SLR - January 2023 - Tiffanie Liu, DPM – PGY3
Title: Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General AnaesthesiaReference: Mufarrih SH, Qureshi NQ, Schaefer MS, Sharkey A, Fatima H, Chaudhary O, Krumm S, Baribeau V, Mahmood F, Schermerhorn M, Matyal R. Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia. Eur J Vasc Endovasc Surg. 2021 Sep;62(3):476-484. doi: 10.1016/j.ejvs.2021.05.040. Epub 2021 Jul 22. PMID: 34303598.
Level of Evidence: 1
Reviewed By: Tiffanie Liu, DPM – PGY3
Residency Program: MedStar Health, Washington DC
Podiatric Relevance: Podiatric surgeons commonly perform amputations of the lower extremity due to arterial disease or infection. These amputations of the lower extremity are associated with increased post-operative morbidity. Podiatric surgeons are often asked their preference for what type of anesthesia to use during the surgery – patients receive general anesthesia more often than regional anesthesia. Regional anesthesia is defined as epidural, spinal, or peripheral nerve block. Regional anesthesia (particularly peripheral nerve blocks) is underutilized and may be very useful and safe in the patient population served by podiatrists. The aim of this study was to assess pulmonary complications after regional anesthesia compared with general anesthesia.
Methods: A retrospective analysis of 45,492 patients with LE amputations between 2005 and 2018 that included patients who underwent BKA and AKA with comorbidities such as HTN, DM, CHF, acute renal failure, chronic renal failure on hemodialysis, bleeding disorders, and steroid dependence. This study compared patients who received general anesthesia with those who received regional anesthesia. Multivariable logistic regression was used to assess pulmonary complications within 48 hours and 30 days. Primary outcomes include pneumonia, unexplained post operative intubation, inability to be weaned from mechanical ventilation for over 48 hours after surgery. Secondary outcomes include infections, DVT, pulmonary embolism, renal failure, UTI, cardiac arrest, myocardial infarct, and death.
Results: Of the 45, 492 patients, 88% received general anesthesia and 12% received regional anesthesia. Most common comorbidities were HTN > DM > CKD on HD. Trend analysis from 2005 to 2018 showed increase in use of general anesthesia, as well as increase in use of peripheral nerve blocks and decrease in spinal and epidural anesthesia. Patients receiving regional anesthesia were often older and sicker. General anesthesia patients were at statistically significant higher risk of pulmonary complication at 48 hours and at 30 days, as well as higher risk for blood transfusion, septic shock, and re-operation as opposed to those receiving regional anesthesia. Regional anesthesia was associated with longer hospital stay.
Conclusions: With ultrasound guided injections, regional blocks are more precise than ever before. Patients in this trial had comorbidities such as hypertension, diabetes, and chronic renal failure. Podiatric surgeons often perform LE amputations in this patient population. Higher risk of pulmonary complications, blood transfusion, septic shock, re-operation after general anesthesia was found for patients undergoing LE amputations such as below- and above-knee amputations. This study showed statistically significant reduction in post operative complications after regional anesthesia for patients undergoing amputations. Although regional anesthesia was noted to have longer hospital stay, the difference between the 2 groups was <1 day and the patients receiving regional anesthesia were also older with more co-morbidities. As podiatric surgeons, we should strongly consider using peripheral nerve blocks as opposed to general anesthesia to decrease post operative risks. The peripheral nerve block may also be helpful in decreasing post operative pain and opioid use.