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General or regional? Exploring patients’ anaesthetic preferences and perception of regional anaesthesia
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ARTICLE IN PRESS
Rev Esp Anestesiol Reanim. 2019;xxx(xx):xxx---xxx
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
ORIGINAL ARTICLE
General or regional? Exploring patients’ anaesthetic preferences and perception of regional anaesthesia夽 J.S. Lavado ∗ , D. Gonc ¸alves, L. Gonc ¸alves, C. Sendino, E. Valente Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal Received 31 May 2018; accepted 2 December 2018
KEYWORDS Regional anaesthesia; General anaesthesia; Fear; Knowledge; Patient preference
Abstract Introduction and objectives: Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients’ fears, anxiety, and knowledge) related to patients’ anaesthetic preference. Material and methods: Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA. Results: One hundred and 2 patients agreed to participate. Mean age was 52.6 ± 13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA’s real risks and benefits. Conclusions: Knowing patients’ fears is essential for the anaesthesiologist address their patients’ needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
夽
Please cite this article as: Lavado JS, Gonc ¸alves D, Gonc ¸alves L, Sendino C, Valente E. ¿General o regional? Preferencias anestésicas de los pacientes y su percepción sobre la anestesia regional. Rev Esp Anestesiol Reanim. 2018. https://doi.org/10.1016/j.redar.2018.12.004 ∗ Corresponding author. E-mail address: joanasfl[email protected] (J.S. Lavado). 2341-1929/© 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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PALABRAS CLAVE Anestesia regional; Anestesia general; Miedos; Conocimiento; Preferencias de los pacientes
¿General o regional? Preferencias anestésicas de los pacientes y su percepción sobre la anestesia regional Resumen Introducción y objetivos: La anestesia regional (AR) ha ganado popularidad debido a sus beneficios y su seguridad. Sin embargo, muchos pacientes rechazan la AR en favor de la anestesia general (AG). Este estudio investiga las variables (factores demográficos, percepción de seguridad, miedos y conocimientos sobre la AR) relacionadas con las preferencias anestésicas de los pacientes. Material y métodos: Los participantes eran mayores de 18 a˜ nos, propuestos para una consulta anestésica. Rellenaron un cuestionario previamente a su cita. Resultados: Ciento dos pacientes accedieron a participar. La media de edad era de 52,6 ± 13,5 a˜ nos. El 57,8% eran mujeres y el 44,5% contaba al menos con 12 a˜ nos de estudios. Dados a elegir, el 54% prefería AG y el 20,7% rechazaba AR en caso de que se lo propusiera el anestesiólogo. Entre los pacientes que ya habían experimentado anestesia neuroaxial, el 40% no quería repetirlo. Los pacientes que preferían AG en lugar de AR la percibían como más segura y expresaban mayor ansiedad por permanecer despiertos durante la cirugía. Estos fueron también los que tenían mayor temor al pinchazo, al dolor de espalda y a sentir dolor durante la cirugía. Los resultados indican que los pacientes no conocían los verdaderos riesgos y beneficios de la AR. Conclusiones: El conocimiento de los temores de los pacientes es esencial y ayudará a los anestesiólogos a satisfacer las necesidades de sus pacientes. Los anestesiólogos deben esforzarse en mejorar las perspectivas de la población y su conocimiento sobre la RA. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Background and objectives Regional anaesthesia (RA) has gained popularity among anaesthesiologists thanks to its numerous benefits and good safety profile. However, patients often refuse this type of procedure, preferring general anaesthesia (GA). Since patient refusal is an absolute contraindication for RA, many patients fail to benefit from the advantages of this technique. It is essential to explore RA from the patient’s perspective, since anaesthesiologists can only achieve their goals if they acknowledge their patient’s concerns. Many studies on this topic have been performed outside Europe, and may not reflect the cultural differences and concerns that may influence acceptance of RA. Some, moreover, were performed more than 10 years ago, and may not reflect the opinion of today’s patients. In addition, no studies have hitherto questioned patients on their understanding of the benefits of RA. The aim of this study was to investigate the variables (demographic factors, patients’ fears, anxieties, and perception of GA and RA in terms of safety, risks and benefits) associated with patients’ anaesthetic preference (GA or RA). The ultimate objective was to identify surgery-specific factors, and thus increase patient confidence in and acceptance of RA.
Methods A total of 102 patients were evaluated during a 3-month period (February---April 2017), prior to their pre-anaesthesia
consultation. The patients were scheduled for surgery (general, orthopaedic, urological, ENT, ocular, or gynaecological) or interventions outside the operating room (mainly gastroenterological). The patients were enrolled before their pre-anaesthesia consultation by an anaesthesiologist member of the research team. All consecutive patients aged over 18 years that were able to give written informed consent were invited to participate in the study; only 1 patient refused. The study was approved by the Ethics Committee and the hospital’s Board of Directors. Written informed consent was obtained from all patients. No patient dropped out of the study after signing the consent form. The patients completed a questionnaire in the waiting room, before their appointment with the anaesthesiologist, and before being offered a particular anaesthetic technique. The questionnaire (annexe, available in the online version of this article) was based on earlier studies and included a brief explanation of GA and RA to enable patients to understand the differences between these techniques.1---5 The body of the questionnaire was divided into 3 parts: Part 1 contained demographic questions, Part 2 asked after the patient’s previous experience with anaesthesia, and Part 3 explored the patient’s anaesthesia preferences and perception of safety, and evaluated their knowledge of RA and their concerns with the technique. Questions relating to 7 benefits of RA were answered with a ‘‘yes’’ or ‘‘no’’. In order to avoid erroneous information, all the sentences were true. The data were analysed using the Statistical Package for the Social Sciences (SPPS --- version 22.0 for Windows) (IBM, USA). Descriptive statistics were used to summarise the data. The percentages reported were calculated from valid answers.
