The Application of Regional Anaesthesia in Türkiye: National Survey Study

Regional anaesthesia (RA) techniques are commonly used both for anaesthesia during surgical interventions and for postoperative pain management. The advancements in needles and catheters used in RA, as well as the introduction of new and safer local anaesthetics into clinical practice, have increased interest in RA.¹ Additionally, in recent applications of ultrasound-(USG) guided RA, target structures, anatomical relationships, and drug distribution can be visualized.² Therefore, it has significantly expanded the scope of anaesthetists’ practices, leading to the introduction of new blocks in clinical settings and changes in preferences between existing blocks.³ In our country, basic and advanced clinical USG courses for anaesthesiologists are organized by anaesthesia associations to support USG and RA education. However, there is no comprehensive recent study in our country investigating RA applications, USG usage, or the changes caused by USG in clinical practice.

This study aims to explore the preferences of anaesthesiologists regarding RA techniques and the extent to which USG is utilized in these practices. Specifically, it seeks to identify factors influencing these preferences and assess how widespread the use of USG is in the administration of RA across different institutions.

The survey study titled “Regional Anaesthesia Applications in Türkiye: A National Survey Study” was conducted between September 2023 and March 2024, after obtaining approval from the Ege University Medical Research Ethics Committee (approval no.: 2023-0291, dated: 11.05.2023). The survey, created on SurveyMonkey.com, was distributed electronically or in-person to anaesthesiology and reanimation specialists working in various provinces of Türkiye. The survey was designed to be filled out by a minimum of 200 anaesthesiologists. The purpose and objectives of the study were explained to the participating anaesthesiologists. Participation in the study was entirely voluntary. The survey consists of 34 questions, addressing topics such as demographic characteristics, neuraxial block and peripheral nerve block (PNB) applications, drug selection, education, and safety measures (Appendix 1: Survey form).

The first six questions were aimed at identifying the demographic characteristics of the participants, (age, gender, institution where specialist training was received, current institution, job title, and education related to peripheral block application). Questions 7-14 asked about RA preferences: in upper extremities, lower extremities, abdominal surgery, and day-case surgeries. Questions 15-24 addressed the choice of needles, application methods, and safety precautions taken in neuraxial anaesthesia. Questions 25-29 inquired about the drugs used for peripheral blocks, methods, precautions taken to avoid nerve damage, and RA complications. Questions 30-31 asked about sedation preferences during RA. Finally, questions 33 and 34 evaluated anaesthesiologists’ RA preferences for paediatric patients.

Statistical Analysis

Our analyses were performed using SPSS 26.0 software, with a 95% confidence level. In the analyses, frequency and percentage values were calculated for categorical variables, while the mean and standard deviations were computed for age. The relationship between job title, current institution, and categorical variables was analyzed using the chi-square test.

A total of 215 anaesthesiologists started the survey, with 204 completing all questions. 32.4% of participants were 30 years old or younger, 37.3% were between 31 and 40 years old, and 30.4% were 41 years old or older. The average age was 35.98, with a standard deviation of 7.85 (Table 1).

The most common reason for not choosing RA is the patient’s refusal, which was cited by 85.8% of respondents, followed by insufficient time (37.7%) and concerns about complications (22.1%).

Among the most common positions for performing routine neuraxial techniques, sitting (53.9%) and condition-dependent positions (36.8%) are prominent. For spinal anaesthesia, sharp-tipped needles (73.0%) and 25G needles (68.1%) are generally preferred. The most commonly used local anaesthetic for spinal anaesthesia is bupivacaine, which accounts for 99.0% of cases.

The most frequently used method for defining the epidural space is the loss of resistance to fluid (89.2%), while the most commonly used drugs for epidural test doses are 3 mL of 2% lidocaine (52.0%) and 3 mL of 1.5% lidocaine with 15 µg of adrenaline (41.2%). The most commonly used drugs for postoperative epidural analgesia are opioids and local anaesthetics, used together (73.5%) (Table 2).

The percentage of people using epidural catheters for postoperative analgesia is 88.7%, while 39.2% use adjunct medications for spinal block. Among the adjunct medications used, fentanyl (70.5%) and morphine (29.5%) are the most common (Table 3).

There is a request to rank the frequency of complications after RA. The most common complication is postspinal headache, at 67.2%. The second most frequent is Horner’s syndrome, at 32% (Table 4).

When examining the postoperative RA method preferences in paediatric patients, peripheral block (40.7%) and caudal block (39.7%) are the most commonly preferred methods. These are followed by the epidural catheter procedure (3.4%) and spinal anaesthesia (2.5%), demonstrating their respective proportions. Additionally, the proportion of those who do not prefer regional techniques in children is also noteworthy, with 33.3% (Table 4).

When examining the age limits for applying regional analgesia in paediatric patients, it is observed that a significant portion of participants (45.6%) do not apply it to very young children. Some participants (22.1%) stated that they applied regional analgesia to all children without specifying age limits, while others (32.4%) mentioned that they did not apply regional analgesia to paediatric patients (Table 4).

