This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (9) Citing Articles via Google Scholar Google Scholar Articles by Oldman, M. Articles by Chan, V. W. S. Search for Related Content PubMed PubMed Citation Articles by Oldman, M. Articles by Chan, V. W. S. Related Collections Economics and Health Care Research Surgery Anesthetic Techniques Regional Anesthesia

---

REGIONAL ANESTHESIA

A Survey of Orthopedic Surgeons’ Attitudes and Knowledge Regarding Regional Anesthesia

Department of Anaesthesia, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada

Address correspondence to Colin McCartney, FRCA, Department of Anesthesia, Toronto Western Hospital, EC2-046, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada. Address e-mail to colin.mccartney{at}uhn.on.ca Reprints will not be available from the authors.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
We conducted a survey to explore the surgical attitudes and preferences regarding regional anesthesia among Canadian orthopedic surgeons. Surveys were returned by 468 (61%) of 768 surgeons. Forty-eight percent of respondents directed their patients’ choice of anesthetic. Forty percent of surgeons directed their patients to choose regional anesthesia. The principal reasons for favoring regional anesthesia were less postoperative pain (32%), decreased nausea and vomiting (12%), and safety (14%). Reasons for not favoring regional anesthesia were delays in the induction of anesthesia (43%) and an unpredictable success rate (12%). This survey suggests that orthopedic surgeons are supportive of regional anesthesia. Barriers to increased popularity include perceived delays and unreliability.

IMPLICATIONS: Orthopedic surgeons understand the benefits of and are supportive of the use of regional anesthesia in their practices. Barriers to increased popularity include perceived operating room delays and lack of reliability.

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
This survey reports orthopedic surgeons’ attitudes and preferences toward regional anesthesia (RA). Surgeon preference is an important factor influencing patient anesthetic choice. Although much has been written regarding patient preferences (1–4), very little information is available that examines surgeons’ attitudes toward general anesthesia versus RA.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
After IRB approval, a survey consisting of multiple-choice questions, fill-in-the-blank questions, and mock clinical scenarios was mailed to 768 Canadian orthopedic surgeons identified from publicly available membership databases available on the Royal College of Physicians and Surgeons of Canada (http://www.royalcollege.ca) and American Association of Orthopedic Surgeons (http://www.aaos.org) Web sites. Surveys not returned within 6 wk were remailed. Exposure and attitudes to RA were recorded. Anesthetic preferences (general anesthesia alone, general anesthesia and RA, RA alone, or no preference) were determined for hypothetical surgical procedures, both for a healthy patient and for the surgeon (Table 1). A five-point Likert scale of agreement (Fig. 1) examined perceptions of RA. Attitudes toward RA were recorded by categorizing free text into themes (Figs. 2 and 3). Data were analyzed with SPSS (Base 9.0 for Windows; SPSS Inc., Chicago, IL). Noncontinuous data were analyzed with the ² test. P < 0.05 was considered statistically significant.

View larger version (35K): [in this window] [in a new window]   Figure 1. Perceptions of regional anesthesia. When compared with general anesthesia (GA), regional anesthesia (RA) is less successful than GA (<SUCCESS); safer for patients (SAFER); more time efficient (>TIME EFFIC); associated with less postoperative sedation (<SEDATION); better for postoperative pain control (<PAIN); reserved only for high-risk surgical patients (HI RISK); associated with more postoperative nausea (>NAUSEA); associated with later discharge from the postanesthesia care unit (>PACU); protective against thromboembolic disease (<THROMBOSIS); less cost-efficient (>COST); associated with less blood loss (<BLOOD); better for patient satisfaction (>SATISFACTION); and associated with earlier hospital discharge (>EARLY DISCHARGE). Data are displayed as median, range, and interquartile range.

View larger version (23K): [in this window] [in a new window]   Figure 2. Principal reasons regional anesthesia is favored. PONV = postoperative nausea and vomiting.

View larger version (16K): [in this window] [in a new window]   Figure 3. Principal reasons regional anesthesia is not favored. OR = operating room; GA = general anesthesia.

	Results

Top Abstract Introduction Methods Results Discussion References

The population characteristics of the respondents are shown in Table 2. Surgeon knowledge of RA was acquired from the following sources: residency and fellowship training (56%), clinical work (35%), anesthetic colleagues (31%), medical school (5%), journals (4%), and seminars (1%).

