In recent years important developments have been established in the field of regional anaesthesia aiming at improved patient outcome and patient satisfaction. Peripheral nerve blocks, when applicable, became an alternative to epidural and spinal anaesthesia . Likewise, peripheral nerve blocks provide improved home readiness after ambulatory surgery, thus optimizing cost effectiveness . In addition the use of ropivacaine or levobupivacaine provides long-lasting neural blockade along with lower cardio- and neuro-toxicity compared to bupivacaine . While the advantages of regional anaesthesia using different techniques and more modern compounds qualify for general use, no data are available on the transfer of clinical evidence to clinical routine. Therefore, the present survey investigated the current practice of regional anaesthesia in Germany.
In 2003, all anaesthesia departments in Germany (n = 1381) received our questionnaire. The questionnaire was accompanied by a covering letter explaining the nature of the survey. To ease anonymous return a prepaid envelope was attached. Most items were designed as multiple-choice questions. The chief anaesthesiologists or their deputies were asked to comment on the following questions: total number of surgical beds, number of annual anaesthetic procedures, percentage of regional anaesthetic procedures compared to general anaesthesia, specification of individual regional anaesthesia techniques and the use of varying local anaesthetics for different regional anaesthetic techniques. In addition we asked for the number of board certified anaesthesiologists and residents within each department and collected information on the years of practice since board certification. The information was analysed by one of the authors (B.J.). Statistical analysis was performed by Statistical Analysis System SAS©, Version 12.0 (SAS©, Institute Inc., Cary, NC). In this purely descriptive study, we did not calculate significance and the data are presented as number or percentage of respondents. In case of incomplete reply we indicated these items as missing values and made this transparent in our calculation.
A total of 667 questionnaires were returned anonymously resulting in a return rate of 48.3%. The majority of responding hospitals provided management of <200 beds (n = 360, 59.6%). Only 5.1% of the hospitals (n = 31) provided more than 600 beds, 27.5% (n = 166) of the hospitals performed up to 3000 procedures per year, 58.6% (n = 354) performed 3000–10 000 anaesthetics and 12.7% (n = 77) performed more than 10 000 procedures. Nearly half of the responding hospitals rated their percentage of regional anaesthesia between 10% and 25% (42.5%, n = 257). Approximately a third reported a percentage between 25% and 50% (33.9%, n = 205) and only 6% (n = 36) stated a rate above 50%. In general, hospital size – either represented by the number of surgical beds or the number of anaesthetic procedures per year – related to the rate of regional anaesthesia displayed an inversely proportional correlation (Table 1 and Fig. 1). This correlation was also documented in regard to the academic status of the responding hospitals (Table 2 and Fig. 2).
Concerning the use of standard central nerve blocks (i.e. spinal and lumbar epidural anaesthesia) all hospitals reported high application rates, independent of hospital size. More advanced central techniques (i.e. combined spinal epidural, thoracic epidural) showed rising use with increasing hospital size. This trend continued with regard to peripheral nerve blocks. Whereas a standard axillary approach to the brachial plexus was commonly used in almost all hospitals, the use of interscalene and infraclavicular techniques again displayed a proportional relation to the hospital size. For peripheral nerve blocks of the lower extremity (femoral, sciatic, psoas compartment) a similar relation was documented (Table 3).
The use of different local anaesthetics showed no relation to hospital size (Table 4). Regarding the structure of the anaesthesiology staff it appeared that the relation between residents and board certified anaesthesiologists (consultants) changed with the size of the department. In small hospitals a majority of consultants cared for the patients, but with increasing hospital size the relation changed to a majority of residents providing the care (Table 5 and Fig. 3).