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General or regional? Perception of patients on regional anesthesia
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18.3%
Very nervous
7.9% 24.7%
Nervous
21.8% 32.3%
Slightly nervous
37.6% 20.4%
Calm
Very calm
23.8% 4.3% 8.9%
Level of anxiety at the thought of remaining awake during surgery Level of anxiety at the thought of undergoing anaesthesia
Figure 1
Patients’ level of anxiety with respect to undergoing anaesthesia and remaining awake during surgery.
To identify correlations between variables, the Student’s t test was used for continuous and categorical variables; correlation analysis was used to test 2 continuous variables, and 2 statistics were used to test 2 categorical variables. Statistical significance was set at p < 0.05.
Results The average age of the sample was 52.6 ± 13.5 years, 57.8% were women, and 44.5% had at least 12 years of education or a university degree. In terms of surgical specialty, 38.2% were scheduled for general surgery, 22.5% for orthopaedic surgery, 18.6% for gynaecological surgery, 3.9% for urological procedures, 2% for ocular surgery, and 4.9% were candidates for interventions outside the operating room.
Previous experience with anaesthesia Analyzing previous experience with anaesthesia showed that 91.2% of patients had previously received anaesthesia, 59.8% had previously undergone GA, 37.3% had had spinal anaesthesia (SA) and 4.9% had had nerve blocks (NB). Of the 38 patients who had previously received SA, 8 (21%) stated that they had had complications (minor or major). Patients treated with NB did not report any complications. Only 4.4% stated that they knew someone who had had RA-related complications. Overall, the complications reported were sensory deficit in the legs, pain during surgery, urinary retention, nausea and vomiting, an allergic reaction, and a patient who had experienced paralysis and had ‘‘head’’ problems.
Patients’ perspective of regional general anaesthesia Safety was rated from 1 (very safe) to 4 (very dangerous). Although patients generally tended to consider that GA was safer (mean 2.2 ± 0.6) than RA (mean 2.3 ± 0.7 for SA and 2.4 ± 0.6 for NB), the differences were not significant. Sex
was the only demographic characteristic that was significantly associated with a perception of RA being safer. More women perceived RA as being safer (mean = 2.5 ± 0.7 for SA and 2.5 ± 0.6 for NB) than men (mean = 2.1 ± 0.7 for SA and 2.1 ± 0.6 for NB, p = 0.04 for SA and p = 0.02 for NB) No differences were found in the perception of GA safety between women and men. There was no correlation between education or age and perception of anaesthesia safety. Anxiety at the thought of anaesthesia, and specifically at the thought of remaining awake during surgery, was rated from 1 (very calm) and 5 (very nervous). Patients felt considerably more nervous about the thought of being awake during surgery than the thought of recieving general anaesthesia (mean = 3.3 ± 1.1 vs. 2.9 ± 1.1, p < 0.01) (Fig. 1). Women were more anxious about anaesthesia than men (mean = 3.2 ± 1.1 vs. 2.6 ± 1, p = 0.02). There were no differences between sexes in terms of anxiety at the thought of being awake during surgery. Different levels of anxiety were not correlated with either age or educational level. In Part 2 of the questionnaire, participants were presented with 8 possible negative episodes normally associated with RA. For each sentence, the patients were asked to rate: (a) their level of fear, and (b) the probability of each episode occurring under RA, as shown in Table 1. The episodes rated by most patients as more likely to occur also corresponded to those they most feared, namely, residual sensory alterations, pain during surgery, paraplegia and back pain. Fear was also highly correlated with the perceived probability of each episode (total p < 0.01). Demographic factors correlated with specific fears of RA were: older age correlated with a greater fear of infection and sensory disturbances, and lower educational level correlated with fear of needles (p < 0.05). No differences were observed between the sexes in this part of the questionnaire.
Preference for general or regional anaesthesia In terms of choice, 54% of patients preferred GA over RA. Patients were asked to give their reasons for this in a free
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J.S. Lavado et al. Table 1
Distribution of patients level of fear and their estimate of the likelihood regional anaesthesia-related complications.