Perceptions of RA are summarized in Figure 1. Respondents tended to agree that RA is safer and provides better pain control and less postoperative sedation. Anesthetic choices are shown in Table 1 and reveal discrepancies between the technique that the surgeons would choose for their patients and that which they would choose for themselves. The main reason RA was favored was decreased pain (32%), and reasons for not favoring RA included delay to the operating room (OR) (43%) and unpredictable success (12%) (Figs. 2 and 3).

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
RA is not universally used in orthopedic surgery, despite its advantages. Many patients do not have a fixed preference regarding choice of anesthetic (5) and may be influenced by the recommendation of their surgeon, whose opinion can vary widely (6). Surgeons establish a relationship with patients well in advance of surgery and have many opportunities to influence patient choice. In contrast, the anesthesiologist may meet the patient only on the day of surgery, and addressing patient expectations at this time can lead to confusion and anxiety.

Our survey confirms the perception that many orthopedic surgeons influence patient anesthetic choice. Forty-eight percent of surgeons direct their patients’ choice of anesthetic before surgery, of which 84% direct their patients to choose RA. This suggests that surgeons are supportive of RA.

Surgeons appear to be aware of the many advantages that RA can provide (7–9). However, both blood transfusion and deep venous thrombosis are common in the orthopedic surgical population, and it is disappointing that there was not stronger agreement of benefit in these areas. This may be because recent advances in prophylaxis have neutralized the effect on thromboembolism.

Respondents had stronger opinions about the anesthetic that they would personally wish to receive compared with that which their patients would receive. Fewer respondents chose the "no preference" response as the anesthetic choice for themselves compared with their patients’ anesthetic choice. It seems that surgeons are not always willing to undergo the same procedures that they would recommend to their patients.

Factors that decrease the popularity of RA among surgeons include perceived delay to the operating room (OR) and unpredictable success. To increase the popularity of RA among surgeons, we should develop practical ways of performing blocks quickly and effectively. The introduction of protocols for the use of RA within a surgical unit may help to achieve the consistency and reliability of the blocks performed and may increase the familiarity of surgeons with RA techniques. Performing the block in another location, e.g., a regional block room, ahead of surgery can reduce delay to the OR (10) and increase the time available for block placement and evaluation. The use of local anesthetics with a short latency, such as lidocaine, together with modifications of anesthetic technique (11) can also improve the onset time and reliability of regional blocks. Familiarity and confidence of surgeons and anesthesiologists with rescue techniques, such as distal peripheral nerve blocks and local anesthetic infiltration, may avoid the need for general anesthesia.

Resident exposure to certain regional blocks is not frequent (12,13) and may not be sufficient for them to develop competency (14). Increasing exposure and concentrating experience, e.g., by a regional block room (15), should improve the proficiency of future generations of anesthesiologists in RA techniques.

There are no surgeon-oriented educational materials that address the issue of RA versus general anesthesia. Increasing surgical awareness of the advantages of RA may result in improved patient safety and better outcomes.

The response rate of 61% is not uncommon for a postal survey. However, we were unable to determine the opinions of 39% of our sample. This is a limitation to our findings, because the nonresponders may hold differing views about RA. The average age of the Canadian orthopedic surgeon is older then the average age of our respondents (16), suggesting that nonresponders were in an older age group. This population of surgeons may hold differing opinions of RA compared with their younger colleagues.

In summary, orthopedic surgeons understand the benefits of and support the use of RA for their patients. Barriers to increased popularity include perceived OR delays and lack of reliability. These issues can be resolved with physician education, improvements in training, and organization of the RA facility.

