and skill retention.
Author Contributions
Martine S. Nielsen: conceptualization, data collection, data curation, formal analysis, and writing – original draft. Anders M. Grejs: conceptualization, writing – review and editing. Anders B. Nielsen: conceptualization, writing – review and editing. Lars Konge: conceptualization, writing – review and editing. Anders B. Mjelle: data collection, writing – review and editing. Johanna Hästbacka: data collection, writing – review and editing. Katrin Thormar: data collection, writing – review and editing. Olof Wall: data collection, writing – review and editing. Maria Cronhjort: data collection, writing – review and editing. Lene Russell: data collection, writing – review and editing. Anne C. Brøchner: conceptualization, writing – original draft. All authors reviewed and approved the final manuscript.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1: aas70190‐sup‐0001‐Supinfo.pdf.
Acknowledgments
Open Patient data Explorative Network (OPEN) Odense University Hospital, Region of Southern Denmark, for ensuring access to and counselling regarding the registration of data in the online‐based Research Electronic Data Capture system (REDCap).
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. Fuzier R., Lammens S., Becuwe L., et al., “The Use of Ultrasound in France: A Point of View From Experienced Regional Anesthesiologists,” Acta Anaesthesiologica Belgica 67, no. 1 (2016): 9–15. [PubMed] [Google Scholar]
- 2. Lamperti M., Biasucci D. G., Disma N., et al., “European Society of Anaesthesiology Guidelines on Peri‐Operative Use of Ultrasound‐Guided for Vascular Access (PERSEUS Vascular Access),” European Journal of Anaesthesiology 37, no. 5 (2020): 344–376, 10.1097/eja.0000000000001180. [DOI] [PubMed] [Google Scholar]
- 3. Zieleskiewicz L., Muller L., Lakhal K., et al., “Point‐of‐Care Ultrasound in Intensive Care Units: Assessment of 1073 Procedures in a Multicentric, Prospective, Observational Study,” Intensive Care Medicine 41, no. 9 (2015): 1638–1647, 10.1007/s00134-015-3952-5. [DOI] [PubMed] [Google Scholar]
- 4. Kalagara H., Coker B., Gerstein N. S., et al., “Point‐of‐Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist,” Journal of Cardiothoracic and Vascular Anesthesia 36, no. 4 (2022): 1132–1147, 10.1053/j.jvca.2021.01.018. [DOI] [PubMed] [Google Scholar]
- 5. Novitch M., Prabhakar A., Siddaiah H., et al., “Point of Care Ultrasound for the Clinical Anesthesiologist,” Best Practice & Research. Clinical Anaesthesiology 33, no. 4 (2019): 433–446, 10.1016/j.bpa.2019.06.003. [DOI] [PubMed] [Google Scholar]
- 6. Frankel H. L., Kirkpatrick A. W., Elbarbary M., et al., “Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients‐Part I: General Ultrasonography,” Critical Care Medicine 43, no. 11 (2015): 2479–2502, 10.1097/ccm.0000000000001216. [DOI] [PubMed] [Google Scholar]
- 7. Levitov A., Frankel H. L., Blaivas M., et al., “Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients‐Part II: Cardiac Ultrasonography,” Critical Care Medicine 44, no. 6 (2016): 1206–1227, 10.1097/ccm.0000000000001847. [DOI] [PubMed] [Google Scholar]
- 8. Mongodi S., Bonomi F., Vaschetto R., et al., “Point‐Of‐Care Ultrasound Training for Residents in Anaesthesia and Critical Care: Results of a National Survey Comparing Residents and Training Program Directors' Perspectives,” BMC Medical Education 22, no. 1 (2022): 647, 10.1186/s12909-022-03708-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. O'Brien E. M., Guris R. D., Quarshie W., and Lin E. E., “The State of Point‐Of‐Care Ultrasound Training in Pediatric Anesthesia Fellowship Programs in the United States: A Survey Assessment,” Paediatric Anaesthesia 34, no. 6 (2024): 544–550, 10.1111/pan.14851. [DOI] [PubMed] [Google Scholar]
