Current Practice in Postoperative Epidural Analgesia:
A German Survey
Sandra Kampe, MD*, Peter Kiencke, PhD, Jens Krombach, MD, Karen Cranfield,
Stefan Mario Kasper, MD*, and Christoph Diefenbach, MD*
Departments of *Anesthesiology and Intensive Care Medicine and Medical Statistics, University of Cologne, Cologne,
Germany; Department of Anesthesiology, University of California-San Francisco, San Francisco, California; and
Department of Anesthesiology, Aberdeen Royal Infirmary, Aberdeen, Scotland
We surveyed current German practice in postoperative
epidural analgesia (EA). Of 300 questionnaires sent
anonymously, 147 (49%) were returned fully com-
pleted. A 24-h acute pain service (APS) was offered in
41% of German hospitals. Seventy percent of the large
teaching hospitals (1000 beds) offered an APS,
whereas just 9% of the hospitals of 500 beds provided
an APS. Small-size hospitals (200 beds) preferred
ropivacaine as the local anesthetic (LA) in contrast to
large teaching hospitals using more bupivacaine than
ropivacaine. In the general ward setting, 36% of the re-
spondents used plain LA, and 64% combined the LA
with an opioid. If ropivacaine was used, 0.2% was the
S
urveys have been performed in recent years in-
vestigating the use of acute pain services (APS)
for postoperative pain treatment (1), examining
the practice of thoracic epidural anesthesia and anal-
gesia (EA) (2), and evaluating current practices in
obstetric analgesia (3,4).
Available literature indicates that the administra-
tion of epidural drugs has changed from bolus doses
to continuous epidural infusions (5,6), and patient-
controlled epidural analgesia (PCEA) (7). The epidural
combination of small-dose local anesthetic (LA) plus
opioid has been investigated extensively in clinical
studies (7,8), but no data are available reporting the
frequency of use of these techniques and drug combi-
nations in the postoperative setting. The aim of the
present survey was to determine current German
practice in postoperative EA.
Supported in part by a grant from AstraZeneca, Wedel, Germany.
Presented in part at the 10th Anniversary Meeting of the Euro-
pean Society of Anaesthesiologists, April 6 9, 2002, in Nice.
Accepted for publication August 13, 2002.
Address correspondence and reprint requests to Sandra Kampe,
MD, Department of Anesthesiology and Intensive Care Medicine,
University of Cologne, Joseph-Stelzmann-Str. 9, 50931 Cologne,
Germany. Address e-mail to sandra.kampe@medizin.uni-koeln.de.
DOI: 10.1213/01.ANE.0000034859.43898.20
2002 by the International Anesthesia Research Society
0003-2999/02
FRCA,
most popular concentration (78%), combined with mor-
phine (17%), fentanyl (14%), or sufentanil (75%). If bu-
pivacaine was used, 0.25% was the preferred concentra-
tion (30%), combined with morphine (40%), fentanyl
(8%), or sufentanil (60%). On wards, 58% of German
anesthetic departments used continuous epidural infu-
sion, 57% bolus doses, and 20% patient-controlled EA
mode. We conclude that the availability of a 24-h APS
(41%) in German hospitals corresponds favorably to in-
ternational data. EA with the combination of LAs and
opioids was the most common modality in the ward
setting.
(Anesth Analg 2002;95:17679)
Methods
A list of 685 German hospitals with at least 3 surgical
departments was obtained from the central list of Ger-
man hospitals. A sampling of 300 hospitals was se-
lected by using a random start, stratified by
geography/region, teaching versus nonteaching, and
number of beds. The questionnaire was sent with a
cover letter explaining the nature of the survey to the
chief anesthesiologists, and containing a prepaid re-
turn envelope without identifying information. The
questionnaire, designed to be completed anonymous,
consisted mainly of multiple-choice questions. Multi-
ple responses were possible. Respondents were asked,
in addition to detailed demographic information,
about total number of beds, number of anesthesiolo-
gists, number of anesthetics per year, availability of an
APS and the organizational model, and about the
surgical departments that request postoperative EA
(abdominal surgery, vascular surgery, cardiothoracic
surgery, urologic surgery, gynecology [without ob-
stetrics], trauma, and orthopedic surgery).
The questionnaire requested the following informa-
tion for each surgical ward:
Use of postoperative EA.
