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Original contribution
Anesthesiologists of Greater Orlando & University of Central Florida, 2699 Lee Rd, Suite 510, Winter Park, FL 32789
Department of Anesthesiology, Fangcheng County Hospital, Henan, China
Keywords:
Regional anesthesia;
Survey;
Safety;
Training
Abstract
Study objective: Neuraxial anesthesia has been widely used in China. Recently, Chinese anesthesiologists
have applied nerve stimulator and ultrasound guidance for peripheral nerve blocks. Nationwide surveys
about regional anesthesia practices in China are lacking. We surveyed Chinese anesthesiologists about regional anesthesia techniques, preference, drug selections, complications, and treatments.
Design: A survey was sent to all anesthesiologist members by WeChat. The respondents can choose mobile
device or desktop to complete the survey. Each IP address is allowed to complete the survey once.
Main results: A total of 6589 members read invitations. A total of 2654 responses were received with
fully completed questionnaires, which represented an overall response rate of 40%. Forty-one percent
of the respondents reported that more than 50% of surgeries in their hospitals were done under regional
anesthesia. Most of the participants used test dose after epidural catheter insertion. The most common
drug for test dose was 3-mL 1.5% lidocaine; 2.6% of the participants reported that they had treated a
patient with epidural hematoma after neuraxial anesthesia. Most anesthesiologists (68.2%) performed
peripheral nerve blocks as blind procedures based on the knowledge of anatomical landmarks. A
majority of hospitals (80%) did not stock Intralipid; 61% of the respondents did not receive peripheral nerve
block training.
Conclusions: The current survey can serve as a benchmark for future comparisons and evaluation of regional anesthesia practices in China. This survey revealed potential regional anesthesia safety issues in China.
2016 Elsevier Inc. All rights reserved.
1. Study objective
Regional anesthesia/analgesia (RA) has become popular
in surgical care and postoperative pain management. RA
http://dx.doi.org/10.1016/j.jclinane.2016.03.071
0952-8180/ 2016 Elsevier Inc. All rights reserved.
116
J. Huang, H. Gao
identifying problems, and consequently continuous improvement of clinical practices. The results may also be used as a
tool for assessment of the teaching process, knowledge expansion, and hospital developments associated with RA.
The current survey is the rst nationwide attempt to document the current trends in RA practice in China. The results
may be used as a benchmark for future comparisons and evaluation of RA practices in China.
We surveyed Chinese anesthesiologists about RA techniques, preference, drug selections, complications, and
treatments.
2. Design
There are more than 78,000 registered anesthesiologist
members in New Youth Anesthesia Forum. After approval
from the committee of New Youth Anesthesia Forum, a survey was sent to all anesthesiologist members by WeChat.
The respondents can choose mobile device or desktop to complete the survey. Each IP address is allowed to complete the
survey once.
The survey was designed to ask questions about RA techniques, drug selections, uid administration, complications,
and postoperative pain management.
The survey questions included basic demographic information about the anesthesiologist's hospital level (grade I, II, or
III) and title. To minimize the bias for few open questions,
question formats were used: Yes or No boxes, selection of best
possible answer out of 2 to 5 alternatives options. No monetary
compensation was provided for any kind of participation in
this survey.
Fig. 1
3. Main results
The survey was undertaken from December 2, 2015, to January 2, 2016. New Youth Anesthesia Forum sends new messages to each member every day. The members read the
messages that they are interested. The server can record how
many members open and read the invitation. Only those members who read the survey invitation were included in the study.
A total of 6589 members read invitations. A total of 2654 responses were received with fully completed questionnaires,
which represented an overall response rate of 40%. Majority
of surveys (2583) were completed by mobile devices; the rest
(71) was received by computer.
