Call for standardisation in the management of regional anaesthesia in Europe

Thanks to the support from ESRA members, an assessment of regional anaesthesia practices found in 36 European countries has been published (Eur J Anaesthesiol Intensive Care Med 2023;2:4(e0026))

Insight was drawn from nearly 800 responses to a survey created by a Faculty of European regional anaesthesia (RA) experts and was disseminated through ESRA and via professional networks.  However, 86% of respondents were accessed through the European Society of Regional Anaesthesia & Pain Therapy (ESRA), for whose engagement the authors wish to express their gratitude.

The key findings from the survey include:

• The use of RA has grown in the past five years, the highest increase was noted in Iberia (Spain/Portugal), Italy, and UK and Ireland (median increase of 50%) compared with the lowest in Germany/Switzerland/Austria (GSA) and Belgium/Netherlands/Luxembourg (Benelux) (22 and 23%). Increases were also related to specific applications with upper and lower limb surgery as well as postoperative pain with reported median increases of 50%.
• Spinal anaesthesia (single injection) is the most common RA procedure and applies primarily to lower limb surgery (92% of respondents), Caesarean section (72%), and abdominal procedures (71%), while peripheral nerve block single shot is most used for lower and upper limb surgery (87%) and post-operative pain (65%).
• However there is significant country variation. For example, epidural single injection was the least commonly performed overall, but there were wide variations by country with France reporting 17% usage to 72% in Iberia. Similarly, for PNB continuous infusion with Greece at 32% and Germany/Switzerland/Austria (GSA) at 90%. These variations highlight a lack of consensus as to which procedure is best for which application or potentially a lack of awareness or training of newer procedures.
• Use of ultrasound when placing regional anaesthesia blocks was consistent across most countries with the highest rate of use in Benelux (99%), GSA (99%), UK and Ireland (98%), Denmark/Norway/Finland/Sweden (Nordic) (97%), Iberia (96%) and France (94%), but a much lower rate of use in Greece (45%).
• Anaesthetists predominantly monitor RA block efficacy with pain sensitivity (79%) and the ability to sense temperature (68%) being the most common methods of checking for pain relief. Median reported estimated failure rate of regional anaesthesia blocks across all countries was 5%, with highest rates seen for PNB single shot, PNB continuous infusion and interfascial plane block (median 10%).
• Most respondents reported a high frequency (over 50%) of systematically reporting multiple complication types, most commonly infection, headache, and nerve injury (all up to 69%), but respondents from Italy had notably low levels of reporting (highest 42% for headache) and 33% of all respondents reported that no complications are reported at all. This clearly highlights a lack of consensus as to not just which complications should be tracked but even if complications should be tracked.
• Although some countries are following international guidelines such as the ESRA guidelines (e.g. Benelux, Eastern Europe, Greece, Iberia and Italy), others are following more local or national guidelines (e.g. France and UK and Ireland) or their hospital guidelines (e.g. GSA and Nordic Europe).
• ISO Standard NRFit™ is in use in several responder countries, with the UK and Ireland the most likely to have implemented (61%). All countries reported the expectation that NRFit would be implemented within the next 5 years, with the sole exception of the Nordics. Most survey respondents said they would welcome more information and, when questioned as to what they perceive to be the major barrier to its implementation, cited financial obstacles.

The study identified the need for European standardisation and consistency in the use of RA, underpinned by three calls to action:

• To determine European best practice in measuring block efficacy
• To create a universal template to be capturing and reporting complications
• To facilitate the adoption of ISO Standard NRFit across Europe, through a programme of education and agreement on clear implementation processes

The full text can be accessed free of charge from the journal at https://journals.lww.com/ejaintensivecare/fulltext/2023/08000/regional_anaesthesia_practices__insights_from_a.5.aspx