Becoming paralysed Headache Vomiting Pain during surgery Difficulties in inserting the needle Sensory alterations (e.g., leg/arm) Back pain after regional anaesthesia Puncture site infection
Table 2
If you had to receive regional anaesthesia, how would you rate your fear of...?: (1, not at all afraid; 5, very afraid)
In your opinion, what is the probability of these episodes occurring with regional anaesthesia?: (1, very unlikely; 5, highly likely)
1---2
1---2
30.1% 50.6% 52.6% 29.5% 43.5% 28.4% 28.2% 43.6%
3
4---5
31.3% 32.9% 32.1% 25.6% 24.4% 23% 33.3% 30.8%
38.5% 16.4% 15.3% 44.9% 32% 48.7% 38.4% 25.6%
49.3% 59.3% 49.3% 41.1% 44.9% 39.7% 39.5% 58.9%
3
4---5 28.8% 25% 36.6% 35.6% 34.8% 32.4% 36.6% 30.8%
21.9% 15.3% 14.1% 23.2% 20.3% 27.9% 23.9% 10.3%
Reasons for anaesthesia preference. Reason for preference
General anaesthesia
Regional anaesthesia
Prefer to be asleep Back problems Previous positive experience General anaesthesia is safer/better Fear of feeling pain Due to the type of surgery It’s better for the surgeon Do not know or do not provide explain preference Prefer to be awake Faster recovery Safer than general anaesthesia Previous positive experience Due to the type of surgery Do not know or do not explain preference
text field (spontaneous answer). The reasons were categorised later (Table 2). Some (20.7%) patients would refuse RA if offered it by the anaesthesiologist, which corresponded with 39% of patients who preferred GA. Patients who preferred GA though it was safer than patients who preferred RA (mean = 2.1 ± 0.6 vs. 2.4 ± 0.5, p = 0.04). No correlation was observed between anaesthetic preference and perception of the safety of SA or NB. There was no correlation between general anxiety at the thought of anaesthesia and anaesthetic preference. However, patients who preferred GA over RA expressed greater anxiety at remaining awake during surgery (mean = 3.9 ± 1 and 2.9 ± 1, respectively; p < 0.01). Patients that preferred GA over RA had a greater fear of needles (mean = 3.2 ± 1.4 vs. 2.3 ± 1.2, p < 0.01), pain during surgery (mean = 3.7 ± 1.2 and 2.9 ± 1.3, respectively, p = 0.01) and back pain after RA (mean = 3.4 ± 1.3 vs. 2.7 ± 1.2, p = 0.04), as shown in Table 3. Anaesthesia preference was not correlated with demographic variables (age, sex or education).
38.3% 6.4% 4.2% 6.4% 6.4% 2.1% 2.1% 34% 17.5% 5% 22.5% 12.5% 2.5% 40%
Knowledge of regional anaesthesia Many patients were unaware of the benefits of RA listed in the questionnaire, as shown in Table 3. In terms of evaluating their knowledge, we speculated that a patient who answered ‘‘yes’’ to more questions (that is, who had greater knowledge of the benefits of RA) would consider RA to be a safer procedure and would, therefore, prefer it over GA. However, we did not find statistically significant correlations, either for the perceived safety of SA and NB, and the preference of RA over GA. Similarly, we found no correlation between the number of questions answered affirmatively and less fear of the technique.
Willingness to receive regional anaesthesia again Thirty-eight patients had previously received SA. Of these, 40% said they would not go through it again. The reasons for this were given spontaneously, and mainly concerned technical difficulties, sensory alterations, and anxiety at the
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General or regional? Perception of patients on regional anesthesia Table 3
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Patients’ awareness of the benefits of regional anaesthesia.
Did you know that with regional anaesthesia...
Yes
Is it easier to control postoperative pain? There is less risk of thrombosis? Fewer drugs are needed to control pain? There is less risk of pulmonary complications? There is less risk of cardiac complications? Intestinal function is restored more rapidly? There is less risk of bleeding or the need for blood transfusion (depending on the intervention)?
likelihood of remaining awake during surgery, or of feeling pain during the intervention. One patient would not choose it again due to a recent diagnosis of multiple sclerosis. Only 5 patients had previously received NB, and of these 4 would be willing to repeat the procedure.
Discussion The results show that patients who preferred GA considered it to be a safer procedure than patients who preferred RA. This may be due to historical reasons, since GA was the most common technique several decades ago, and people tend to prefer the known over the unknown (mere-exposure effect). Previous studies also show patients’ preference for GA over RA.1 However, patients that have previously received RA are less likely to prefer GA.2,3,6,7 In fact, preference for GA and RA was justified by previous positive experiences. This familiarity effect may also help to explain why women stated that RA was safer than AG, since epidural analgesia for childbirth is widely accepted as a safe technique in the country where this study was performed. The reasons for preferring GA over of RA were similar to those reported in previous studies, and mainly involved misgivings about RA and fear at the thought of being awake during the intervention.1---5 Patients who preferred GA over RA expressed greater fear of back pain, needles, and pain during the procedure. The fear of pain during surgery was also one of the spontaneous reasons given for preferring GA, and is also the situation most likely to occur, according to patients. This was surprising, since RA is considered the gold standard technique for pain management. Interestingly, patients who refused to repeat RA did not list ‘‘feeling pain’’ among their reasons, instead, they stated that they did not like the sensation of ‘‘feeling the surgery, or of being awake during the procedure’’. Sedation may have improved the experience of these patients. In fact, patients who preferred GA reported more anxiety at the thought of being awake during surgery. Similarly, fear of being awake was the spontaneous answer given by 38.3% of patients to justify their preference for GA. However, it should be noted that some patients who preferred RA did so because they did not wish to lose consciousness. We could speculate that patients do not want to lose control of events in the operating room, or are afraid of revealing personal information while anaesthetised. Future studies could investigate this preference.
