Journal of Clinical Anesthesia (2016) 34, 115123

Original contribution

Regional anesthesia practice in China:

a survey,
Jeffrey Huang MD (Associate Professor)a,, Huan Gao MD b
a

Anesthesiologists of Greater Orlando & University of Central Florida, 2699 Lee Rd, Suite 510, Winter Park, FL 32789
Department of Anesthesiology, Fangcheng County Hospital, Henan, China

Received 30 January 2016; revised 17 March 2016; accepted 17 March 2016

Keywords:
Regional anesthesia;
Survey;
Safety;
Training

Abstract
Study objective: Neuraxial anesthesia has been widely used in China. Recently, Chinese anesthesiologists
have applied nerve stimulator and ultrasound guidance for peripheral nerve blocks. Nationwide surveys
about regional anesthesia practices in China are lacking. We surveyed Chinese anesthesiologists about regional anesthesia techniques, preference, drug selections, complications, and treatments.
Design: A survey was sent to all anesthesiologist members by WeChat. The respondents can choose mobile
device or desktop to complete the survey. Each IP address is allowed to complete the survey once.
Main results: A total of 6589 members read invitations. A total of 2654 responses were received with
fully completed questionnaires, which represented an overall response rate of 40%. Forty-one percent
of the respondents reported that more than 50% of surgeries in their hospitals were done under regional
anesthesia. Most of the participants used test dose after epidural catheter insertion. The most common
drug for test dose was 3-mL 1.5% lidocaine; 2.6% of the participants reported that they had treated a
patient with epidural hematoma after neuraxial anesthesia. Most anesthesiologists (68.2%) performed
peripheral nerve blocks as blind procedures based on the knowledge of anatomical landmarks. A
majority of hospitals (80%) did not stock Intralipid; 61% of the respondents did not receive peripheral nerve
block training.
Conclusions: The current survey can serve as a benchmark for future comparisons and evaluation of regional anesthesia practices in China. This survey revealed potential regional anesthesia safety issues in China.
2016 Elsevier Inc. All rights reserved.

1. Study objective
Regional anesthesia/analgesia (RA) has become popular
in surgical care and postoperative pain management. RA

Disclosure: No funding for the research.

All authors had no conicts of interest.
Correspondence: Jeffrey Huang, MD, Anesthesiologists of Greater Orlando & University of Central Florida, 2699 Lee Rd, Suite 510, Winter Park,
FL 32789. Tel.: +1 407 896 9500; fax: +1 407 896 9585.
E-mail address: jeffreyhuangmd@gmail.com (J. Huang).

http://dx.doi.org/10.1016/j.jclinane.2016.03.071
0952-8180/ 2016 Elsevier Inc. All rights reserved.

can provide site specic, high-quality pain relief, while

reducing opioid consumption [1]. Peripheral nerve blocks
provide postoperative pain management, enhance early
mobilization and rehabilitation, and improve patient satisfaction [1]. Neuraxial anesthesia has been widely used in
China. Recently, Chinese anesthesiologists have applied nerve
stimulator (NS) and ultrasound (US) guidance for peripheral
nerve blocks.
To the best of our knowledge, nationwide surveys about
RA practices in China are lacking. A national survey may provide data for comparisons among different levels of hospitals,

116

J. Huang, H. Gao

identifying problems, and consequently continuous improvement of clinical practices. The results may also be used as a
tool for assessment of the teaching process, knowledge expansion, and hospital developments associated with RA.
The current survey is the rst nationwide attempt to document the current trends in RA practice in China. The results
may be used as a benchmark for future comparisons and evaluation of RA practices in China.
We surveyed Chinese anesthesiologists about RA techniques, preference, drug selections, complications, and
treatments.

2. Design
There are more than 78,000 registered anesthesiologist
members in New Youth Anesthesia Forum. After approval
from the committee of New Youth Anesthesia Forum, a survey was sent to all anesthesiologist members by WeChat.
The respondents can choose mobile device or desktop to complete the survey. Each IP address is allowed to complete the
survey once.
The survey was designed to ask questions about RA techniques, drug selections, uid administration, complications,
and postoperative pain management.
The survey questions included basic demographic information about the anesthesiologist's hospital level (grade I, II, or
III) and title. To minimize the bias for few open questions,
question formats were used: Yes or No boxes, selection of best
possible answer out of 2 to 5 alternatives options. No monetary
compensation was provided for any kind of participation in
this survey.

