regional anesthesia / analgesia ( ra ) techniques represent a well - established part of perioperative care , providing site  specific , high quality pain relief , while reducing the systemic opioid consumption .
furthermore , neuraxial or peripheral nerve catheters offer prolonged postoperative analgesia , facilitate early mobilization and rehabilitation and increase patient satisfaction .
ongoing research has shown that ra may have positive effects on specific outcome parameters , such as inflammation , bowel function , coagulation and cancer recurrence .
all these well - established or potential advantages have led to a continuously growing interest in ra , especially peripheral nerve blocks ( pnbs ) .
in addition , anesthesia societies and education committees worldwide encourage the use of ra techniques and their teaching and training during residency . despite literature abundance on potential benefits associated with ra
, there are sparse evidence - based data to evaluate the frequency of ra application perioperatively at national or international level . to the best of our knowledge ,
recent nationwide or multicentre surveys based on objective data retrieved from hospital records are lacking .
nevertheless , such studies may provide material for comparisons among different countries and time periods , reveal problems and drawbacks , and consequently promote continuous improvement of clinical practices .
they may also represent a useful tool for assessment of the teaching process , knowledge expansion , hospital resources and technical developments associated with ra .
the current survey is the first nationwide attempt to document the current trends in ra practice in greece .
the collected data and results may serve as a benchmark for future intra- and inter - country comparisons and evaluation of the efficacy of currently running educational and training programs .
the aim of the survey was to explore the practice of ra in greece during 2011 - regarding the frequency , preference and familiarity with the various ra techniques - and to explore the factors that may influence its routine application .
we considered that the data of this survey could reveal the existing weak points and drawbacks , and thus lead to approaches for improving the structure , process and outcomes of the ra clinical practice in greece .
this nationwide cross - sectional descriptive study was approved and endorsed by the scientific committee of the greek section of the european society of regional anaesthesia and pain therapy ( esra hellas ) , which acted as ethics committee .
a four - part questionnaire on the practice of ra in greece during the year 2011 was developed for the survey ( appendix ) .
potential respondents were the directors of all greek anesthesia departments . in order to assure the questionnaire validity and readability , five senior anesthesiologists , experienced with ra ,
were consulted to review and assess its content , design and structure . according to 2011 data of official websites
, there were 230 anesthesia departments , distributed in the seven major greek health districts [ table 1 and figure 1 ] .
contact was achieved with 128 departments and the survey questionnaire was emailed to their directors in march 2012 .
an accompanying letter invited them to participate , after explaining the aim of the survey and clarifying that participation was voluntary and that the questionnaire could be completed anonymously .
a second , reminder e - mail was sent 6 weeks later , in case of no response . after a further 6 weeks
, the remaining non respondents were contacted for a third time by fax , e - mail and/or telephone , with the survey being terminated on june 30 , 2012 .
the characteristics of the contacted anesthesiology departments a map of greece showing the seven major health districts of the country specific instructions were given to the participants for a sound inclusion of accurate data , derived from their hospital records or electronic databases . in order to minimize the bias for few open questions ,
the directors of the departments were asked to answer themselves or supervise the completion of the questionnaire . for the same purpose ,
four question formats were used : yes or no boxes , selection of best possible answer out of 2 - 5 alternatives , fill - in the blank and check - off options .
returned questionnaires were evaluated for their consistency ( complete data , missing values ) and were analyzed by the use of the statistical package for the social sciences ( ibm - spss , 20 armonk , ny : ibm corp . ) .
the results are presented mainly in a descriptive form , including total numbers , frequencies , or percentages , where applicable .
comparisons , wherever appropriate , were made with the chi - square statistical test , given that p < 0.05 was considered as significant .
we retrospectively calculated the required sample size for the comparison of a proportion , given that the proportion of ra utilization in the hospitals was 45.5% . with the margin of error to be 0.05 and 95% confidence level
it was found that 381 operations would be the minimum required sample size for valid conclusions .
returned questionnaires were evaluated for their consistency ( complete data , missing values ) and were analyzed by the use of the statistical package for the social sciences ( ibm - spss , 20 armonk , ny : ibm corp . ) .
the results are presented mainly in a descriptive form , including total numbers , frequencies , or percentages , where applicable .
comparisons , wherever appropriate , were made with the chi - square statistical test , given that p < 0.05 was considered as significant .
we retrospectively calculated the required sample size for the comparison of a proportion , given that the proportion of ra utilization in the hospitals was 45.5% . with the margin of error to be 0.05 and 95% confidence level it was found that 381 operations would be the minimum required sample size for valid conclusions .
of the 230 registered anesthesia departments , 128 were contacted by e - mails , as we did not manage to reach the directors of the rest . according to the greek ministry of health ,
most of the noncontacted departments were located in rural county hospitals without scheduled anesthetic procedures or with few minor operations .