31.7% 25.6% 38% 31.6% 39.7% 38% 32.5%
No 68.3% 74.4% 62% 68.4% 60.3% 62% 67.5%
Less than half (39%) of patients who preferred GA over RA stated that they would refuse RA if offered it by the anaesthesiologist (about one fifth of the total sample). This was surprisingly high, considering that in our country the patientdoctor relationship is paternalistic and patients tend to trust their doctor to choose the best for them. Exploring the factors that distinguish patients who refuse RA from those who merely express a preference for GA could be a subject for further research. Previous authors have stated that anaesthesiologists and patients may have different concerns about RA.3,8 Indeed, anaesthesiologists are usually concerned about post dural puncture headache, vomiting, and infection (along with possible neurological complications), while these were the least of the patients’ fears. This could be because patients are aware that these complications are rare, or because they consider them to be minor effects that they have already experienced and from which they can recover without permanent damage. Instead, along with the fear of neurological damage, patients expressed concerns that are not included among the known complications associated with RA. It is essential to identify the differences between the concerns of the anaesthesiologist and those of the patient, since anaesthesiologist could underestimate some of these concerns, and not discuss them when suggesting RA. Other authors have investigated patients’ concerns about neurological damage after RA. However, the patient’s perception of the likelihood of each possible complication occurring has not been explored. In our study, we observed a discrepancy between patients’ perception and the actual incidence of complications. While 21.9% of patients thought there was a high probability of becoming paraplegic, 27.9% of suffering from sensory alterations, and 23.9% of presenting back pain, the real probability of suffering neurological damage is much lower. According to the Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anaesthesia and Pain Medicine, the incidence of neuroaxial injury for any reason in the general population is between 0.001 and 0.07%, and the incidence of NB-related neuroaxial injury is between 0.02% and 0.04%.9 Similarly, back pain can be caused by various factors, such as positioning or duration of surgery, and its incidence does not vary between GA and RA.10 Patient perceptions could be influenced by third hand reports and stories. The lack of promotion of RA in the general public was evidenced by the patient’s ignorance of its benefits. The percentage of patients who were familiar with each benefit
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6 ranged from 25.6% to 39.7%. Explaining the benefits of RA and discussing patients’ concerns can sometimes be difficult due to time restrictions during the pre-anaesthesia consultation. Moreover, it is difficult to emphasise the value of this technique. This task would be made easier by raising public awareness of RA8,11 through different communications channels, such as health centres, the media and the Internet, using plain language. Surgeons can also help anaesthesiologists in this regard, since the preferences of the former may affect the patient’s choice of anaesthesia,7 and many patients discuss anaesthesia options with their surgeon before speaking with the anaesthesiologist. This study had certain limitations. The sample was small, and few patients had received NB; this prevented us from performed certain statistical tests. Previous experience with anaesthesia was evaluated on the basis of the patient’s recollection of their medical history, which could have introduced memory bias. However, collecting information from medical reports could also have introduced bias, since patients could have undergone anaesthesia in different hospitals, or many years ago, and reports of the procedure could be difficult to access, or even entirely missing. Be that as it may, the aim of this study was to identify perceptions and subjective opinions of RA that could mainly have been influenced by the patient’s recollection of previous experiences. For this reason, memory bias is less relevant in this study than in more objective studies. The fact that some patients (4.9%) were scheduled for surgical specialties in which RA was not an option could have influenced the results. Nevertheless, eliminating these participants from the sample did not significantly alter the results. As the questionnaire was completed before the pre-anaesthesia consultation, the patients did not know for certain what type of anaesthesia would be suggested, thereby minimising this effect. Although the aim of this study was to assess the patient’s perspective before their appointment with the anaesthesiologist, an interesting topic for future research would be to evaluate how patients’ beliefs about RA change after consultation with the anaesthesiologist. In conclusion, the fear of remaining awake during surgery seems to be one of the main factors determining patients’ preference for GA over RA, together with their opinions on the safety of anaesthetic procedures, and the fear of RA. Patients are not aware of the real risks and benefits of RA. This shows that anaesthesiologists must continue their
J.S. Lavado et al. efforts to educate patients in order to achieve a more positive perception of RA.
Funding This study has not received subsidies from financial agencies in the public or commercial sectors.
Conflicts of interest The authors declare that they have no conflicts of interest.