Regional anaesthesia reduces costs, morbidity and mortality and improves patient outcome [4,5]. Although some inherent disadvantages with severe complications – like systemic toxicity or long-lasting neurologic complications – are well documented , the use of regional anaesthetic procedures seems to increase continuously . Therefore, this study aimed at providing an overview concerning current regional anaesthesia practice in daily hospital routine in Germany. Our data showed surprising results as hospital size and the rate of regional anaesthesia displayed an inversely proportional relation: the smaller the hospital size, the higher the rate of regional anaesthesia related to the total number of anaesthetics. In contrast, the number of different techniques employed was proportionally related to the hospital size. Our conclusions are limited by the fact that the calculations represent statistical means and it should be clearly stated that some small hospitals – particularly those who specialized in traumatic or chronic rheumatoid surgery – utilize the whole gamut of regional anaesthesia techniques.
In Germany, hospitals with small anaesthesia departments rely on only a limited number of techniques but use them frequently. In contrast, larger departments offer the whole variety of regional anaesthetic techniques, but rarely use them. This may be related to a broader surgical spectrum and the different staff structure with a large number of residents supported by a small number of consultants. Reliable application of a regional anaesthetic technique requires skills and experience, which is likely represented by a consultant anaesthesiologist. Residents should gain these skills during their clinical education, but in a majority of German hospitals this training – even in University hospitals – is not standardized or scheduled. As such, the impact of ‘learning curves’ has been outlined  and minimal caseloads have been recommended ; however, the German medical association demands only basic regional anaesthesia experience for board eligibility in anaesthesiology . While central nerve blocks seem adequately represented (100 procedures), the claimed number of 50 peripheral procedures is likely inadequate considering the diversity of techniques available (see Table 3). An identical problem was currently addressed in North America , where residents frequently report limited access to peripheral nerve blocks during their training. Similar to German practice, American residents seem to be adequately trained in spinal and epidural techniques, but 40% of them fail to perform the minimum caseload of 40 peripheral blocks recommended by the Accreditation Council on Graduate Medical Education (ACGME) . Recently, guidelines have been published to address this problem by establishing a standardized curriculum for regional anaesthesia training . However, these guidelines refer to fellowship training, thereby addressing only post-graduates after their board certification. Given the fact that regional anaesthesia expertise has positive employment implications  such fellowship programs might have significant appeal.
The causal connection between training, rate of success and rate of application was recently demonstrated within the scope of a detailed comparison of regional anaesthesia practice in German speaking countries . They discovered that during their training in regional anaesthesia Swiss residents are supervised and monitored more intensively than German colleagues, consequently their success rates where higher and the overall rate of regional anaesthesia compared to the total number of anaesthetics delivered was more than twice as high. In France, residents also seem to gather a more adequate experience in regional anaesthesia practice. At the end of their residency they performed 75 peripheral blocks on average . Access to comparative data of other European countries is limited, nonetheless, it is well documented that, especially in France, the use of regional anaesthesia is rapidly increasing .
Concerning the use of different local anaesthetics our data showed that the proven benefits of ropivacaine (cardio-toxicity, motor block) did not result in a higher application rate compared to bupivacaine (in 2003 levobupivacaine was not available in Germany). In daily routine, these advantages might still be offset by economic considerations in favour of bupivacaine. However, limitations of the present study should be considered, as biases potentially confound its significance. An anonymous design was selected to reduce the reservations to respond and to omit any trend to give idealized answers, thus resulting in self-report bias. The majority (77%) of the answering consultants were board certified for more than 10 yr and, therefore, well experienced. This suggests high reliability of the data. By addressing every anaesthetic institution in Germany we aimed to get representative information. However, bias through non-responses cannot be excluded. Additionally, we did not analyse the case mix of the sampled hospitals, which impairs the significance of our results.
Against this background the present situation of regional anaesthesia in Germany can be outlined as follows: in small hospitals consultant anaesthesiologists rely on a rather small armamentarium of regional techniques, whereas in large departments some regional anaesthesia enthusiasts provide the full spectrum. Due to institutional limitations the majority of residents does not profit from this exposure [10,14]. Hence, we conclude that there is a strong needs to improve or at least implement residency or fellowship programmes with special regard to regional anaesthesia.
The Authors would like to thank Dr. David Rakoff for revising the manuscript. This survey was supported by ASTRA ZENECA, Wedel, Germany.
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