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Kirkham AM, Candeliere J, Stelfox HT, Nagpal SK, Dubois L, MacFadden DR, McIsaac DI, Roberts DJ. A Meta-Analysis to Derive Population-Based Quality Benchmarks of the Incidence of Surgical Site Infection after Lower Limb Revascularization Surgery. Ann Vasc Surg 2024; 104:81-92. [PMID: 37453466 DOI: 10.1016/j.avsg.2023.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The reported incidence of surgical site infection (SSI) after lower limb revascularization surgery varies. We conducted a systematic review and meta-analysis of population-based studies reporting the incidence of SSI in adults who underwent these surgeries in high-income countries to derive SSI quality benchmarks. METHODS We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception-to-April 28th, 2022) for population-based studies estimating the cumulative incidence of SSI among adults who underwent lower limb revascularization surgery for peripheral artery disease (PAD) in high-income countries. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risks of bias. We used random-effects models to pool data and GRADE to assess certainty. RESULTS Among 6,258 citations, we included 53 studies (n = 757,726 patients); 8 of which (n = 435,769 patients) reported nonoverlapping data that were meta-analyzed. The pooled cumulative incidence of any SSI was 6.0 in 100 patients [95% confidence interval (CI) = 4.3-8.0 in 100 patients; n = 8 studies; n = 435,769 patients; moderate certainty]. The cumulative incidence of Szilagyi grade I (cellulitis), grade II (subcutaneous tissue), and grade III (prosthetic graft) SSI was 6.5 in 100 patients (95% CI = 4.3-8.6 in 100 patients; n = 2 studies; n = 39,645 patients; low certainty), 2.1 in 100 patients (95% CI = 2.0-2.3 in 100 patients; n = 2 studies; low certainty), and 0.4 in 100 patients (95% CI = 0.4-0.4 in 100 patients; n = 1 study; n = 333,275 patients; low certainty), respectively. The pooled cumulative incidence of any early (in-hospital/≤30-days) and late (>30-days) SSI was 6.2 in 100 patients (95% CI = 4.4-8.0 in 100 patients; n = 7 studies; n = 431,273 patients; moderate certainty) and 3.7 in 100 patients (95% CI = 2.2-5.2 in 100 patients; n = 2 studies; n = 10,565 patients; low certainty), respectively. CONCLUSIONS This systematic review derived population-based benchmarks of the incidence of any SSI; Szilagyi I, II, and III SSI; and early and late SSI after lower limb revascularization surgery. These may be used by practicing surgeons and healthcare leaders/administrators to guide quality improvement efforts in the United States and perhaps other countries.
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Affiliation(s)
- Aidan M Kirkham
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Critical Care Medicine, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Derek R MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Infectious Disease, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
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Keekstra N, Biemond M, van Schaik J, Schepers A, Hamming JF, van der Vorst JR, Lindeman JHN. Toward Uniform Case Identification Criteria in Observational Studies on Peripheral Arterial Disease: A Scoping Review. Ann Vasc Surg 2024; 106:71-79. [PMID: 38615752 DOI: 10.1016/j.avsg.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The diagnosis of peripheral arterial disease (PAD) is commonly applied for symptoms related to atherosclerotic obstructions in the lower extremity, though its clinical manifestations range from an abnormal ankle-brachial index to critical limb ischemia. Subsequently, management and prognosis of PAD vary widely with the disease stage. A critical aspect is how this variation is addressed in administrative database-based studies that rely on diagnosis codes for case identification. The objective of this scoping review is to inventory the identification strategies used in studies on PAD that rely on administrative databases, to map the pros and cons of the International Classification of Diseases (ICD) codes applied, and to propose a first outline for a consensus framework for case identification in administrative databases. METHODS Registry-based reports published between 2010 and 2021 were identified through a systematic PubMed search. Studies were subcategorized on the basis of the expressed study focus: claudication, critical limb ischemia, or general peripheral arterial disease, and the ICD code(s) applied for case identification mapped. RESULTS Ninety studies were identified, of which 36 (40%) did not specify the grade of PAD studied. Forty-nine (54%) articles specified PAD grade studied. Five (6%) articles specified different PAD subgroups in methods and baseline demographics, but not in further analyses. Mapping of the ICD codes applied for case identification for studies that specified the PAD grade studied indicated a remarkable heterogeneity, overlap, and inconsistency. CONCLUSIONS A large proportion of registry-based studies on PAD fail to define the study focus. In addition, inconsistent strategies are used for PAD case identification in studies that report a focus. These findings challenge study validity and interfere with inter-study comparison. This scoping review provides a first initiative for a consensus framework for standardized case selection in administrative studies on PAD. It is anticipated that more uniform coding will improve study validity and facilitate inter-study comparisons.