thus , even though the rate of contacts was 55.6% of all the registered anesthesia departments , the 128 contacted hospitals reflected 79.9% ( 421,493 out of 527,263 ) of the operations that were performed throughout greece during 2011 , according to the official data of the ministry of health , the health network and the pan - hellenic society of private hospitals .
the type and geographical distribution of the contacted anesthesia departments are shown in table 1 .
the data acquired from the answered questionnaires corresponded to 187,703 operations and according to the statistical calculation , they created an adequate sample size for analysis . in the participating hospitals , ra
was used in 45.5% ( 85,386/187,703 ) of the surgical procedures ( 95% confidence interval [ ci ] 0.4519 - 0.458 ) .
central neuraxial blocks ( cnbs , 95% ci : 0.8574 - 0.8699 ) were far more popular than pnbs ( pnbs , 95% ci : 0.1339 - 0.1389 ) , ( p = 0.021 ) as shown in figure 2 . among all regional modalities , subarachnoid anesthesia was the most commonly applied technique ( 95% ci : 0.5142 - 0.5238 ) , ( p = 0.042 ) as shown in figure 3 . regarding the types of surgery , subarachnoid anesthesia was instituted mostly in orthopedic surgery , while epidural technique was more often performed in gynecological / obstetric surgical procedures [ figure 4 ] .
notably , in the central institutions of the capital most cesarean deliveries were performed under epidural or combined spinal - epidural ( cse , 50.3% ) , whereas in county hospitals , single - shot spinal was the regional technique of choice ( 64.9 - 90.1% ) .
the pnbs were mainly used in patients undergoing upper ( 41.3% ) or lower extremity ( 50.7% ) orthopedic surgery .
the application rates of central neuraxial and peripheral nerve blocks in greek hospitals the application rates of al regional techniques in greek hospitals : subarachnoid anesthesia , epidural anesthesia , combined - spinal anesthesia / analgesia and peripheral nerve blocks the application rates of subarachnoid and epidural anesthesia in various types of surgical procedures peripheral nerve catheters were used only in 284 cases ( 2.4% of pnbs ) and remained in place for 48 - 72 h. most pnbs ( 70.2% ) were performed in hospitals of the capital , while only 29.8% were reported by peripheral hospitals ( p = 0.019 ) .
the vast majority of pnbs ( 78.5% ) were performed by the use of a neurostimulator , whereas ultrasound application alone or combined with neurostimulation was quite limited ( 1.5% and 3.5% , respectively ) . in a relatively high percentage of pnbs ( 16% ) ,
the elicitation of paresthesia was the main method to confirm the correct placement of the needle .
the reported number of consultant anesthesiologists serving in the responded departments was 345 . according to the survey , the vast majority ( 94.49% ) were very well accustomed with cnbs , whereas only 46.38% were familiar with pnbs .
the main reported limitations to ra application were the lack of necessary equipment ( 58.23% ) and inadequate training in the specific technique ( 49.29% ) .
the cnbs - especially single - shot spinal  were very popular , while the use of pnbs was quite limited , mainly due to lack of equipment and inadequate training .
unfortunately , our results can not be directly compared to those of other national surveys , since recent relevant studies with a similar design to ours are lacking .
few previously performed surveys in european countries , also based on data from hospital records , showed quite low rates of ra use : in france during 1996 and in german speaking countries ( germany , austria and switzerland ) during 2002 the average percentage of ra was only 23% . among the latter countries , switzerland reported the highest proportion of ra , thus 48% in adult patients . obviously , the aforementioned percentages reflect the use of ra in the previous two decades and the rates have possibly changed significantly over the last years .
more recent data show that there is a rising trend toward ra ; in chile and nigeria , > 90% of the respondent anesthesiologists reported the routine use of ra techniques .
it should be noted though that the results of these surveys are not based on hospital data , but on answers given by individual anesthesiologists ( n = 140 - 209 respondents ) . according to our results ,
cnbs were much more favored over pnbs ; this preference was in accordance with the reported familiarity with the former techniques by greek anesthesiologists .
previous data show that throughout europe the overall application rate of cnbs was 17% in 1992 , whereas , in individual countries , it fluctuated from 25.32% in sweden up to 56% in france during the mid to late 90 s. spinal was the mostly preferred technique by greek anesthesiologists for cnbs .
similarly , a european survey of 1995 , showed higher rates for spinals over epidurals or cses , thus 56% , 40% and 4% respectively .
a french survey conducted in 1996 reported that spinals and epidurals were equally applied ( by a rate of 28% each ) , with no data on cse . in recent times
, chilian anesthesiologists also expressed a similar preference for spinal and lumbar epidural blocks ( 98 vs. 96% ) , while in nigeria , regular use of spinals was reported by 93% , while epidural techniques were preferred only by 15% of the respondent anesthesiologists .