References 1. Shevde K, Panagopoulos G. A survey of 800 patients’ knowledge, attitudes and concerns regarding anesthesia. Anesth Analg. 1991;73:190---8. 2. Bheemanna NK, Channaiah SR, Gowda PK, Sanmugham VH, Chanappa NM. Fears and perceptions associated with regional anesthesia: a study from a tertiary care hospital in South India. Anesth Essays Res. 2017;11:483---8. 3. Dove P, Gilmour F, Weightman WM, Hocking G. Patient perceptions of regional anesthesia: influence of gender, recent anesthesia experience and perioperative concerns. Reg Anesth Pain Med. 2011;36:332---5. 4. Matthey PWM, Finegan BA, Finucane BT. The public’s fears about and perception of regional anaesthesia. Reg Anesth Pain Med. 2004;29:96---101. 5. Gajraj NM, Sharma ML, Souter AJ, Pole Y, Sidawi JE. A survey of obstetric patients who refuse regional anesthesia. Anaesthesia. 1995;50:740---1. 6. Rhee WJ, Chung CJ, Youn HL, Lee KH, Lee SC. Factors in patient dissatisfaction and refusal regarding spinal anesthesia. Korean K Anesthesiol. 2010;59:260---4. 7. Wu CL, Naqibuddin M, Fleisher LA. Measurement of patient satisfaction as an outcome of regional anesthesia and analgesia: a systematic review. Reg Anesth Pain Med. 2001;26:196---208. 8. Birnbach D. The public’s perception of regional anesthesia: why don’t they get ‘‘the point’’? Reg Anesth Pain Med. 2004;29:86---9. 9. Benzon HT, Asher YG, Hartrick CT. Back pain and neuroaxial anesthesia. Anesth Analg. 2016;122:2047---58. 10. Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, et al. The Second ASRA Practice Advisory on neurologic complications associated with Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med. 2015;40:401---30. 11. McCartney CJL. We need to educate about perioperative pain control and not just regional anesthesia. Reg Anesth Pain Med. 2004;29:382.
ARTICLE IN PRESS
Rev Esp Anestesiol Reanim. 2019;xxx(xx):xxx---xxx
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
ORIGINAL ARTICLE
General or regional? Exploring patients’ anaesthetic preferences and perception of regional anaesthesia夽 J.S. Lavado ∗ , D. Gonc ¸alves, L. Gonc ¸alves, C. Sendino, E. Valente Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal Received 31 May 2018; accepted 2 December 2018
KEYWORDS Regional anaesthesia; General anaesthesia; Fear; Knowledge; Patient preference
Abstract Introduction and objectives: Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients’ fears, anxiety, and knowledge) related to patients’ anaesthetic preference. Material and methods: Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA. Results: One hundred and 2 patients agreed to participate. Mean age was 52.6 ± 13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA’s real risks and benefits. Conclusions: Knowing patients’ fears is essential for the anaesthesiologist address their patients’ needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
夽
Please cite this article as: Lavado JS, Gonc ¸alves D, Gonc ¸alves L, Sendino C, Valente E. ¿General o regional? Preferencias anestésicas de los pacientes y su percepción sobre la anestesia regional. Rev Esp Anestesiol Reanim. 2018. https://doi.org/10.1016/j.redar.2018.12.004 ∗ Corresponding author. E-mail address: joanasfl[email protected] (J.S. Lavado). 2341-1929/© 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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PALABRAS CLAVE Anestesia regional; Anestesia general; Miedos; Conocimiento; Preferencias de los pacientes
¿General o regional? Preferencias anestésicas de los pacientes y su percepción sobre la anestesia regional Resumen Introducción y objetivos: La anestesia regional (AR) ha ganado popularidad debido a sus beneficios y su seguridad. Sin embargo, muchos pacientes rechazan la AR en favor de la anestesia general (AG). Este estudio investiga las variables (factores demográficos, percepción de seguridad, miedos y conocimientos sobre la AR) relacionadas con las preferencias anestésicas de los pacientes. Material y métodos: Los participantes eran mayores de 18 a˜ nos, propuestos para una consulta anestésica. Rellenaron un cuestionario previamente a su cita. Resultados: Ciento dos pacientes accedieron a participar. La media de edad era de 52,6 ± 13,5 a˜ nos. El 57,8% eran mujeres y el 44,5% contaba al menos con 12 a˜ nos de estudios. Dados a elegir, el 54% prefería AG y el 20,7% rechazaba AR en caso de que se lo propusiera el anestesiólogo. Entre los pacientes que ya habían experimentado anestesia neuroaxial, el 40% no quería repetirlo. Los pacientes que preferían AG en lugar de AR la percibían como más segura y expresaban mayor ansiedad por permanecer despiertos durante la cirugía. Estos fueron también los que tenían mayor temor al pinchazo, al dolor de espalda y a sentir dolor durante la cirugía. Los resultados indican que los pacientes no conocían los verdaderos riesgos y beneficios de la AR. Conclusiones: El conocimiento de los temores de los pacientes es esencial y ayudará a los anestesiólogos a satisfacer las necesidades de sus pacientes. Los anestesiólogos deben esforzarse en mejorar las perspectivas de la población y su conocimiento sobre la RA. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Background and objectives Regional anaesthesia (RA) has gained popularity among anaesthesiologists thanks to its numerous benefits and good safety profile. However, patients often refuse this type of procedure, preferring general anaesthesia (GA). Since patient refusal is an absolute contraindication for RA, many patients fail to benefit from the advantages of this technique. It is essential to explore RA from the patient’s perspective, since anaesthesiologists can only achieve their goals if they acknowledge their patient’s concerns. Many studies on this topic have been performed outside Europe, and may not reflect the cultural differences and concerns that may influence acceptance of RA. Some, moreover, were performed more than 10 years ago, and may not reflect the opinion of today’s patients. In addition, no studies have hitherto questioned patients on their understanding of the benefits of RA. The aim of this study was to investigate the variables (demographic factors, patients’ fears, anxieties, and perception of GA and RA in terms of safety, risks and benefits) associated with patients’ anaesthetic preference (GA or RA). The ultimate objective was to identify surgery-specific factors, and thus increase patient confidence in and acceptance of RA.