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Affiliation(s)
- Niels Keekstra
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mathijs Biemond
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Jan H N Lindeman
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
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Schmidt AP, Del Maschi MM, Andrade CF. Anesthetic management for lower extremity vascular bypass procedures: The impact of general or regional anesthesia on clinical outcomes. Vascular 2023:17085381231193492. [PMID: 37540895 DOI: 10.1177/17085381231193492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
PURPOSE Postoperative complications after major surgery, especially vascular procedures, are associated with a significant increase in costs and mortality. Previous studies evaluating general anesthesia versus regional or neuraxial anesthesia for infrainguinal bypass have produced conflicting results. The main aim of the present study is to review current evidence on the application of regional or general anesthesia in patients undergoing infrainguinal bypass surgery and its potential favorable effects on postoperative outcomes. CONTENTS Patients undergoing vascular surgery often have multiple comorbidities, and it is important to outline both benefits and risks of regional anesthesia techniques. Neuraxial anesthesia in vascular surgery allows overall avoidance of general anesthesia and does provide short-term benefits beyond analgesia. Previous observational studies suggest that neuraxial anesthesia for lower limb revascularization may reduce morbidity and length of stay. However, evidence of long-term benefits is lacking in most procedures and further work is still warranted. CONCLUSIONS Neuraxial anesthesia is usually an effective anesthesia technique for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may display some benefit from neuraxial anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from regional techniques. Notably, systemic antithrombotic and anticoagulation therapy is common among this population and may affect anesthetic choices.
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Affiliation(s)
- André P Schmidt
- Serviço de Anestesia e Medicina Perioperatória, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Serviço de Anestesia, Santa Casa de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
- Serviço de Anestesia, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
- Programa de Pós-graduação em Ciências Pneumológicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Marine M Del Maschi
- Serviço de Anestesia e Medicina Perioperatória, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Cristiano F Andrade
- Programa de Pós-graduação em Ciências Pneumológicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Li A, Dreksler H, Nagpal SK, Brandys T, Jetty P, Dubois L, Parsons Leigh J, Stelfox HT, McIsaac DI, Roberts DJ. Outcomes After Neuraxial or Regional Anaesthesia Instead of General Anaesthesia for Lower Limb Revascularisation Surgery: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Studies. Eur J Vasc Endovasc Surg 2023; 65:379-390. [PMID: 36336286 DOI: 10.1016/j.ejvs.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether receipt of neuraxial or regional anaesthesia instead of general anaesthesia for lower limb revascularisation surgery affects patient outcomes. DATA SOURCES MEDLINE, EMBASE, Evidence Based Medicine Reviews, and Google Scholar. REVIEW METHODS After protocol registration, the data sources were searched for randomised and non-randomised studies comparing neuraxial or regional anaesthesia with general anaesthesia for lower limb revascularisation surgery in adults. Two investigators independently selected articles, extracted data, and assessed risks of bias. Data were pooled using random effects models. GRADE was used to assess certainty in cumulative evidence. RESULTS From 10 755 citations identified, five randomised (n = 970) and 13 non-randomised (n = 96 800) studies were included. Use of neuraxial instead of general anaesthesia for lower limb revascularisation surgery was associated with no statistically significant reduction in short term (in hospital or 30 day) mortality in randomised studies (pooled odds ratio [OR] 0.77; 95% confidence interval [CI] 0.33 - 1.81; low certainty) and a statistically significant reduction in adjusted short term mortality