Anesth Analg 2002;95:17679 1767
1768 REGIONAL ANESTHESIA KAMPE ET AL.
POSTOPERATIVE EPIDURAL ANALGESIA IN GERMANY
Table 1. General Results
No. of
departments
Abdominal surgery 133
Vascular surgery 90
Cardiothoracic surgery 55
Trauma 92
Orthopedics 46
Urologic surgery 77
Gynecology 67
Data are presented as mean sd (range).
EA epidural analgesia.
Choice of epidural drugs: LA (ropivacaine, bupiva-
caine, others, including the exact concentration of
LA used), opioids (morphine, fentanyl, sufentanil,
others), additional drugs (e.g., clonidine, others).
Mode of delivery: bolus doses, continuous epi-
dural infusion, PCEA (background infusion plus
on-demand bolus doses).
Duration of postoperative EA.
All data were for the year 2000 and were collected and
computerized by one of the authors (PK), who special-
izes in statistics. Because of the anonymous nature of the
questionnaire, no follow-ups were conducted.
Statistical analysis was performed by using the SPSS
9.0 statistical package (SPSS Inc., Chicago, IL). Unless
indicated, data were presented as numbers or percent-
ages of respondents.
Results
A total of 147 completed questionnaires were re-
turned, indicating a response rate of 49%. All hospitals
provided exact demographic data. No questionnaire
was excluded. The 147 hospitals provided different
surgical departments (Table 1). For the frequency in
the use of postoperative EA, see Table 1. A 24-h APS
was offered in 41% of German hospitals. The large
teaching hospitals (1000 beds) provided an APS in
70%, hospitals with 8011000 beds in 40%, and hospi-
tals with 501 800 beds in 44%; 9% of the hospitals
with 500 beds provided an APS.
Small hospitals (200 beds) used ropivacaine in
72% versus 28% using bupivacaine. Hospitals with
201500 beds used an equal proportion of ropivacaine
(59%) and bupivacaine (55%), as did hospitals with
501 800 beds (ropivacaine 61%, bupivacaine 62%).
Larger hospitals used less ropivacaine than bupiva-
caine (8011000 beds: 51% ropivacaine versus 70%
bupivacaine; 1000 beds: 62% ropivacaine versus 72%
bupivacaine). There were no other LAs used for post-
operative EA. On wards, 36% used plain LA, and 64%
combined the LA with opioids. If ropivacaine was
used, 0.2% was the most popular concentration (78%),
ANESTH ANALG
2002;95:17679
Use of EA (%) Duration of EA (days)
13.2 15.5 (0100) 3.8 1.2
15.8 19.3 (080) 4.2 1.4
40.9 32.1 (0100) 4.1 1.1
10.1 13.9 (080) 3.9 1.3
17.2 16.3 (060) 3.7 1.1
9.9 13.8 (080) 3.4 1.2
7.7 12.6 (085) 2.7 1.0
combined with morphine (17%), fentanyl (14%), or
sufentanil (75%). If bupivacaine was used, 0.25% was
the preferred concentration (30%), combined with
morphine (40%), fentanyl (8%), or sufentanil (60%).
Clonidine as an adjunct to epidural LA was used in
8%, buprenorphine in 3%, and droperidol in 1%.
In the ward setting, 58% of German departments
used continuous epidural infusion, 57% bolus doses,
and 20% the PCEA mode. The duration of postopera-
tive EA is presented in Table 1.
Discussion
In 1993, a survey of 105 hospitals from 17 European
nations found that 34% had an organized APS (1). In
the United Kingdom, the number of hospitals with
multidisciplinary APS had increased from 2.8% before
September 1990 to 42.7% at the end of 1994 (9). Data
from the United States indicate that 42% of the hospi-
tals have an APS (10). Our data from the year 2000 are
in accordance with these statistics. However, it should
be remembered that there is no generally accepted
definition of APS (11).
International data concerning epidural opioid admin-
istration on wards are conflicting. A United Kingdom
survey to examine the practice of thoracic EA found that
95% of respondents used an opioid-based bupivacaine
solution for epidural infusion, and these were most com-
monly (63%) cared for on general surgical wards (12). A
Scottish survey of extradural opioid practice reported
that 69% of consultants frequently send their patients to
a high-dependency unit after epidural opioid adminis-
tration (13). However, the epidural combination of LA
plus opioid has become the most common choice for EA
on wards in Germany.
Few international data are available on the frequency
of use of continuous epidural infusion or PCEA. Contin-
uous epidural infusion is the most common choice
(100%) in Australia after thoracotomy (14), and in obstet-
ric patients in the United States (95.2%), and in Canada
(90.6%) (15,16). Notably, continuous epidural infusion
and bolus doses are used frequently on German general
wards, but use of the PCEA mode is still small.