Methods A total of 102 patients were evaluated during a 3-month period (February---April 2017), prior to their pre-anaesthesia
consultation. The patients were scheduled for surgery (general, orthopaedic, urological, ENT, ocular, or gynaecological) or interventions outside the operating room (mainly gastroenterological). The patients were enrolled before their pre-anaesthesia consultation by an anaesthesiologist member of the research team. All consecutive patients aged over 18 years that were able to give written informed consent were invited to participate in the study; only 1 patient refused. The study was approved by the Ethics Committee and the hospital’s Board of Directors. Written informed consent was obtained from all patients. No patient dropped out of the study after signing the consent form. The patients completed a questionnaire in the waiting room, before their appointment with the anaesthesiologist, and before being offered a particular anaesthetic technique. The questionnaire (annexe, available in the online version of this article) was based on earlier studies and included a brief explanation of GA and RA to enable patients to understand the differences between these techniques.1---5 The body of the questionnaire was divided into 3 parts: Part 1 contained demographic questions, Part 2 asked after the patient’s previous experience with anaesthesia, and Part 3 explored the patient’s anaesthesia preferences and perception of safety, and evaluated their knowledge of RA and their concerns with the technique. Questions relating to 7 benefits of RA were answered with a ‘‘yes’’ or ‘‘no’’. In order to avoid erroneous information, all the sentences were true. The data were analysed using the Statistical Package for the Social Sciences (SPPS --- version 22.0 for Windows) (IBM, USA). Descriptive statistics were used to summarise the data. The percentages reported were calculated from valid answers.
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General or regional? Perception of patients on regional anesthesia
3
18.3%
Very nervous
7.9% 24.7%
Nervous
21.8% 32.3%
Slightly nervous
37.6% 20.4%
Calm
Very calm
23.8% 4.3% 8.9%
Level of anxiety at the thought of remaining awake during surgery Level of anxiety at the thought of undergoing anaesthesia
Figure 1
Patients’ level of anxiety with respect to undergoing anaesthesia and remaining awake during surgery.
To identify correlations between variables, the Student’s t test was used for continuous and categorical variables; correlation analysis was used to test 2 continuous variables, and 2 statistics were used to test 2 categorical variables. Statistical significance was set at p < 0.05.
Results The average age of the sample was 52.6 ± 13.5 years, 57.8% were women, and 44.5% had at least 12 years of education or a university degree. In terms of surgical specialty, 38.2% were scheduled for general surgery, 22.5% for orthopaedic surgery, 18.6% for gynaecological surgery, 3.9% for urological procedures, 2% for ocular surgery, and 4.9% were candidates for interventions outside the operating room.
Previous experience with anaesthesia Analyzing previous experience with anaesthesia showed that 91.2% of patients had previously received anaesthesia, 59.8% had previously undergone GA, 37.3% had had spinal anaesthesia (SA) and 4.9% had had nerve blocks (NB). Of the 38 patients who had previously received SA, 8 (21%) stated that they had had complications (minor or major). Patients treated with NB did not report any complications. Only 4.4% stated that they knew someone who had had RA-related complications. Overall, the complications reported were sensory deficit in the legs, pain during surgery, urinary retention, nausea and vomiting, an allergic reaction, and a patient who had experienced paralysis and had ‘‘head’’ problems.
Patients’ perspective of regional general anaesthesia Safety was rated from 1 (very safe) to 4 (very dangerous). Although patients generally tended to consider that GA was safer (mean 2.2 ± 0.6) than RA (mean 2.3 ± 0.7 for SA and 2.4 ± 0.6 for NB), the differences were not significant. Sex
was the only demographic characteristic that was significantly associated with a perception of RA being safer. More women perceived RA as being safer (mean = 2.5 ± 0.7 for SA and 2.5 ± 0.6 for NB) than men (mean = 2.1 ± 0.7 for SA and 2.1 ± 0.6 for NB, p = 0.04 for SA and p = 0.02 for NB) No differences were found in the perception of GA safety between women and men. There was no correlation between education or age and perception of anaesthesia safety. Anxiety at the thought of anaesthesia, and specifically at the thought of remaining awake during surgery, was rated from 1 (very calm) and 5 (very nervous). Patients felt considerably more nervous about the thought of being awake during surgery than the thought of recieving general anaesthesia (mean = 3.3 ± 1.1 vs. 2.9 ± 1.1, p < 0.01) (Fig. 1). Women were more anxious about anaesthesia than men (mean = 3.2 ± 1.1 vs. 2.6 ± 1, p = 0.02). There were no differences between sexes in terms of anxiety at the thought of being awake during surgery. Different levels of anxiety were not correlated with either age or educational level. In Part 2 of the questionnaire, participants were presented with 8 possible negative episodes normally associated with RA. For each sentence, the patients were asked to rate: (a) their level of fear, and (b) the probability of each episode occurring under RA, as shown in Table 1. The episodes rated by most patients as more likely to occur also corresponded to those they most feared, namely, residual sensory alterations, pain during surgery, paraplegia and back pain. Fear was also highly correlated with the perceived probability of each episode (total p < 0.01). Demographic factors correlated with specific fears of RA were: older age correlated with a greater fear of infection and sensory disturbances, and lower educational level correlated with fear of needles (p < 0.05). No differences were observed between the sexes in this part of the questionnaire.
