ASRA and ESRA: Global Alignment in Skills, Competency, and Training Standards for UGRA

As regional anesthesia continues to expand across perioperative, emergency, and acute pain settings, it becomes increasingly important to understand how major professional societies define the skills and competencies required for safe practice. Two organizations, ASRA in the United States and ESRA in Europe, have shaped the global training landscape more than any others. Their guidance forms the backbone of how clinicians learn, practice, and refine ultrasound‑guided regional anesthesia (UGRA).

Both ASRA and ESRA emphasize that competency in regional anesthesia begins with a deep understanding of anatomy and sonoanatomy. Trainees must be able to identify nerves, fascial planes, and vascular structures in both static and dynamic ultrasound views, and they must understand how these structures shift with patient positioning, probe manipulation, and understand, but not demonstrate, needle advancement. These expectations are consistent across ASRA workshops, ESRA Diploma materials, and the ASRA–ESRA Joint Committee Recommendations for UGRA education.6,14

The societies also agree that ultrasound fundamentals, image optimization, probe stability, needle‑tip visualization, and recognition of correct injectate spread, are essential technical skills that must be mastered early in training. ASRA’s assessment guidance reinforces the importance of needle‑probe alignment and simulation‑based practice to improve needle‑tip detection.9 ESRA’s curriculum similarly requires demonstration of these skills during formal examination.14

Alignment

Where ASRA and ESRA are most aligned is in their commitment to competency‑based skill acquisition. Both societies reject the idea that a fixed number of procedures defines proficiency. Instead, they emphasize progressive learning supported by supervised practice, structured feedback, and objective assessment tools.6,14 Trainees are expected to demonstrate reproducible performance, adapt techniques to patient‑specific anatomy, and exercise sound judgment when selecting blocks. Safety remains central in both frameworks. ASRA’s guidelines on anticoagulation, infection control, and LAST management are widely adopted internationally.1–3 ESRA reinforces these standards in its educational materials and examinations.5,14

Despite this strong alignment, ASRA and ESRA differ in how they structure and formalize training. ESRA offers a highly structured curriculum through the ESRA Diploma (EDRA), which outlines specific knowledge domains, required competencies, and standardized assessments.11–15 This creates a consistent training pathway across Europe and provides a formal credential that validates a clinician’s proficiency. ASRA, in contrast, focuses more heavily on safety guidelines, perioperative standards, and evidence‑based practice advisories, such as the 5th edition anticoagulation guideline.1,2 Its most influential contributions shape how regional anesthesia is practiced across the United States, but ASRA does not prescribe a specific block curriculum or national assessment structure.

Of note, although the EDRA (Part 2 -B) requires student to demonstrate an ability to adjust and interpret an ultrasound image as part of an examiner assessed live scan session, there is no requirement for the student to demonstrate competency in needle tip placement once an anatomical target and approach has been identified. Given that the rationale for ultrasound use when performing regional blocks is the facilitation of accurate needle tip placement, such an omission is a significant shortfall of the current exam process. It is not a given that knowledge of a process translates to a practical skill. Accurate and safe needle manipulation when attempting to target a specific anatomical landmark is a critical element of block performance and thus should also be evaluated as part of any exam designated as an assessment of block skill. Student needle and probe adjustment can be evaluated with a very simple, inexpensive, commercially available ultrasound phantom.

Mutually Recognized Regional Blocks (ASRA–ESRA Consensus)

Region	Blocks Included in ASRA–ESRA Consensus Publications
Upper Extremity	Interscalene • Supraclavicular • Infraclavicular • Axillary • Median • Ulnar • Radial • Musculocutaneous
Lower Extremity	Femoral • Fascia Iliaca • Adductor Canal • Obturator • Sciatic (proximal) • Popliteal Sciatic • Tibial • Common Peroneal
Abdominal Wall	TAP • Subcostal TAP • Quadratus Lumborum (QL 1–3) • Ilioinguinal/Iliohypogastric • Rectus Sheath
Chest Wall	PECS I • PECS II • Serratus Anterior Plane • Intercostal Nerve Block
Paraspinal / Truncal	Erector Spinae Plane (ESP) • Paravertebral • Retrolaminar

ASRA vs ESRA: Training Alignment Table

Training Element	ASRA (United States)	ESRA (Europe)	Alignment Level
Foundational Anatomy & Sonoanatomy	Strong emphasis	Strong emphasis	Full alignment
Ultrasound Fundamentals	Required competency	Required competency	Full alignment
Safety Guidelines	Emphasized across ASRA guidelines	Reinforces ASRA standards	Full alignment
Competency‑Based Training	Skill‑based, not numbers‑based	Skill‑based, not numbers‑based	Full alignment
Structured Curriculum	Institution‑dependent	Formal ESRA training pathways	Partial alignment
Assessment & Credentialing	Local privileging	Standardized exams	Partial alignment
Core Block Categories	Widely taught	Included in ESRA training	High alignment
Training Standardization	Flexible	Harmonized	Moderate alignment
Needle skill assessment	None	None	Full alignment

Key Takeaways: ASRA vs ESRA

• Shared Core Skills: Anatomy, sonoanatomy, ultrasound fundamentals, and safety.

• Shared Training Philosophy: Competency‑based progression, supervised practice, and objective assessment.

• ASRA Strengths: Safety guidelines, perioperative standards, and broad practice advisories.

• ESRA Strengths: Structured curriculum, standardized assessments, and formalized training pathways.

• Global Impact: Together, they create the most unified international framework for UGRA training.

• Failures: Neither currently take any steps to assess needle tip placement ability, despite this being a core recognized essential skill.

Summary

In summary, ASRA and ESRA are deeply aligned in what clinicians must know and be able to do: understand anatomy, master ultrasound fundamentals, perform blocks safely, and exercise sound clinical judgment. Their differences lie primarily in how training is delivered and assessed—with ESRA offering a formalized, credentialed pathway and ASRA emphasizing safety, evidence, and institutional autonomy. Together, their shared principles and complementary strengths form the closest thing the field has to a global standard for UGRA training. However, needle tip placement should be recognized as a core recognized essential skill. 

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“Valkyrie Simulators is strategically positioned to deliver the full spectrum of Core UGRA Blocks, facilitate needle skill assessment and to scale seamlessly as new, advanced blocks are adopted across global training programs.”

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References

1. ASRA Pain Medicine. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: Evidence‑Based Guidelines (Fifth Edition). 2025.

2. Guideline Central. ASRA Guidelines for Regional Anesthesia with Antithrombotic or Thrombolytic Therapy. 2025.

3. Pain Medicine News. ASRA Issues Updated Guidelines on Oral Anticoagulants and Regional Anesthesia. 2025.

4. NYSORA. Regional Anesthesia in Anticoagulated Patients.

5. ESRA Newsletter. Block and Load: ASRA’s Regional Anesthesia Guidelines. 2025.

6. Sites BD, Chan VW, Neal JM, et al. ASRA–ESRA Joint Committee Recommendations for Education and Training in Ultrasound‑Guided Regional Anesthesia. Reg Anesth Pain Med.

7. ASRA Pain Medicine. Guidelines & Advisories.

8. Narouze SN, et al. Joint Committee Recommendations for Ultrasound‑Guided Interventional Pain Procedures.

9. ASRA. Assessment of Ultrasound‑Guided Regional Anesthesia. Guideline Central.

10. ASRA–ESRA Joint Committee. Education and Training in UGRA. PDF archive.

11–15. ESRA. European Diploma of Regional Anaesthesia (EDRA) Curriculum.