ANESTH ANALG
2002;95:17679
It is important to acknowledge the potential biases
in this study including self-report bias, representative-
ness, and nonresponse bias. We thought that the anon-
ymous character of the survey would reduce any in-
tention to answer false behaviors or perceptions of the
respondent. By sampling a strictly stratified group of
hospitals from Germany, we hoped to attain a repre-
sentative sample. The demographics of the respon-
dents compared favorably with that of the central list
used for random selection, and suggests that our sam-
ple, despite its relatively small size, was indeed rep-
resentative. Our response rate was satisfactory as we
did not conduct follow-ups. However, the possibility
of a nonresponse bias still exists.
Despite its limitations, this survey presents a picture of
current German practice in postoperative EA. Our data
show that German anesthesiologists prefer the combina-
tion of LA plus opioids for postoperative EA in the
general ward setting. Continuous epidural infusion and
bolus doses are frequently used, but use of the PCEA
mode is still small. Comparison with practice in other
countries is difficult, because of a lack of data.
There is a need for further international surveys on
EA practice to compare data and to recommend strat-
egies for postoperative EA in the surgical patient.
The authors thank Prof. Dr. W. Buzello for his critical reading of the
manuscript. The authors are also indebted to the anesthesiologists who
took time from their busy schedules to participate in this survey.
References
1. Rawal N, Allvin R, Euro Pain Working Party. Acute pain ser-
vices in Europe: a 17-nation survey of 105 hospitals. Eur J
Anaesthesiol 1998;15:354 63.
REGIONAL ANESTHESIA KAMPE ET AL. 1769
POSTOPERATIVE EPIDURAL ANALGESIA IN GERMANY
2. OHiggens F, Tuckey JP. Thoracic epidural anaesthesia and
analgesia: United Kingdom practice. Acta Anaesthesiol Scand
2000;44:108792.
3. Wulf H, Stamer U. Current practices in obstetrical analgesia in
German university clinics: results of a 1996 survey. Anaesthesist
1998;47:757 64.
4. Hawkins JL, Gibbs CP, Orleans M, et al. Obstetric anesthesia
work force survey, 1981 versus 1992. Anesthesiology 1997;87:
135 43.
5. Kampe S, Weigand C, Kaufmann J, et al. Postoperative analge-
sia with no motor block by continuous epidural infusion of
ropivacaine 0.1% and sufentanil after total hip replacement.
Anesth Analg 1999;89:395 8.
6. Schug SA, Scott DA, Payne J, et al. Postoperative analgesia by
continuous epidural infusion of ropivacaine after upper abdom-
inal surgery. Br J Anaesth 1996;76:48791.
7. Brodner G, Mertes N, Van Aken H, et al. What concentration of
sufentanil should be combined with ropivacaine 0.2% wt/vol
for postoperative patient-controlled epidural analgesia? Anesth
Analg 2000;90:649 57.
8. Kampe S, Randebrock G, Kiencke P, et al. Comparison of con-
tinuous epidural infusion of ropivacaine and sufentanil with
intravenous patient-controlled analgesia after total hip replace-
ment. Anaesthesia 2001;56:1189 93.
9. Windsor AM, Glynn CJ, Mason DG. National provision of acute
pain services. Anaesthesia 1996;51:228 31.
10. Warfield CA, Kahn CH. Acute pain management: programs in
US hospitals and experiences and attitudes among US adults.
Anesthesiology 1995;83:1090 4.
11. Neugebauer E, Hempel K, Sauerland S, et al. The status of
perioperative pain therapy in Germany: Results of a represen-
tative, anonymous survey of 1,000 surgical clinics. Chirurg (Ger-
many) 1998;69:461 4.
12. OHiggins F, Tuckey JP. Thoracic epidural anaesthesia and
analgesia: United Kingdom practice. Acta Anaesthesiol Scand
2000;44:108792.
13. Carson D, Binning A, Thomson M. Epidural analgesia in
Scotland: a survey of extradural opioid practice. Health Bull
(Edinb) 1996;54:51 62.
14. Cook TM, Riley RH. Analgesia following thoracotomy: a survey
of Australian practice. Anaesth Intensive Care 1997;25:520 4.
15. Plumer MH, Rottmann R. How anesthesiologists practice ob-
stetric anesthesia. Reg Anesth 1996;21:49 60.
16. Oyston J. Obstetrical anaesthesia in Ontario. Can J Anaesth
1995;42:111725.