	Footnotes

 
Presented in part at the eighth annual spring meeting of the American Society of Regional Anesthesia, San Diego, CA, April 3–6, 2003.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Tait AR, Voepel-Lewis T, Monro HM, Malviya S. Parents’ preferences for participating in decisions made regarding their child’s anesthetic care. Paediatr Anaesth 2001; 11: 283–90.[Web of Science][Medline]
2. Preble LM, Perlstein L, Katsoff-Seidman L, et al. The patient care evaluation system: patients’ perceptions of anesthetic care. Conn Med 1993; 57: 363–6.[Medline]
3. Tong D, Chung F, Wong D. Predictive factors in global and anesthesia satisfaction in ambulatory surgery patients. Anesthesiology 1997; 87: 856–64.[Web of Science][Medline]
4. Myles PS, Williams DL, Hendrata M, et al. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. Br J Anaesth 2000; 84: 6–10.[Abstract/Free Full Text]
5. Matthey P, Finucane BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth 2000; 48: 333–9.
6. Newsom R, Luff A, Wainwright C, Canning C. UK survey of attitudes to local anaesthesia for vitreoretinal surgery. Eye 2001; 15: 708–11.[Medline]
7. Stadler M, Bardiau F, Seidel L, et al. Difference in risk factors for postoperative nausea and vomiting. Anesthesiology 2003; 98: 46–52.[Web of Science][Medline]
8. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493–7.[Abstract/Free Full Text]
9. Ganapathy S, McCartney CJ, Beattie WS, Chan VW. Best evidence in anesthetic practice: prevention—epidural anesthesia and analgesia does not reduce 30-day all-cause mortality and major morbidity after abdominal surgery. Can J Anaesth 2003; 50: 143–6.[Web of Science][Medline]
10. Williams BA, Kentor ML, Williams JP, et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology 2000; 93: 529–38.[Web of Science][Medline]
11. Koscielniak-Nielsen ZJ, Nielsen PR, Nielsen SL, et al. Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline. Acta Anaesthesiol Scand 1999; 43: 398–404.[Web of Science][Medline]
12. Smith MP, Sprung J, Zura A, et al. A survey of exposure to regional anesthesia in American anesthesia residency training programs. Reg Anesth Pain Med 1999; 24: 11–6.[Web of Science][Medline]
13. Kopacz DJ, Neal JM. Regional anesthesia and pain medicine: residency training—the year 2000. Reg Anesth Pain Med 2002; 27: 9–14.[Web of Science][Medline]
14. Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia "learning curve": what is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996; 21: 182–90.[Web of Science][Medline]
15. Martin G, Lineberger CK, MacLeod DB, et al. A new teaching model for resident training in regional anesthesia. Anesth Analg 2002; 95: 1423–7.[Abstract/Free Full Text]
16. Shipton D, Badley EM, Mahomed NN. Critical shortage of orthopaedic services in Ontario, Canada. J Bone Joint Surg Am 2003; 85: 1710–5.[Abstract/Free Full Text]

This article has been cited by other articles:

				E. R. Mariano, V. J. Loland, N. S. Sandhu, R. H. Bellars, M. L. Bishop, R. Afra, S. T. Ball, R. S. Meyer, R. C. Maldonado, and B. M. Ilfeld Ultrasound Guidance Versus Electrical Stimulation for Femoral Perineural Catheter Insertion J. Ultrasound Med., November 1, 2009; 28(11): 1453 - 1460. [Abstract] [Full Text] [PDF]

				A. J. R. Macfarlane, G. A. Prasad, V. W. S. Chan, and R. Brull Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review Br. J. Anaesth., September 1, 2009; 103(3): 335 - 345. [Abstract] [Full Text] [PDF]

				J. Marino, J. Russo, M. Kenny, R. Herenstein, E. Livote, and J. E. Chelly Continuous Lumbar Plexus Block for Postoperative Pain Control After Total Hip Arthroplasty. A Randomized Controlled Trial J. Bone Joint Surg. Am., January 1, 2009; 91(1): 29 - 37. [Abstract] [Full Text] [PDF]

				D. Masursky, F. Dexter, C. J. L. McCartney, S. A. Isaacson, and N. A. Nussmeier Predicting Orthopedic Surgeons' Preferences for Peripheral Nerve Blocks for Their Patients Anesth. Analg., February 1, 2008; 106(2): 561 - 567. [Abstract] [Full Text] [PDF]

				F. R. Cichocki JR., T. A. Barbolt, S. J. Savidge, G. Chen, and J. Zhou A Bioabsorbable Microcatheter for the Continuous and Direct Treatment of Surgical Sites J Biomater Appl, September 1, 2007; 22(2): 145 - 162. [Abstract] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (9) Citing Articles via Google Scholar Google Scholar Articles by Oldman, M. Articles by Chan, V. W. S. Search for Related Content PubMed PubMed Citation Articles by Oldman, M. Articles by Chan, V. W. S. Related Collections Economics and Health Care Research Surgery Anesthetic Techniques Regional Anesthesia