There is a significant relationship between the institution where the participant works and the percentage of surgeries performed under RA (P < 0.05). According to this, 43.8% of those working in university hospitals perform surgeries under RA in 40-60% of cases; 59.0% of those working in teaching and research hospitals perform them in more than 60% of cases; 44.7% of those working in state hospitals perform them in 40-60% of cases; and 62.5% of those working in private hospitals perform them in 40-60% of cases.

There is a significant relationship between the institution where the participant works and the preference for PNB or catheter infusion for postoperative analgesia (P < 0.05). According to this, 53.8% of those working in university hospitals, 76.9% of those in teaching and research hospitals, 60.5% of those in state hospitals, and 87.5% of those in private hospitals prefer PNBs or catheter infusions for postoperative analgesia (Table 5).

There is a significant relationship between the institution where the participant works and the first choice of analgesia in open abdominal surgery (P < 0.05). According to this, 63.8% of university hospital workers and 55.3% of state hospital workers prefer transversus abdominis and rectus blocks, while 55.1% of teaching and research hospital workers and 62.5% of private hospital workers prefer epidural analgesia.

There is a significant relationship between the institution where the participant works and the most commonly used technique in PNB (P < 0.05). According to this, 78.8% of those working in university hospitals use USG plus nerve stimulator (USG+NS), 60.3% of those in teaching and research hospitals use USG, 42.1% of those in state hospitals use either USG+NS or USG, and 50.0% of those in private hospitals use USG.

RA has become a widely used technique in recent years, both worldwide and in Türkiye. The growing popularity of RA can be attributed to its advantages, including the reduction in opioid consumption, decreased stress response during surgery, reduced intraoperative and postoperative blood loss, provision of high-quality analgesia specific to the region, enhanced early mobilization and rehabilitation, and the ability to communicate with the patient and better guide treatment due to the patient being conscious. Developments in RA techniques, such as advancements in needles, catheters, and imaging methods, have further contributed to its increased popularity.

The younger population has followed the developments in RA more closely. It is believed that the higher percentage of residents who are still in ongoing training contributed to this trend. A similar age, professional experience, and role distribution was found in a thesis study conducted in Türkiye.⁴ When the distribution of participants by institution was compared, it was found to be similar to that in the study by Gürkan et al.³ and the distribution of aneasthesiologists in the country. The basis of RA education was based on specialist training. RA education is of a certain standard in all hospitals providing training and is supported by practical training by the Regional Anesthesia Association. The facilities of hospitals, patient profiles, and the knowledge, skills, interests, and experience of the educators may vary, which could make standardization more challenging.

In postoperative pain management guidelines, the importance of multimodal analgesia is emphasized and its use is recommended. The widespread and successful application of RA and analgesia methods has shown positive outcomes in reducing opioid use. Regarding the participants’ preferences for postoperative analgesia, the most common choice was acetaminophen and non-steroidal anti-inflammatory drugs, followed by PNBs or catheter infusion (Table 6).

 The widespread use of PNB is thought to be due to its anaesthetic properties and effectiveness in pain management.

Postoperative pain management following shoulder surgery can be challenging. A systematic review of 2,391 articles on postoperative pain following shoulder surgery suggested that interscalene blocks were ideal for early postoperative analgesia.⁵ In a study by Lin et al.⁶, the interscalene block was identified as the most beneficial PNB for shoulder surgery, while the supraclavicular block was suggested as an alternative. In our study, more than half of the participants preferred the interscalene block as their first choice. The axillary block, which is simple, easy to apply, and safe, is the most commonly used PNB, especially for elbow, forearm, and hand surgeries.^{3, 7}

A meta-analysis published in 2024 highlighted the importance of the Enhanced Recovery After Surgery protocol, in improving recovery after hip and knee surgeries, with nerve blocks and infiltration analgesia, which are key components of this protocol.⁸ A significant portion of participants in our study preferred spinal and epidural anaesthesia for postoperative analgesia in both surgeries. In recent years, there has been a trend towards peripheral blocks due to undesirable complications of neuraxial anaesthesia.

Thoracic epidural analgesia has long been the gold standard for multimodal analgesia in thoracotomy.⁹ With the widespread use of USG, ESP block applications are used more frequently than the more invasive thoracic epidural and paravertebral applications. The ESP block has also been shown to improve chronic post-thoracotomy pain syndrome in patients, weeks after surgery.¹⁰ Regional blocks play a significant role in abdominal surgery, improving postoperative recovery.¹¹ Recently, the interest in transversus abdominis plane blocks has increased substantially, and they have been shown to provide sufficient analgesia for abdominal surgery.¹²

In our study, the most common reason for not choosing RA was found to be the patient’s refusal. This result is consistent with studies conducted in Türkiye.^{3, 4} However, a study in China found that the most common reason for not using RA was concern about complications.¹³ In our study, concern about complications was found to be the third most common reason, at a rate of 22.1%. We think that real-time block application with USG in RA reduces the concern for complications.