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Table 3
Hospital grade
Grade I
187 (7.05%)
Grade II
1221 (46.01%)
Grade III
1246 (46.95%)
Title
Resident physicians
976 (36.77%)
Attending physicians
1062 (40.02%)
Chief physicians
616 (23.21%)
Percentage of surgeries done under RA each year
10%
242 (9.12%)
20%-30%
562 (21.18%)
31%-50%
747 (28.15%)
N 51%
1103 (41.56%)
LA
Bupivacaine
Ropivacaine
Lidocaine
Baricity
Hyperbaric solution
Isobaric solution
Hypobaric solution
Additives
None
Fentanyl
Sufentanil
1875 (70.65%)
745 (28.07%)
34 (1.28%)
1198 (45.14%)
1277 (48.12%)
179 (6.74%)
2508 (94.5%)
76 (2.86%)
70 (2.64%)
Patient position
Lateral
Sitting
Interspace
L2-3
L3-4
L4-5
L5-S1
Needle size for spinal anesthesia
22G
24G
25G
27G
2629 (99.06%)
25 (0.94%)
814 (30.67%)
1792 (67.52%)
47 (1.77%)
1 (0.04%)
1075 (40.5%)
658 (24.83%)
613 (23.1%)
307 (11.57%)
Table 4
Fluid administration
Routinely preload
Never
113 (4.26%)
Routine preload for all patients
855 (32.22%)
Selective patients (eg, cesarean, long NPO time) 1686 (63.53%)
Preload volume
Crystalloid uid preload 500 mL
1648 (62.09%)
Crystalloid uid preload 1000 mL
190 (7.16%)
Colloid uid preload 500 mL
680 (25.62%)
Colloid uid preload 1000 mL
11 (0.41%)
None
125 (4.71%)
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Table 5
J. Huang, H. Gao
Table 7
Epidural anesthesia
1297 (48.87%)
1176 (44.31%)
181 (6.82%)
91 (3.43%)
2212 (83.35%)
125 (4.71%)
226 (8.52%)
496 (18.69%)
1126 (42.43%)
301 (11.34%)
731 (27.54%)
1810 (68.2%)
326 (12.28%)
341 (12.85%)
177 (6.67%)
288 (10.85%)
630 (23.74%)
637 (24%)
1099 (41.41%)
543 (20.46%)
2111 (79.54%)
1021 (38.47%)
1633 (61.53%)
Table 6
4. Discussions
WeChat is a free instant messaging service application for
smartphone and developed by Tencent in China. WeChat has
Table 8
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2
No
Fig. 2
Yes
Question Does your hospital always stock Intralipid? (1, grade I hospital; 2, grade II hospital; 3, grade III hospital) (P b .05).
2
Yes
No
Fig. 3 Question Have you treated a patient with epidural hematoma after neuraxial anesthesia? (1, grade I hospital; 2, grade II hospital; 3,
grade III hospital) (P b .05).
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with 1:200,000 epinephrine is not commercially available, but
1.5% lidocaine is commercially available. To reduce medication errors and contaminations, they used 1.5% lidocaine without epinephrine.
Epidural hematoma is a rare but potentially injurious complication from epidural catheterization [7]. The incidence spinal hematoma is associated with these factors: female sex,
increased age, traumatic needle/catheter placement, indwelling
epidural catheter placement during immediate preoperative,
intraoperative, and postoperative anticoagulation therapy [8].
Epidural hematomas are best diagnosed by a high-resolution
magnetic resonance imaging. Treatment options range
from conservative observation, medications, to laminectomy
[9]. Ehrenfeld et al [7] conducted an electronic retrospective
chart review of 43,200 patient charts. They found an incidence
rate of 1:7200 for epidural hematomas resulting from a
catheter insertion. A study was conducted to estimate the
incidence of complications occurring with epidural analgesia
in obstetric practice. The authors concluded that epidural hematoma rate was 1 in 168,000 in obstetric women [10]. In
our survey, 2.6% of the participants reported that they had
treated a patient who had epidural hematoma after neuraxial
anesthesia. When the respondents were stratied by hospital
grade, for the question about whether anesthesiologists had
treated a patient with epidural hematoma after epidural anesthesia, there was signicant difference among 3 groups. The
higher level care hospitals had more comorbidity patients;
therefore, anesthesiologists encountered higher incidence of
epidural hematoma.