the popularity of spinal across the world is not surprising , since it is technically easy to perform , provides a rapid and dense block with small doses of local anesthetics , and is minimally traumatic if small gauge , noncutting needles are used .
spinal technique is also taught and performed early during training and has a relative fast learning curve with achievement of competence after 45 attempts .
regarding the current trends in greece , the results show that even though spinal blocks are preferred , epidural and cse techniques have also their place in everyday clinical practice , accounting for the 40% of the cnbs , probably due to the advantages the epidural catheters offer for postoperative analgesia .
this finding is in accordance with the results of a recent survey on postoperative analgesia , reporting that epidural catheters were used in 44.5% of greek anesthesia departments .
similarly , data from sweden showed that spinals were chosen for short lasting surgical procedures ( up to 1 h ) , while epidurals and cses were preferred when postoperative epidural analgesia was planned .
regarding the cnbs distribution in various types of surgery , the present survey showed that spinals were most commonly used in orthopedic patients .
the aforementioned advantages , along with the high technical success rates ( > 90% ) render the spinal technique a popular option for this specific group of patients ( old age , spinal skeletal deformities ) .
similarly to our results , in sweden , spinal anesthesia was also preferred in orthopedics ( 59.7 - 80.6% ) , although - unlike greece - it was popular in urological procedures , too ( 74.1% ) .
french anesthesiologists used mainly spinals in nonobstetric surgical procedures , but preferred epidurals in obstetrics . in accordance with that
, the present greek survey showed that epidurals were more often instituted in obstetrics / gynecology , at a rate within the range reported by the swedish survey for the respective group of procedures ( epidural rate : 19.4 - 66.1% ) .
interestingly , according to our results , cesarean delivery was more commonly performed under epidurals / cse in institutions of the greek capital , whereas single - shot spinal was the method of choice in the county .
the use of epidural catheters in central hospitals is probably explained by the adequacy of nursing stuff , the function of acute pain service and the training of residents in more meticulous ra techniques . according to the present survey ,
over the last years - especially with the introduction of ultrasound into clinical practice - pnbs have gained popularity mainly in orthopedics and traumatology , but available recent data from different countries are not uniform .
a canadian survey showed that 20% of the anesthesiologists in academic hospitals in ottawa perform blocks rarely or never , while only 8% perform > 10 blocks / month .
even lower percentages are reported in nigeria , where 47.1% of the respondent anesthesiologists have never attempted pnbs , while only 2.9% use them regularly .
conversely , in chile , routine application of pnbs was reported by 73.7% of the respondents . in our survey , almost half the anesthesiologists working in the respondent departments were familiar with pnbs , even though the application rates were much lower .
the main reported limitations to the use of ra techniques were the lack of equipment , while inadequate training was also a significant contributing factor .
similarly , in other surveys , inadequate skills / training was a major drawback , while the lack of suitable patients was declared by a small percentage of respondents .
pnbs routine application may also be hindered by lack of anatomical knowledge , ignorance of potential benefits , lack of familiarity / acceptability by surgeons , strict time table with rapid turnover of cases , as well as logistic impedance in an ambulatory or fast tracking operative setting .
the role of training is probably reflected to our results , which showed that most pnbs are performed in central hospitals , which are usually teaching ones , opposed to the county institutions .
a significant limitation to systematic training in ra techniques is the lack of a formal stepwise program incorporated in the curriculum of the residency .
thus , undertraining during residency possibly accounts  at least in part - for the low application rates of pnbs in greece . on the other hand , in the united states the pnb experience during residency and subsequent confidence
has significantly increased over the last decade , especially for commonly used blocks , such as the femoral , interscalene and popliteal . according to a recent survey in the united states , > 90% of the residents
achieve the accreditation council for graduate medical education mandated goal of 40 pnbs , while 74% perform actually more than 60 pnbs during their residency , usually under ultrasound guidance .
moreover , ultrasound - guided pnbs are taught in all american board of anesthesiology - accredited residency programs , where > 20 pnbs are performed per week . on the contrary ,
the use of ultrasound guidance was quite limited in greece ; the vast majority of pnbs were performed by the aid of a neurostimulator , while elicitation of paresthesia is still advocated by a high percentage of physicians .
the use of neurostimulation is reported to be similarly high in chile ( 64% ) , but quite lower in nigeria ( 31.4% ) .
notably , although the majority of nigerian anesthesiologists ( 76.4% ) reported to have seen a peripheral nerve stimulator before , most of them do not use them .
the problems revealed by this survey were highlighted in pan - hellenic congresses of ra , so as all parties to be informed about the weaknesses of the current system .
suggestions for improvement were discussed with attendants and members of the esra - hellas and of the hellenic society of anesthesiology .