Fig. 1

Statistical analyses were performed using 2 test. All tests

were 2 tailed with a type I error rate of 0.05.

3. Main results
The survey was undertaken from December 2, 2015, to January 2, 2016. New Youth Anesthesia Forum sends new messages to each member every day. The members read the
messages that they are interested. The server can record how
many members open and read the invitation. Only those members who read the survey invitation were included in the study.
A total of 6589 members read invitations. A total of 2654 responses were received with fully completed questionnaires,
which represented an overall response rate of 40%. Majority
of surveys (2583) were completed by mobile devices; the rest
(71) was received by computer.

3.1. Participant's demographic data

The respondents were distributed throughout the country
(Fig. 1; Table 1).
Hospitals in China are classied according to a 3-tier system by a hospital's ability to provide medical care and medical
education and conduct medical research. Hospitals are designated as grade I, grade II, or grade III. Physician title included
resident physician, attending physician, and chief physician.

3.2. Neuraxial block techniques

Neuraxial block was initiated in the lateral position by the
majority of anesthesiologists (Table 2). Most anesthesiologists

Participant's demographic data.

Regional anesthesia practice in China

Table 1

117
Table 3

Participant's demographic data

Hospital grade
Grade I
187 (7.05%)
Grade II
1221 (46.01%)
Grade III
1246 (46.95%)
Title
Resident physicians
976 (36.77%)
Attending physicians
1062 (40.02%)
Chief physicians
616 (23.21%)
Percentage of surgeries done under RA each year
10%
242 (9.12%)
20%-30%
562 (21.18%)
31%-50%
747 (28.15%)
N 51%
1103 (41.56%)

Spinal anesthesia drug selection

LA
Bupivacaine
Ropivacaine
Lidocaine
Baricity
Hyperbaric solution
Isobaric solution
Hypobaric solution
Additives
None
Fentanyl
Sufentanil

1875 (70.65%)
745 (28.07%)
34 (1.28%)
1198 (45.14%)
1277 (48.12%)
179 (6.74%)
2508 (94.5%)
76 (2.86%)
70 (2.64%)

3.5. Epidural anesthesia

placed needle in L23 and L34 interspace; 40.5% of respondents used 22G spinal needle for spinal anesthesia.

3.3. Spinal anesthesia drug selection

The most common spinal anesthetic was bupivacaine
(Table 3). The use of adjuvants, particularly opioids, was not
common; 45.14% and 48.12% used hyperbaric solution and
isobaric solution for spinal anesthesia, respectively.

The respondents used loss of resistance with saline

(48.87%) and loss of resistance with air (44.31%) to identify
epidural space (Table 5). Most of the participants used test
dose after epidural catheter insertion. The most common drug
for test dose was 3-mL 1.5% lidocaine. More than 60% of the
respondents would apply neuraxial anesthesia if patient's
platelet count was more than 70.

3.6. Neuraxial anesthesia complications and treatments

3.4. Fluid administration
Approximately 63.53% of the respondents selectively administer uid before neuraxial anesthesia (Table 4). Crystalloid, between 500 and 1000 mL (69.25%), was the most
commonly administered.

Approximately 62% of the respondents used conservative

therapy to treat postdural puncture headache (Table 6); 67%
did not use epidural blood patch; and 2.6% of the participants
reported that they had treated a patient with epidural hematoma after neuraxial anesthesia.