- 10. Galarza L., Wong A., and Malbrain M., “The State of Critical Care Ultrasound Training in Europe: A Survey of Trainers and a Comparison of Available Accreditation Programmes,” Anaesthesiology Intensive Therapy 49, no. 5 (2017): 382–386, 10.5603/AIT.a2017.0075. [DOI] [PubMed] [Google Scholar]
- 11. Mizubuti G., Allard R., Ho A. M., Cummings M., and Tanzola R. C., “A Survey of Focused Cardiac Ultrasonography Training in Canadian Anesthesiology Residency Programs,” Canadian Journal of Anaesthesia 64, no. 4 (2017): 441–442, 10.1007/s12630-016-0800-1. [DOI] [PubMed] [Google Scholar]
- 12. Adler A. C., Brown K. A., Conlin F. T., Thammasitboon S., and Chandrakantan A., “Cardiac and Lung Point‐Of‐Care Ultrasound in Pediatric Anesthesia and Critical Care Medicine: Uses, Pitfalls, and Future Directions to Optimize Pediatric Care,” Paediatric Anaesthesia 29, no. 8 (2019): 790–798, 10.1111/pan.13684. [DOI] [PubMed] [Google Scholar]
- 13. Lee S. C., Yang E. C., Navarro J. C., Minard C. G., Huang X., and Deng Y., “An Introductory Point‐of‐Care Ultrasound Curriculum for an Anesthesiology Residency Program,” MedEdPORTAL 18 (2022): 11291, 10.15766/mep_2374-8265.11291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Good R., Orsborn J., and Stidham T., “Point‐of‐Care Ultrasound Education for Pediatric Residents in the Pediatric Intensive Care Unit,” MedEdPORTAL 14 (2018): 10683, 10.15766/mep_2374-8265.10683. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Sanders J. A., Navas‐Blanco J. R., Yeldo N. S., Han X., Guruswamy J., and Williams D. V., “Incorporating Perioperative Point‐of‐Care Ultrasound as Part of the Anesthesia Residency Curriculum,” Journal of Cardiothoracic and Vascular Anesthesia 33, no. 9 (2019): 2414–2418, 10.1053/j.jvca.2019.04.010. [DOI] [PubMed] [Google Scholar]
- 16. Remskar M. H., Theophanous R., Bowman A., et al., “Current Use, Training, and Barriers of Point‐of‐Care Ultrasound in Anesthesiology: A National Survey of Veterans Affairs Hospitals,” Journal of Cardiothoracic and Vascular Anesthesia 37, no. 8 (2023): 1390–1396, 10.1053/j.jvca.2023.03.042. [DOI] [PubMed] [Google Scholar]
- 17. Sharma A., Minh Duc N. T., Luu Lam Thang T., et al., “A Consensus‐Based Checklist for Reporting of Survey Studies (CROSS),” Journal of General Internal Medicine 36, no. 10 (2021): 3179–3187, 10.1007/s11606-021-06737-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Nielsen M. S., Grejs A. M., Nielsen A. B., Konge L., and Brøchner A. C., “Ultrasound in Anesthesiology in the Nordic Countries‐Protocol of an International Survey on Availability, Frequency of Use, Operator Training, and Certification,” Acta Anaesthesiologica Scandinavica 68, no. 9 (2024): 1279–1282, 10.1111/aas.14482. [DOI] [PubMed] [Google Scholar]
- 19. Harris P. A., Taylor R., Minor B. L., et al., “The REDCap Consortium: Building an International Community of Software Platform Partners,” Journal of Biomedical Informatics 95 (2019): 103208, 10.1016/j.jbi.2019.103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. R Core Team , “R: A Language and Environment for Statistical Computing,” 2023. R Foundation for Statistical Computing, Vienna, Austria.