The most common position for performing routine neuraxial techniques was found to be the sitting position. A study by Aksu et al.¹⁴ showed that the interspinous distance was wider in the sitting position than in the lateral decubitus position. This suggests that the sitting position may enhance the success of neuraxial blocks. It was observed that spinal anaesthesia was typically performed using sharp-tipped 25G needles, with bupivacaine being the most commonly preferred local anaesthetic due to its long duration of action and availability. A study conducted in India in 2021 yielded results similar to those in our country.¹⁵ In defining the epidural space, the loss of resistance using fluid, was the most common method, although this technique requires experience and is subjective. In inexperienced hands, the failure rate can be as high as 15%. Using air, on the other hand, is associated with adverse effects such as headache, nerve injury, and insufficient spread of the medication, which are not observed with fluid. To increase success rates, new techniques with high sensitivity and specificity should be preferred.¹⁶ Many participants indicated that they use a test dose, with 3 mL of 2% lidocaine being the most commonly used.

The use of epidural catheters for postoperative analgesia was found to be very common. Their widespread use is likely due to their ability to provide both anaesthesia and analgesia. The combination of opioids and local anaesthetics was the most common choice for this purpose. The use of adjuvants can enhance the effect of local anaesthetics and prolong intraoperative and postoperative analgesia. Studies have shown that a smaller dose of bupivacaine is associated with less hypotension and faster recovery.¹⁷ Fentanyl was the most commonly used adjuvant. However, prolonged opioid use can lead to adverse effects like respiratory depression, nausea, and vomiting.

In PNB, the use of blind techniques has largely been abandoned due to the serious complications they can cause and the widespread use of USG. In comparison with other countries, blind techniques were still used in China, NS was common in Greece, and USG was the preferred method in India.^{1, 13, 18} It was observed that the choice of local anaesthetic in PNB was bupivacaine-prilocaine or bupivacaine and lidocaine combination, which provides a rapid onset of action and long duration of effect. It is advisable that lidocaine should be preferred because of the methemoglobinemia-inducing effect of prilocaine. Fentanyl and dexamethasone were commonly used as adjuvants in PNBs, helping to reduce the required dose of local anaesthetics while maintaining effective anaesthesia without enhancing motor blockade. Despite the benefits of these drugs, many are not approved by the Food and Drug Administration, and caution should be exercised in their use.¹⁹

The incidence of local anaesthetic systemic toxicity (LAST) in PNBs was found to be 20/10,000, while in epidural blocks, it was 4/10,000.²⁰ LAST is a serious and life-threatening complication that requires immediate intervention. The standard treatment for LAST is the administration of Intralipid solution, which should be readily available in clinics performing RA procedures, with expiration dates regularly monitored. Our study found that most clinics had intralipid solutions available.

It was noted that sedation was frequently used both before and after RA procedures. Sedation helps ensure patient cooperation, prevent sudden movements, and enhance procedural safety. However, some participants avoided sedation, arguing that it might mask the early warning signs of LAST.²¹

In our study, the use of peripheral block catheters for postoperative analgesia was found to be rare, and in most clinics, they were not used. (Table 7). We believe that the low usage could be attributed to a lack of materials and insufficient knowledge and training about their safety. Similar findings have been reported in other national studies.^{1, 13}

In our study, caudal blocks were the most commonly used peripheral blocks in children, but a significant proportion of participants also reported not preferring RA in paediatric cases. Most participants indicated that age limits were crucial in paediatric RA applications, with many avoiding the use of paediatric RA applications in very young children. The difficulty in recognizing surface landmarks, as well as the variability in the depth and location of nerves in growing children, makes RA more challenging. However, these difficulties have been overcome with the use of USG.²²

RA application rates were higher in educational and research hospitals and university hospitals, likely due to the training provided to residents and the diversity of cases encountered. In contrast, PNB and catheter infusions were more common in private hospitals, likely due to better availability of equipment. However, the small number of participants from private hospitals in this study may not fully reflect the actual distribution.

Study Limitations

There are several limitations to our study. We created a heterogeneous group of experts in RA, experienced physicians outside of RA, and resident physicians in training. The survey was administered both online and face-to-face and using a single method, particularly face-to-face administration, could have reduced measurement errors. Due to the low number of participants, we believe the results may not fully reflect national preferences, and larger studies with more participants are needed.

RA is a widely used and developing field in our country frequently preferred by young physicians. The importance of supporting RA education during residency training has become more prominent. It was observed that the limited use of PNBs due to equipment shortages and insufficient training, has been partially overcome, and their application has become more widespread. Hospitals providing training should be supported with the necessary equipment and USG resources.

RA plays a crucial role in postoperative multimodal analgesia. By reducing opioid consumption and providing long-lasting analgesia, RA contributes to shorter hospital stays and reduced healthcare costs. The most common contraindication for RA was found to be the patient’s refusal. The application rate can be increased by adequately explaining the procedure to the patient and discussing its advantages. It is essential to implement the recommended safety measures for RA, and clinics where these procedures are performed must have intralipid solutions available. This would likely reduce morbidity and mortality associated with local anaesthetic toxicity.

Our study can serve as a reference for future research, providing valuable insights into the detailed use of RA applications.