3.7. Peripheral nerve blocks

Most anesthesiologists (68.2%) performed peripheral nerve
blocks as blind procedures based on the knowledge of anatomTable 2

Neuraxial block techniques

Patient position
Lateral
Sitting
Interspace
L2-3
L3-4
L4-5
L5-S1
Needle size for spinal anesthesia
22G
24G
25G
27G

2629 (99.06%)
25 (0.94%)
814 (30.67%)
1792 (67.52%)
47 (1.77%)
1 (0.04%)
1075 (40.5%)
658 (24.83%)
613 (23.1%)
307 (11.57%)

Table 4

Fluid administration

Routinely preload
Never
113 (4.26%)
Routine preload for all patients
855 (32.22%)
Selective patients (eg, cesarean, long NPO time) 1686 (63.53%)
Preload volume
Crystalloid uid preload 500 mL
1648 (62.09%)
Crystalloid uid preload 1000 mL
190 (7.16%)
Colloid uid preload 500 mL
680 (25.62%)
Colloid uid preload 1000 mL
11 (0.41%)
None
125 (4.71%)

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Table 5

J. Huang, H. Gao
Table 7

Epidural anesthesia

Techniques to identify epidural space

Loss of resistance to air
Loss of resistance to saline
Hand in drop
Test dose
No
Yes, 1.5% lidocaine 3 mL
Yes, 1.5% lidocaine with 1:200,000
epinephrine 3 mL
Other drugs
Minimal platelet count for neuraxial anesthesia
N 100
N 70
N 50
Based on patient history, PT/PTT/INR, and physical
examinations; platelet count as a reference

1297 (48.87%)
1176 (44.31%)
181 (6.82%)
91 (3.43%)
2212 (83.35%)
125 (4.71%)
226 (8.52%)
496 (18.69%)
1126 (42.43%)
301 (11.34%)
731 (27.54%)

Peripheral nerve blocks

Peripheral nerve block techniques

Blind technique
NS
US guidance
US guidance and NS
Barriers to provide nerve blocks
Insufciency time
Patient refusal
Failure of the techniques
Concern potential complications
Hospitals always stock Intralipid
Yes
No
Peripheral nerve block training
Yes
No

1810 (68.2%)
326 (12.28%)
341 (12.85%)
177 (6.67%)
288 (10.85%)
630 (23.74%)
637 (24%)
1099 (41.41%)
543 (20.46%)
2111 (79.54%)
1021 (38.47%)
1633 (61.53%)

INR = international normalized ratio; PT = prothrombin time; PTT =

partial thromboplastin time.

ical landmarks (Table 7). The use of either ultrasound or nerve

stimulationguided regional blocks were reported by 12.85%
and 12.28% of the respondents, respectively. The main
barriers to provide peripheral nerve blocks were concern of
potential complications (41%), refusal of the patients (24%),
and the failure rate of the blocks (24%) and it is time consuming (10%). A majority of hospitals (80%) did not stock Intralipid; 61% of the respondents did not receive peripheral nerve
block training.

3.8. Postoperative pain management

After epidural anesthesia for surgery, only 33.5% of the respondents used epidural analgesia for postoperative pain

Table 6

Neuraxial anesthesia complications and treatments

Postdural puncture headache treatment

Conservative treatment (bed rest, oral/IV
1643 (61.91%)
pain medications)
Prophylactic epidural blood patch
118 (4.45%)
Epidural blood patch after symptoms developed
55 (2.07%)
Epidural saline or epidural colloid
838 (31.57%)
The volume of blood for epidural blood patch
No blood patch
1778 (66.99%)
10 mL
484 (18.24%)
15 mL
220 (8.29%)
20 mL
172 (6.48%)
Treated a patient with epidural hematoma after neuraxial anesthesia
No
2585 (97.4%)
Yes
69 (2.6%)

management (Table 8). Very few anesthesiologists (5%)

placed peripheral nerve catheter for postoperative pain control.
When the respondents were stratied by hospital level, for
the question about whether they had treated a patient with epidural hematoma after epidural anesthesia, there was signicant
difference among 3 groups (P b .05) (Fig. 2). For the question
about whether their hospitals always stock Intralipid, there was
signicant difference among 3 groups (P b .05) (Fig. 3).