Local anesthetic systemic toxicity (LAST) rate was
approximately 20 of 10,000 peripheral nerve blocks
and 4 per 10,000 epidural blocks [11]. LAST remains
as a serious potential complication of RA. Intralipid infusion has become a standard care in the management
of LAST. The Association of Anesthetists of Great
Britain and Ireland published guidelines in 2007 that
recommended that all departments administering potentially toxic doses of local anesthetics should keep lipid
emulsion immediately available [12]. A survey in England
and Wales showed that Intralipid was stocked in 95.1% of the
acute National Health Service hospitals [13]. Based on the
available data, it would seem reasonable to have a [lipid] rescue kit available in any setting in which RA is practicedand,
in fact, in any location where local anesthetics are administered by any professional, by any route, and in almost any
dose [14]. In our survey, large majority of hospitals (80%)
in China did not stock Intralipid. When the respondents were
stratied by hospital grade, for the question about whether
their hospital routinely stocked Intralipid, there was signicant
difference among 3 groups. The higher level care hospitals
tended to stock Intralipid because they had more resources
and better training.
In a study, the authors included more than 7000 peripheral
nerve and plexus blocks; they reported that the blocks were
performed with US (13%), NS (30%), US with NS (50%),
and other (7%) techniques [15]. There are very few peripheral
J. Huang, H. Gao
nerve blocks without US and/or NS. Blind blocks that rely
solely on anatomical landmarks and/or fascia clicks are known
to produce serious complications [16,17]. Blind block may
carry a risk of nerve injury by direct puncture [18]. It is why
NS became the criterion standard for nerve identication in
RA over the past decade; now, ultrasound guidance technique
becomes popular. Most anesthesiologists (68.2%) in China
performed peripheral nerve blocks by blind blocks. Only
32.8% used NS and ultrasound guidance. A majority of anesthesiologists did not receive peripheral nerve block training.
Blind technique for peripheral nerve blocks was popular in
China; this was largely due to lack of tools (NS, US) or lack
of knowledge and training.
In our survey, the barriers for anesthesiologists to provide
peripheral nerve block were quoted concern for nerve injury
(41%), failure rate of the blocks (24%), and patient refusal
(24%) and it is time consuming (11%). These results were
quite different from a survey in the UK [19]. The anesthesiologists in UK believed that the main barriers to provide RA
were the length of time required to establish the block
(86%). Poor patient acceptability was cited by 45%; low success rate, by 21%; and concern for nerve damage, by 12% of
respondents. The culture and training contributed the differences. Especially violence against doctors was quite common
in China. Physicians worried about potential complications
which may affect the physician-patient relationship. Peripheral
nerve block is a time-consuming process; busy operating room
schedule and shortage prevented anesthesiologists to provide
peripheral nerve block.
The number of the responders who used loss of resistance
to air (48.87%) was used almost equal to those who used loss
of resistance to saline (44.31%) to identify the epidural space.
The result was consistent with the conclusion of Antibas et al
[20]. Most of the responders indicated that they placed spinal
or epidural needle at L34 (67.52%) and L23 (30.67%). Anesthesiologists use Tufer's line as an anatomical landmark in
spinal and epidural anesthesia. However, utilization of Tufer's line to assess intervertebral space level for lumbar puncture is not very accurate.
There are limitations with this study. The survey study cannot validate the accuracy and honesty of the response. Therefore, prospective study is recommended.
The current survey can serve as a benchmark for future
comparisons and evaluation of RA practices in China. This
survey revealed potential RA safety issues in China. Almost
half of the surgeries were done under RA. No epinephrinecontaining epidural test dose (a safeguard against intravascular
injection) was used by a majority of anesthesiologists. The
risks of LA toxicity may be increased. In addition, only 20%
hospitals stocked Intralipid, a drug to rescue LA toxicity,
which may further increase the potential risks of morbidity
and mortality of LA toxicity. This survey alerts the need to implement a national education program to train anesthesiologists for RA techniques and enhance knowledge. Local
hospitals are urged to equip more basic RA tools (NSs and
US) to improve patient safety.
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