- 21. Terkawi A. S., Karakitsos D., Elbarbary M., Blaivas M., and Durieux M. E., “Ultrasound for the Anesthesiologists: Present and Future,” Scientific World Journal 2013 (2013): 683685, 10.1155/2013/683685. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Naji A., Chappidi M., Ahmed A., Monga A., and Sanders J., “Perioperative Point‐of‐Care Ultrasound Use by Anesthesiologists,” Cureus 13, no. 5 (2021): e15217, 10.7759/cureus.15217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Jensen M. B., Sloth E., Larsen K. M., and Schmidt M. B., “Transthoracic Echocardiography for Cardiopulmonary Monitoring in Intensive Care,” European Journal of Anaesthesiology 21, no. 9 (2004): 700–707, 10.1017/s0265021504009068. [DOI] [PubMed] [Google Scholar]
- 24. Todsen T., Melchiors J., Charabi B., et al., “Competency‐Based Assessment in Surgeon‐Performed Head and Neck Ultrasonography: A Validity Study,” Laryngoscope 128, no. 6 (2018): 1346–1352, 10.1002/lary.26841. [DOI] [PubMed] [Google Scholar]
- 25. Hoppmann R. A., Rao V. V., Bell F., et al., “The Evolution of an Integrated Ultrasound Curriculum (iUSC) for Medical Students: 9‐Year Experience,” Critical Ultrasound Journal 7, no. 1 (2015): 18, 10.1186/s13089-015-0035-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Russell F. M., Herbert A., Lobo D., Ferre R., and Nti B. K., “Evaluation of Point‐of‐Care Ultrasound Training for Family Physicians Using Teleultrasound,” Family Medicine 55, no. 4 (2023): 263–266, 10.22454/FamMed.2023.469019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Burckett‐St Laurent D. A., Cunningham M. S., Abbas S., Chan V. W., Okrainec A., and Niazi A. U., “Teaching Ultrasound‐Guided Regional Anesthesia Remotely: A Feasibility Study,” Acta Anaesthesiologica Scandinavica 60, no. 7 (2016): 995–1002, 10.1111/aas.12695. [DOI] [PubMed] [Google Scholar]
- 28. Carstensen S. M. D., Just S. A., Velander M., et al., “E‐Learning and Practical Performance in Musculoskeletal Ultrasound: A Multicentre Randomized Study,” Rheumatology (Oxford) 62, no. 11 (2023): 3547–3554, 10.1093/rheumatology/kead121. [DOI] [PubMed] [Google Scholar]
- 29. Neelankavil J., Howard‐Quijano K., Hsieh T. C., et al., “Transthoracic Echocardiography Simulation Is an Efficient Method to Train Anesthesiologists in Basic Transthoracic Echocardiography Skills,” Anesthesia & Analgesia 115, no. 5 (2012): 1042–1051, 10.1213/ANE.0b013e318265408f. [DOI] [PubMed] [Google Scholar]
- 30. Østergaard M. L., Rue Nielsen K., Albrecht‐Beste E., Kjær Ersbøll A., Konge L., and Bachmann Nielsen M., “Simulator Training Improves Ultrasound Scanning Performance on Patients: A Randomized Controlled Trial,” European Radiology 29, no. 6 (2019): 3210–3218, 10.1007/s00330-018-5923-z. [DOI] [PubMed] [Google Scholar]
- 31. Tolsgaard M. G., Ringsted C., Dreisler E., et al., “Sustained Effect of Simulation‐Based Ultrasound Training on Clinical Performance: A Randomized Trial,” Ultrasound in Obstetrics & Gynecology 46, no. 3 (2015): 312–318, 10.1002/uog.14780. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Bessmann E. L., Rasmussen L. S., Konge L., Kristensen M. S., Rewers M., and Østergaard D., “Maintaining Competence in Airway Management,” Acta Anaesthesiologica Scandinavica 64, no. 6 (2020): 751–758, 10.1111/aas.13558. [DOI] [PubMed] [Google Scholar]
- 33. Mosier J. M., Malo J., Stolz L. A., et al., “Critical Care Ultrasound Training: A Survey of US Fellowship Directors,” Journal of Critical Care 29, no. 4 (2014): 645–649, 10.1016/j.jcrc.2014.03.006. [DOI] [PubMed] [Google Scholar]
- 34. Eva K. W. and Regehr G., “Self‐Assessment in the Health Professions: A Reformulation and Research Agenda,” Academic Medicine 80, no. 10 (2005): S46–S54, 10.1097/00001888-200510001-00015. [DOI] [PubMed] [Google Scholar]
- 35. Norman G., “Data Dredging, Salami‐Slicing, and Other Successful Strategies to Ensure Rejection: Twelve Tips on How to Not Get Your Paper Published,” Advances in Health Sciences Education: Theory and Practice 19, no. 1 (2014): 1–5, 10.1007/s10459-014-9494-8. [DOI] [PubMed] [Google Scholar]
- 36. Young A. C., Butts C., deBoisblanc B. P., Tejedor R. S., Kantrow S. P., and Lammi M. R., “Implementation of a Longitudinal Critical Care Fellowship Ultrasound Curriculum,” ATS Sch 3, no. 1 (2022): 125–134, 10.34197/ats-scholar.2021-0120OC. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Bessmann E. L., Rasmussen L. S., Konge L., et al., “Anesthesiologists' Airway Management Expertise: Identifying Subjective and Objective Knowledge Gaps,” Acta Anaesthesiologica Scandinavica 65, no. 1 (2021): 58–67, 10.1111/aas.13696. [DOI] [PubMed] [Google Scholar]