Preference for general or regional anaesthesia In terms of choice, 54% of patients preferred GA over RA. Patients were asked to give their reasons for this in a free
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J.S. Lavado et al. Table 1
Distribution of patients level of fear and their estimate of the likelihood regional anaesthesia-related complications.
Becoming paralysed Headache Vomiting Pain during surgery Difficulties in inserting the needle Sensory alterations (e.g., leg/arm) Back pain after regional anaesthesia Puncture site infection
Table 2
If you had to receive regional anaesthesia, how would you rate your fear of...?: (1, not at all afraid; 5, very afraid)
In your opinion, what is the probability of these episodes occurring with regional anaesthesia?: (1, very unlikely; 5, highly likely)
1---2
1---2
30.1% 50.6% 52.6% 29.5% 43.5% 28.4% 28.2% 43.6%
3
4---5
31.3% 32.9% 32.1% 25.6% 24.4% 23% 33.3% 30.8%
38.5% 16.4% 15.3% 44.9% 32% 48.7% 38.4% 25.6%
49.3% 59.3% 49.3% 41.1% 44.9% 39.7% 39.5% 58.9%
3
4---5 28.8% 25% 36.6% 35.6% 34.8% 32.4% 36.6% 30.8%
21.9% 15.3% 14.1% 23.2% 20.3% 27.9% 23.9% 10.3%
Reasons for anaesthesia preference. Reason for preference
General anaesthesia
Regional anaesthesia
Prefer to be asleep Back problems Previous positive experience General anaesthesia is safer/better Fear of feeling pain Due to the type of surgery It’s better for the surgeon Do not know or do not provide explain preference Prefer to be awake Faster recovery Safer than general anaesthesia Previous positive experience Due to the type of surgery Do not know or do not explain preference
text field (spontaneous answer). The reasons were categorised later (Table 2). Some (20.7%) patients would refuse RA if offered it by the anaesthesiologist, which corresponded with 39% of patients who preferred GA. Patients who preferred GA though it was safer than patients who preferred RA (mean = 2.1 ± 0.6 vs. 2.4 ± 0.5, p = 0.04). No correlation was observed between anaesthetic preference and perception of the safety of SA or NB. There was no correlation between general anxiety at the thought of anaesthesia and anaesthetic preference. However, patients who preferred GA over RA expressed greater anxiety at remaining awake during surgery (mean = 3.9 ± 1 and 2.9 ± 1, respectively; p < 0.01). Patients that preferred GA over RA had a greater fear of needles (mean = 3.2 ± 1.4 vs. 2.3 ± 1.2, p < 0.01), pain during surgery (mean = 3.7 ± 1.2 and 2.9 ± 1.3, respectively, p = 0.01) and back pain after RA (mean = 3.4 ± 1.3 vs. 2.7 ± 1.2, p = 0.04), as shown in Table 3. Anaesthesia preference was not correlated with demographic variables (age, sex or education).
38.3% 6.4% 4.2% 6.4% 6.4% 2.1% 2.1% 34% 17.5% 5% 22.5% 12.5% 2.5% 40%
Knowledge of regional anaesthesia Many patients were unaware of the benefits of RA listed in the questionnaire, as shown in Table 3. In terms of evaluating their knowledge, we speculated that a patient who answered ‘‘yes’’ to more questions (that is, who had greater knowledge of the benefits of RA) would consider RA to be a safer procedure and would, therefore, prefer it over GA. However, we did not find statistically significant correlations, either for the perceived safety of SA and NB, and the preference of RA over GA. Similarly, we found no correlation between the number of questions answered affirmatively and less fear of the technique.
Willingness to receive regional anaesthesia again Thirty-eight patients had previously received SA. Of these, 40% said they would not go through it again. The reasons for this were given spontaneously, and mainly concerned technical difficulties, sensory alterations, and anxiety at the
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General or regional? Perception of patients on regional anesthesia Table 3
5
Patients’ awareness of the benefits of regional anaesthesia.
Did you know that with regional anaesthesia...
Yes
Is it easier to control postoperative pain? There is less risk of thrombosis? Fewer drugs are needed to control pain? There is less risk of pulmonary complications? There is less risk of cardiac complications? Intestinal function is restored more rapidly? There is less risk of bleeding or the need for blood transfusion (depending on the intervention)?
likelihood of remaining awake during surgery, or of feeling pain during the intervention. One patient would not choose it again due to a recent diagnosis of multiple sclerosis. Only 5 patients had previously received NB, and of these 4 would be willing to repeat the procedure.