4. Discussions
WeChat is a free instant messaging service application for
smartphone and developed by Tencent in China. WeChat has

Table 8

Postoperative pain management

After epidural anesthesia, using epidural catheter for postoperative

pain management
Always
890 (33.53%)
Occasional
1148 (43.26%)
Never
616 (23.21%)
Peripheral nerve catheter for pain management
Always
135 (5.09%)
Occasional
538 (20.27%)
Never
1981 (74.64%)
How long to keep peripheral nerve catheter after surgery
Never
1929 (72.68%)
24 h
123 (4.63%)
2d
501 (18.88%)
3d
101 (3.81%)

Regional anesthesia practice in China

119

Does your hospital always stock Intralipid?

1200
1000
800
600
400
200
0
1

2
No

Fig. 2

Yes

Question Does your hospital always stock Intralipid? (1, grade I hospital; 2, grade II hospital; 3, grade III hospital) (P b .05).

been used in many elds of information service by the media,

government, hospital, enterprises, etc. WeChat had more than
600 million users. It provides a new tool to conduct survey for
anesthesiologists. There are more than 78,000 registered anesthesiologists members in the New Youth Anesthesia Forum
(a popular anesthesia social network). All members can receive the survey invitation by WeChat. The program is able
to calculate the numbers who read the survey invitation and record their locations. Therefore, we were able to determine the
response rate. Hazard Munro recommended that the minimal
number of survey responses required for survey validity is
equal to the number of questions times 10 [2]. Therefore, the
current 27-question survey required at least 270 responses.
We received 2654 responses in this study. Locations of
respondents showed that the participants come from every
province in China. The respondents were fairly distributed
in China.

The survey showed that large number of surgeries were

performed under RA in China; 41% of the respondents reported that more than 50% of surgeries in their hospitals were done
under RA; and 28% indicated that 31% to 50% of surgeries
were done under RA.
Accidental intravascular injection of local anesthetics (LA)
can result in lethal LA toxicity [3]. Of intravascular catheter
placements, 33% to 67% were unable to be detected by aspiration [4,5]. To avoid this adverse event of RA, an epinephrinecontaining epidural test dose is administered after epidural
catheter placement [6]. The traditional epidural test dose is
3 mL of 1.5% lidocaine with 1:200,000 epinephrine. In our
survey, most of the participants used test dose after epidural
catheter insertion, and the most common drug for test dose
was 3-mL 1.5% lidocaine. In China, epidural tray from manufacture does not contain any medications. Anesthesiologists
have to prepare the medications separately; 1.5% lidocaine

Treated a patient with epidural hematoma after

neuraxial anesthesia?
1400
1200
1000
800
600
400
200
0

2
Yes

No

Fig. 3 Question Have you treated a patient with epidural hematoma after neuraxial anesthesia? (1, grade I hospital; 2, grade II hospital; 3,
grade III hospital) (P b .05).

120
with 1:200,000 epinephrine is not commercially available, but
1.5% lidocaine is commercially available. To reduce medication errors and contaminations, they used 1.5% lidocaine without epinephrine.
Epidural hematoma is a rare but potentially injurious complication from epidural catheterization [7]. The incidence spinal hematoma is associated with these factors: female sex,
increased age, traumatic needle/catheter placement, indwelling
epidural catheter placement during immediate preoperative,
intraoperative, and postoperative anticoagulation therapy [8].
Epidural hematomas are best diagnosed by a high-resolution
magnetic resonance imaging. Treatment options range
from conservative observation, medications, to laminectomy
[9]. Ehrenfeld et al [7] conducted an electronic retrospective
chart review of 43,200 patient charts. They found an incidence
rate of 1:7200 for epidural hematomas resulting from a
catheter insertion. A study was conducted to estimate the
incidence of complications occurring with epidural analgesia
in obstetric practice. The authors concluded that epidural hematoma rate was 1 in 168,000 in obstetric women [10]. In
our survey, 2.6% of the participants reported that they had
treated a patient who had epidural hematoma after neuraxial
anesthesia. When the respondents were stratied by hospital
grade, for the question about whether anesthesiologists had
treated a patient with epidural hematoma after epidural anesthesia, there was signicant difference among 3 groups. The
higher level care hospitals had more comorbidity patients;
therefore, anesthesiologists encountered higher incidence of
epidural hematoma.
Local anesthetic systemic toxicity (LAST) rate was
approximately 20 of 10,000 peripheral nerve blocks
and 4 per 10,000 epidural blocks [11]. LAST remains
as a serious potential complication of RA. Intralipid infusion has become a standard care in the management
of LAST. The Association of Anesthetists of Great
Britain and Ireland published guidelines in 2007 that
recommended that all departments administering potentially toxic doses of local anesthetics should keep lipid
emulsion immediately available [12]. A survey in England
and Wales showed that Intralipid was stocked in 95.1% of the
acute National Health Service hospitals [13]. Based on the
available data, it would seem reasonable to have a [lipid] rescue kit available in any setting in which RA is practicedand,
in fact, in any location where local anesthetics are administered by any professional, by any route, and in almost any
dose [14]. In our survey, large majority of hospitals (80%)
in China did not stock Intralipid. When the respondents were
stratied by hospital grade, for the question about whether
their hospital routinely stocked Intralipid, there was signicant
difference among 3 groups. The higher level care hospitals
tended to stock Intralipid because they had more resources
and better training.
In a study, the authors included more than 7000 peripheral
nerve and plexus blocks; they reported that the blocks were
performed with US (13%), NS (30%), US with NS (50%),
and other (7%) techniques [15]. There are very few peripheral

