Surveys have been performed in recent years investigating the use of acute pain services (APS) for postoperative pain treatment (1), examining the practice of thoracic epidural anesthesia and analgesia (EA) (2), and evaluating current practices in obstetric analgesia (3,4).
Available literature indicates that the administration of epidural drugs has changed from bolus doses to continuous epidural infusions (5,6), and patient-controlled epidural analgesia (PCEA) (7). The epidural combination of small-dose local anesthetic (LA) plus opioid has been investigated extensively in clinical studies (7,8), but no data are available reporting the frequency of use of these techniques and drug combinations in the postoperative setting. The aim of the present survey was to determine current German practice in postoperative EA.
A list of 685 German hospitals with at least 3 surgical departments was obtained from the central list of German hospitals. A sampling of 300 hospitals was selected by using a random start, stratified by geography/region, teaching versus nonteaching, and number of beds. The questionnaire was sent with a cover letter explaining the nature of the survey to the chief anesthesiologists, and containing a prepaid return envelope without identifying information. The questionnaire, designed to be completed anonymous, consisted mainly of multiple-choice questions. Multiple responses were possible. Respondents were asked, in addition to detailed demographic information, about total number of beds, number of anesthesiologists, number of anesthetics per year, availability of an APS and the organizational model, and about the surgical departments that request postoperative EA (abdominal surgery, vascular surgery, cardiothoracic surgery, urologic surgery, gynecology [without obstetrics], trauma, and orthopedic surgery).
The questionnaire requested the following information for each surgical ward:
- Use of postoperative EA.
- Choice of epidural drugs: LA (ropivacaine, bupivacaine, others, including the exact concentration of LA used), opioids (morphine, fentanyl, sufentanil, others), additional drugs (e.g., clonidine, others).
- Mode of delivery: bolus doses, continuous epidural infusion, PCEA (background infusion plus on-demand bolus doses).
- Duration of postoperative EA.
All data were for the year 2000 and were collected and computerized by one of the authors (PK), who specializes in statistics. Because of the anonymous nature of the questionnaire, no follow-ups were conducted.
Statistical analysis was performed by using the SPSS 9.0 statistical package (SPSS Inc., Chicago, IL). Unless indicated, data were presented as numbers or percentages of respondents.
A total of 147 completed questionnaires were returned, indicating a response rate of 49%. All hospitals provided exact demographic data. No questionnaire was excluded. The 147 hospitals provided different surgical departments (Table 1). For the frequency in the use of postoperative EA, see Table 1. A 24-h APS was offered in 41% of German hospitals. The large teaching hospitals (>1000 beds) provided an APS in 70%, hospitals with 801–1000 beds in 40%, and hospitals with 501–800 beds in 44%; 9% of the hospitals with <500 beds provided an APS.
Small hospitals (<200 beds) used ropivacaine in 72% versus 28% using bupivacaine. Hospitals with 201–500 beds used an equal proportion of ropivacaine (59%) and bupivacaine (55%), as did hospitals with 501–800 beds (ropivacaine 61%, bupivacaine 62%). Larger hospitals used less ropivacaine than bupivacaine (801–1000 beds: 51% ropivacaine versus 70% bupivacaine; >1000 beds: 62% ropivacaine versus 72% bupivacaine). There were no other LAs used for postoperative EA. On wards, 36% used plain LA, and 64% combined the LA with opioids. If ropivacaine was used, 0.2% was the most popular concentration (78%), combined with morphine (17%), fentanyl (14%), or sufentanil (75%). If bupivacaine was used, 0.25% was the preferred concentration (30%), combined with morphine (40%), fentanyl (8%), or sufentanil (60%). Clonidine as an adjunct to epidural LA was used in 8%, buprenorphine in 3%, and droperidol in 1%.
In the ward setting, 58% of German departments used continuous epidural infusion, 57% bolus doses, and 20% the PCEA mode. The duration of postoperative EA is presented in Table 1.
In 1993, a survey of 105 hospitals from 17 European nations found that 34% had an organized APS (1). In the United Kingdom, the number of hospitals with multidisciplinary APS had increased from 2.8% before September 1990 to 42.7% at the end of 1994 (9). Data from the United States indicate that 42% of the hospitals have an APS (10). Our data from the year 2000 are in accordance with these statistics. However, it should be remembered that there is no generally accepted definition of APS (11).
International data concerning epidural opioid administration on wards are conflicting. A United Kingdom survey to examine the practice of thoracic EA found that 95% of respondents used an opioid-based bupivacaine solution for epidural infusion, and these were most commonly (63%) cared for on general surgical wards (12). A Scottish survey of extradural opioid practice reported that 69% of consultants frequently send their patients to a high-dependency unit after epidural opioid administration (13). However, the epidural combination of LA plus opioid has become the most common choice for EA on wards in Germany.
Few international data are available on the frequency of use of continuous epidural infusion or PCEA. Continuous epidural infusion is the most common choice (100%) in Australia after thoracotomy (14), and in obstetric patients in the United States (95.2%), and in Canada (90.6%) (15,16). Notably, continuous epidural infusion and bolus doses are used frequently on German general wards, but use of the PCEA mode is still small.
It is important to acknowledge the potential biases in this study including self-report bias, representativeness, and nonresponse bias. We thought that the anonymous character of the survey would reduce any intention to answer false behaviors or perceptions of the respondent. By sampling a strictly stratified group of hospitals from Germany, we hoped to attain a representative sample. The demographics of the respondents compared favorably with that of the central list used for random selection, and suggests that our sample, despite its relatively small size, was indeed representative. Our response rate was satisfactory as we did not conduct follow-ups. However, the possibility of a nonresponse bias still exists.
Despite its limitations, this survey presents a picture of current German practice in postoperative EA. Our data show that German anesthesiologists prefer the combination of LA plus opioids for postoperative EA in the general ward setting. Continuous epidural infusion and bolus doses are frequently used, but use of the PCEA mode is still small. Comparison with practice in other countries is difficult, because of a lack of data.
There is a need for further international surveys on EA practice to compare data and to recommend strategies for postoperative EA in the surgical patient.
The authors thank Prof. Dr. W. Buzello for his critical reading of the manuscript. The authors are also indebted to the anesthesiologists who took time from their busy schedules to participate in this survey.
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