Discussion The results show that patients who preferred GA considered it to be a safer procedure than patients who preferred RA. This may be due to historical reasons, since GA was the most common technique several decades ago, and people tend to prefer the known over the unknown (mere-exposure effect). Previous studies also show patients’ preference for GA over RA.1 However, patients that have previously received RA are less likely to prefer GA.2,3,6,7 In fact, preference for GA and RA was justified by previous positive experiences. This familiarity effect may also help to explain why women stated that RA was safer than AG, since epidural analgesia for childbirth is widely accepted as a safe technique in the country where this study was performed. The reasons for preferring GA over of RA were similar to those reported in previous studies, and mainly involved misgivings about RA and fear at the thought of being awake during the intervention.1---5 Patients who preferred GA over RA expressed greater fear of back pain, needles, and pain during the procedure. The fear of pain during surgery was also one of the spontaneous reasons given for preferring GA, and is also the situation most likely to occur, according to patients. This was surprising, since RA is considered the gold standard technique for pain management. Interestingly, patients who refused to repeat RA did not list ‘‘feeling pain’’ among their reasons, instead, they stated that they did not like the sensation of ‘‘feeling the surgery, or of being awake during the procedure’’. Sedation may have improved the experience of these patients. In fact, patients who preferred GA reported more anxiety at the thought of being awake during surgery. Similarly, fear of being awake was the spontaneous answer given by 38.3% of patients to justify their preference for GA. However, it should be noted that some patients who preferred RA did so because they did not wish to lose consciousness. We could speculate that patients do not want to lose control of events in the operating room, or are afraid of revealing personal information while anaesthetised. Future studies could investigate this preference.
31.7% 25.6% 38% 31.6% 39.7% 38% 32.5%
No 68.3% 74.4% 62% 68.4% 60.3% 62% 67.5%
Less than half (39%) of patients who preferred GA over RA stated that they would refuse RA if offered it by the anaesthesiologist (about one fifth of the total sample). This was surprisingly high, considering that in our country the patientdoctor relationship is paternalistic and patients tend to trust their doctor to choose the best for them. Exploring the factors that distinguish patients who refuse RA from those who merely express a preference for GA could be a subject for further research. Previous authors have stated that anaesthesiologists and patients may have different concerns about RA.3,8 Indeed, anaesthesiologists are usually concerned about post dural puncture headache, vomiting, and infection (along with possible neurological complications), while these were the least of the patients’ fears. This could be because patients are aware that these complications are rare, or because they consider them to be minor effects that they have already experienced and from which they can recover without permanent damage. Instead, along with the fear of neurological damage, patients expressed concerns that are not included among the known complications associated with RA. It is essential to identify the differences between the concerns of the anaesthesiologist and those of the patient, since anaesthesiologist could underestimate some of these concerns, and not discuss them when suggesting RA. Other authors have investigated patients’ concerns about neurological damage after RA. However, the patient’s perception of the likelihood of each possible complication occurring has not been explored. In our study, we observed a discrepancy between patients’ perception and the actual incidence of complications. While 21.9% of patients thought there was a high probability of becoming paraplegic, 27.9% of suffering from sensory alterations, and 23.9% of presenting back pain, the real probability of suffering neurological damage is much lower. According to the Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anaesthesia and Pain Medicine, the incidence of neuroaxial injury for any reason in the general population is between 0.001 and 0.07%, and the incidence of NB-related neuroaxial injury is between 0.02% and 0.04%.9 Similarly, back pain can be caused by various factors, such as positioning or duration of surgery, and its incidence does not vary between GA and RA.10 Patient perceptions could be influenced by third hand reports and stories. The lack of promotion of RA in the general public was evidenced by the patient’s ignorance of its benefits. The percentage of patients who were familiar with each benefit
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6 ranged from 25.6% to 39.7%. Explaining the benefits of RA and discussing patients’ concerns can sometimes be difficult due to time restrictions during the pre-anaesthesia consultation. Moreover, it is difficult to emphasise the value of this technique. This task would be made easier by raising public awareness of RA8,11 through different communications channels, such as health centres, the media and the Internet, using plain language. Surgeons can also help anaesthesiologists in this regard, since the preferences of the former may affect the patient’s choice of anaesthesia,7 and many patients discuss anaesthesia options with their surgeon before speaking with the anaesthesiologist. This study had certain limitations. The sample was small, and few patients had received NB; this prevented us from performed certain statistical tests. Previous experience with anaesthesia was evaluated on the basis of the patient’s recollection of their medical history, which could have introduced memory bias. However, collecting information from medical reports could also have introduced bias, since patients could have undergone anaesthesia in different hospitals, or many years ago, and reports of the procedure could be difficult to access, or even entirely missing. Be that as it may, the aim of this study was to identify perceptions and subjective opinions of RA that could mainly have been influenced by the patient’s recollection of previous experiences. For this reason, memory bias is less relevant in this study than in more objective studies. The fact that some patients (4.9%) were scheduled for surgical specialties in which RA was not an option could have influenced the results. Nevertheless, eliminating these participants from the sample did not significantly alter the results. As the questionnaire was completed before the pre-anaesthesia consultation, the patients did not know for certain what type of anaesthesia would be suggested, thereby minimising this effect. Although the aim of this study was to assess the patient’s perspective before their appointment with the anaesthesiologist, an interesting topic for future research would be to evaluate how patients’ beliefs about RA change after consultation with the anaesthesiologist. In conclusion, the fear of remaining awake during surgery seems to be one of the main factors determining patients’ preference for GA over RA, together with their opinions on the safety of anaesthetic procedures, and the fear of RA. Patients are not aware of the real risks and benefits of RA. This shows that anaesthesiologists must continue their
J.S. Lavado et al. efforts to educate patients in order to achieve a more positive perception of RA.
Funding This study has not received subsidies from financial agencies in the public or commercial sectors.
Conflicts of interest The authors declare that they have no conflicts of interest.
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