Impact of regional versus general anesthesia on the clinical outcomes of patients undergoing major lower extremity amputation
Josue Chery1, Elie Semaan1, Sandip Darji 2, William T Briggs, Joel Yarmush2, Marcus D’Ayala1,3
Department of Surgery1, Department of Anesthesia2, New York Methodist Hospital, Brooklyn, NY 11215, USA.
3 Corresponding author
Marcus D’Ayala, M.D., F.A.C.S.
Chief Division- Vascular Surgery
New York Methodist Hospital
506 Sixth Street
Brooklyn, N.Y. 11215
OBJECTIVE: Patients undergoing major lower extremity amputation for peripheral arterial disease are often elderly, debilitated, and fraught with medical co-morbid conditions that place them at high risk for surgical intervention. Data from lower extremity revascularization surgeries are often extrapolated to determine which anesthetic modality to use for amputations, with preference given to regional anesthesia. However, there is little evidence to support the use of one mode of anesthesia over the other. We conducted this study to determine the effect of anesthetic modality on the clinical outcomes of patients undergoing above or below knee amputations. METHODS: This study is a retrospective review of consecutive patients who underwent major lower extremity amputation at a single center between 2002 and 2011. The study population was divided into two groups based on anesthetic modality, regional versus general anesthesia. These groups were compared based on demographics and co-morbidities. Major outcomes analyzed included death, MI, and pulmonary complications. Secondary outcome measures included cardiac arrhythmias, VTE, and length of ICU and Hospital stay. RESULTS: A total of 463 patients were identified of which 56 patients were excluded for incomplete data, leaving 407 patients. Of these, 259 patients underwent amputation under regional anesthesia and 148 under general. Patients in the regional anesthesia group were older (76.6 years vs 71.6 years, P=0.001) and had a lower BMI (25.2 vs 26.9, P=0.013). They were also less likely to be on pre-operative anti-platelet therapy (ASA/Plavix) or anticoagulation (27% vs 45%, P=0<001). Regional anesthesia was associated with a lower incidence of post operative pulmonary complications (14% vs 45%, P=0.022) and post-operative arrhythmias (14% vs 25%, P=0.006). Length of stay in the ICU (1.92 days vs 3.85 days, P=0.001) and hospital (19.4 days vs 23.1 days, P=0.037) were significantly higher in the group receiving general anesthesia. No significant differences in postoperative MI (12% vs 9%, P=NS), VTE (5% vs 7%, P=NS) or mortality (10% vs 13%, P=NS) was seen between groups. Controlling for procedure, AKA vs BKA, did not significantly alter these results. CONCLUSIONS: Regional anesthesia for patients undergoing lower extremity amputation is associated with a lower incidence of post-operative pulmonary complications and arrhythmias. It is also associated with lower resource utilization. It should be the preferred modality of anesthesia for patients undergoing major lower extremity amputation.
Keywords: amputation, regional, general, anesthesia
The geriatric population continues to increase . Improvement in surgical and anesthetic techniques is necessary to ensure optimal outcome in this growing and complex medical sub-population. It is generally believed that regional anesthesia when compared to general anesthesia have decreased post-operative pain and pulmonary complications but with no significant difference in mortality, adverse cardiovascular outcome and venous thromboembolism [2-10]. Lower extremity amputations, for vascular disease, have long to be known to be a high-risk procedure for mortality and morbidity in the elderly . These patients are often debilitated, and fraught with medical co-morbid conditions that place them at high risk for surgical intervention. Data from lower extremity...
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