J. Huang, H. Gao
nerve blocks without US and/or NS. Blind blocks that rely
solely on anatomical landmarks and/or fascia clicks are known
to produce serious complications [16,17]. Blind block may
carry a risk of nerve injury by direct puncture [18]. It is why
NS became the criterion standard for nerve identication in
RA over the past decade; now, ultrasound guidance technique
becomes popular. Most anesthesiologists (68.2%) in China
performed peripheral nerve blocks by blind blocks. Only
32.8% used NS and ultrasound guidance. A majority of anesthesiologists did not receive peripheral nerve block training.
Blind technique for peripheral nerve blocks was popular in
China; this was largely due to lack of tools (NS, US) or lack
of knowledge and training.
In our survey, the barriers for anesthesiologists to provide
peripheral nerve block were quoted concern for nerve injury
(41%), failure rate of the blocks (24%), and patient refusal
(24%) and it is time consuming (11%). These results were
quite different from a survey in the UK [19]. The anesthesiologists in UK believed that the main barriers to provide RA
were the length of time required to establish the block
(86%). Poor patient acceptability was cited by 45%; low success rate, by 21%; and concern for nerve damage, by 12% of
respondents. The culture and training contributed the differences. Especially violence against doctors was quite common
in China. Physicians worried about potential complications
which may affect the physician-patient relationship. Peripheral
nerve block is a time-consuming process; busy operating room
schedule and shortage prevented anesthesiologists to provide
peripheral nerve block.
The number of the responders who used loss of resistance
to air (48.87%) was used almost equal to those who used loss
of resistance to saline (44.31%) to identify the epidural space.
The result was consistent with the conclusion of Antibas et al
[20]. Most of the responders indicated that they placed spinal
or epidural needle at L34 (67.52%) and L23 (30.67%). Anesthesiologists use Tufer's line as an anatomical landmark in
spinal and epidural anesthesia. However, utilization of Tufer's line to assess intervertebral space level for lumbar puncture is not very accurate.
There are limitations with this study. The survey study cannot validate the accuracy and honesty of the response. Therefore, prospective study is recommended.
The current survey can serve as a benchmark for future
comparisons and evaluation of RA practices in China. This
survey revealed potential RA safety issues in China. Almost
half of the surgeries were done under RA. No epinephrinecontaining epidural test dose (a safeguard against intravascular
injection) was used by a majority of anesthesiologists. The
risks of LA toxicity may be increased. In addition, only 20%
hospitals stocked Intralipid, a drug to rescue LA toxicity,
which may further increase the potential risks of morbidity
and mortality of LA toxicity. This survey alerts the need to implement a national education program to train anesthesiologists for RA techniques and enhance knowledge. Local
hospitals are urged to equip more basic RA tools (NSs and
US) to improve patient safety.

Regional anesthesia practice in China

Appendix A. Regional Anesthesia Questionnaires

121

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