- 38. Clunie M., O'Brien J., Olszynski P., Bajwa J., and Perverseff R., “Competence of Anesthesiology Residents Following a Longitudinal Point‐of‐Care Ultrasound Curriculum,” Canadian Journal of Anaesthesia 69, no. 4 (2022): 460–471, 10.1007/s12630-021-02172-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39. Blehar D. J., Barton B., and Gaspari R. J., “Learning Curves in Emergency Ultrasound Education,” Academic Emergency Medicine 22, no. 5 (2015): 574–582, 10.1111/acem.12653. [DOI] [PubMed] [Google Scholar]
- 40. Breunig M., Hanson A., and Huckabee M., “Learning Curves for Point‐of‐Care Ultrasound Image Acquisition for Novice Learners in a Longitudinal Curriculum,” Ultrasound Journal 15, no. 1 (2023): 31, 10.1186/s13089-023-00329-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Arbelot C., Dexheimer Neto F. L., Gao Y., et al., “Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence,” Anesthesiology 132, no. 4 (2020): 899–907, 10.1097/aln.0000000000003096. [DOI] [PubMed] [Google Scholar]
- 42. Cazes N., Desmots F., Geffroy Y., Renard A., Leyral J., and Chaumoître K., “Emergency Ultrasound: A Prospective Study on Sufficient Adequate Training for Military Doctors,” Diagnostic and Interventional Imaging 94, no. 11 (2013): 1109–1115, 10.1016/j.diii.2013.04.016. [DOI] [PubMed] [Google Scholar]
- 43. Mahmood O., Jørgensen R., Nielsen K., Konge L., and Russell L., “Hands‐on Time in Simulation‐Based Ultrasound Training—A Dose‐Related Response Study,” Ultrasound Int Open 8, no. 1 (2022): E2–E6, 10.1055/a-1795-5138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Nielsen M. S., Clausen J. H., Hoffmann‐Petersen J., Konge L., and Nielsen A. B., “Can Virtual‐Reality Simulation Ensure Transthoracic Echocardiography Skills Before Trainees Examine Patients?,” International Journal of Medical Education 13 (2022): 267–273, 10.5116/ijme.6321.8e5d. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Russell L., Østergaard M. L., Nielsen M. B., Konge L., and Nielsen K. R., “Standardised Assessment of Competence in Focused Assessment With Sonography for Trauma,” Acta Anaesthesiologica Scandinavica 62, no. 8 (2018): 1154–1160, 10.1111/aas.13141. [DOI] [PubMed] [Google Scholar]
- 46. McGaghie W. C., “Mastery Learning: It Is Time for Medical Education to Join the 21st Century,” Academic Medicine 90, no. 11 (2015): 1438–1441, 10.1097/acm.0000000000000911. [DOI] [PubMed] [Google Scholar]
- 47. Nielsen M. S., Lundorff S. H., Hansen P. M., et al., “Anesthesiologists' Skills in Emergency Cricothyroidotomy Mandate a Brush‐Up Training After 3 Months‐A Randomized Controlled Trial,” Acta Anaesthesiologica Scandinavica 68, no. 1 (2024): 91–100, 10.1111/aas.14329. [DOI] [PubMed] [Google Scholar]
- 48. Nielsen M. S., Raben‐Levetzau F. N., Andersen S. A. W., Wennervaldt K., Konge L., and Nielsen A. B., “Retention of Emergency Cricothyroidotomy Skills: A Multicenter Randomized Controlled Trial,” AEM Education and Training 7, no. 4 (2023): e10900, 10.1002/aet2.10900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49. Kelm D. J., Ratelle J. T., Azeem N., et al., “Longitudinal Ultrasound Curriculum Improves Long‐Term Retention Among Internal Medicine Residents,” Journal of Graduate Medical Education 7, no. 3 (2015): 454–457, 10.4300/jgme-14-00284.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50. Dinh V. A., Giri P. C., Rathinavel I., et al., “Impact of a 2‐Day Critical Care Ultrasound Course During Fellowship Training: A Pilot Study,” Critical Care Research and Practice 2015 (2015): 675041, 10.1155/2015/675041. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51. 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,” European Journal of Anaesthesiology 38, no. 3 (2021): 219–250, 10.1097/eja.0000000000001383. [DOI] [PubMed] [Google Scholar]
- 52. Reeves S. T., Finley A. C., Skubas N. J., et al., “Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists,” Journal of the American Society of Echocardiography 26, no. 5 (2013): 443–456, 10.1016/j.echo.2013.02.015. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: aas70190‐sup‐0001‐Supinfo.pdf.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.