furthermore , since 2009 esra - hellas has been organizing educational and training programs on ra twice annually , which have been attended by greek anesthesiologists from all parts of the country .
the number of participants continuously increases , indicating the success of these programs and a growing interest toward education on ra .
this interest is also reflected by the increasing number of greek anesthesiologists that apply for the esra diploma examinations over the last years . regarding the future of ra in greece
, we consider that emphasis should be given to the education and training , especially during residency .
incorporation of a step - wise training program in ra into the curriculum of residency should be the goal of esra and the society of anesthesiology in greece .
in addition , continuing medical education , especially for anesthesiologists working in county hospitals and rural areas , would be an appropriate approach to improving knowledge and skills on ra techniques .
targeted education and case - based learning may apply more successfully to these groups . furthermore , the use of new teaching methods , such as virtual reality and interactive learning modalities might assist the education and training process in the future .
additionally , electronic databases will allow the registration of ra application to become a standard practice .
based on the example of the pediatric ra network , multicenter collaborative networks could also facilitate the collection of detailed prospective data for research and quality improvement .
regarding the technical limitations , the directors of departments and hospitals should join forces with the scientific societies and lobby for access to governmental finance for equipments and facilities for ra practice .
not only the improved quality of provided health care , but also the cost / benefit of ra techniques represents a strong argument supporting the wider use of ra in the national health system .
finally , the data of this survey should serve as a baseline for future assessment of the ra practice and the work that has been done towards improvement .
a possible limitation of the present study is the relatively small number of the respondent anesthesia departments .
nevertheless , such participation rates are relative common in national surveys with a design similar to ours .
we also consider that our sample size [ anesthesiologists ( n = 345 ) and surgical procedures ( n = 187,703 ) ] is adequate , taking into account the country population .
furthermore , the participating departments were distributed to all major greek health districts , and thus we consider that the results are representative and can be extrapolated nationally .
a possible limitation of the present study is the relatively small number of the respondent anesthesia departments .
nevertheless , such participation rates are relative common in national surveys with a design similar to ours .
we also consider that our sample size [ anesthesiologists ( n = 345 ) and surgical procedures ( n = 187,703 ) ] is adequate , taking into account the country population .
furthermore , the participating departments were distributed to all major greek health districts , and thus we consider that the results are representative and can be extrapolated nationally .
the present survey was the first attempt to collect data on the current practice of ra in greece and may offer material for further analysis and a baseline for future comparisons . according to the results ,
neuraxial blockades , especially spinal anesthesia , were preferred over pnbs , which were usually performed without ultrasound guidance .
the main reported limitations to ra application were the lack of equipment and inadequate training .
for these problems to be solved , the greek anesthesiology community should intensify the efforts toward equipment / technology finance and also towards continuous education programs and courses , especially in rural areas .
also , incorporation of ra curriculum in a training program , ideally unified across european countries , would be a significant step towards improvement .
 background and aims : regional anesthesia ( ra ) techniques ( central neuraxial and peripheral nerve blocks [ cnbs and pnbs ] ) are well - established anesthesia / analgesia modalities . 
 however , information on their nationwide use is sparse . 
 the aim of the survey was to assess the utility of ra techniques in greece , during 2011.materials and methods : a nationwide , cross - sectional descriptive survey was conducted ( march to june , 2012 ) , using a structured questionnaire that was sent to 128 greek anesthesia departments.results:sixty-six completed questionnaires ( response rate 51.56% ) were analyzed . 
 the data corresponded to 187,703 operations and represented all hospital categories and geographical regions of greece . on the whole , 
 ra was used in 45.5% of performed surgical procedures ( 85,386/187,703 ) . 
 spinal anesthesia was the technique of choice ( 51.9% of all ra techniques ) , mostly preferred in orthopedics ( 44.8% ) . 
 epidural anesthesia / analgesia ( application rate of 23.2% ) , was mostly used in obstetrics and gynecology ( 50.4% ) . 
 combined spinal - epidural and pnbs were less commonly instituted ( 11.24% and 13.64% of all ra techniques , respectively ) . 
 most pnbs ( 78.5% ) were performed with a neurostimulator , while elicitation of paresthesia was used in 16% of the cases . 
 conversely , ultrasound guidance was quite limited ( 5% ) . the vast majority of consultant anesthesologists ( 94.49% ) were familiar with cnbs , whereas only 46.4% were familiar with pnbs . 
 the main reported limitations to ra application were lack of equipment ( 58.23% ) and inadequate education / training ( 49.29%).conclusion : regional modalities were routinely used by greek anesthesiologists during 2011 . 
 neuraxial blocks , especially spinal anesthesia , were preferred over pnbs . 
 the underutilization of certain ra techniques was attributed to lack of equipment and inadequate training . 
Introduction
Materials and Methods
Statistical analysis
Results
Discussion
Limitations
Conclusions