in non-randomised studies (pooled OR 0.67; 95% CI 0.56 - 0.81; low certainty). Adults allocated to neuraxial anaesthesia in randomised studies had fewer pulmonary complications (pooled OR 0.35; 95% CI 0.16 - 0.76; low certainty). In non-randomised studies, neuraxial instead of general anaesthesia was associated with a lower adjusted odds of any morbidity (pooled OR 0.66; 95% CI 0.52 - 0.84), cardiac complications (pooled OR 0.68; 95% CI 0.58 - 0.79), pneumonia (pooled OR 0.81; 95% CI 0.64 - 1.02), prolonged mechanical ventilation (OR 0.09; 95% CI 0.002 - 0.55), and bypass graft thrombosis (OR 0.70; 95% CI 0.59 - 0.85), as well as a shorter operative duration (low certainty for all). Use of a nerve block instead of general anaesthesia was associated with a lower adjusted odds of delirium (OR 0.16; 95% CI 0.06 - 0.42) and a shorter operative duration (low certainty for both). CONCLUSION Randomised and non-randomised data suggest that neuraxial anaesthesia for lower limb revascularisation surgery reduces morbidity and possibly mortality. Until randomised trials with a low risk of bias become available, this study supports use of neuraxial anaesthesia for these procedures where appropriate.
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Affiliation(s)
- Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada; ICES, Ontario, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Lim JA, Seo Y, Choi EJ, Kwak SG, Ryu T, Lee JH, Park KH, Roh WS. Impact of regional anesthesia on outcomes of geriatric patients undergoing lower extremity revascularization: A propensity score-matched cohort study. Medicine (Baltimore) 2022; 101:e32597. [PMID: 36596067 PMCID: PMC9803409 DOI: 10.1097/md.0000000000032597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Lower extremity revascularization (LER) for peripheral artery disease in elderly patients is associated with a high risk of perioperative morbidity and mortality. This study aimed to a conduct retrospective review and propensity score matching analysis to determine whether the use of regional anesthesia (RA) instead of general anesthesia (GA) in geriatric patients undergoing LER for peripheral artery disease results in improved short-term mortality and health outcomes. We reviewed medical records of 1271 patients aged >65 years who underwent LER at our center between May 1998 and February 2016. According to the anesthesia method, patients were grouped in the GA and RA groups. The primary outcome was short-term mortality (7-day and 30-day). The secondary outcomes were 5-year survival rate, intraoperative events, postoperative morbidity, and postoperative length of stay. A propensity score-matched cohort design was used to control for potentially confounding factors including patient demographics, comorbidities, American Society of Anesthesiologists physical status, and preoperative medications. After propensity score matching, 722 patients that received LER under GA (n = 269) or RA (n = 453) were identified. Patients from the GA group showed significantly higher 7-day mortality than those from the RA group (5.6% vs 2.7% P = .048); however, there was no significant difference in 30-day mortality between the groups (GA vs RA: 6.3% vs 3.6%, P = .083). The 5-year survival rate and incidence of arterial and central venous catheter placement or intraoperative dopamine and epinephrine use were significantly higher in the GA group than in the RA group (P < .05). In addition, the frequency of immediate postoperative oxygen therapy or mechanical ventilation support was higher in the GA group (P < .05). However, there was no difference in the postoperative cardiopulmonary and cerebral complications between the 2 groups. These results suggest that RA can reduce intraoperative hemodynamic support and provide immediate postoperative respiratory intensive care. In addition, the use of RA may be associated with better short-term and 5-year survival rates in geriatric patients undergoing LER.
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Affiliation(s)
- Jung A Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Yohan Seo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Eun-Joo Choi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Sang Gyu Kwak
- Department of Medical Statistics, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Taeha Ryu
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Jae Hoon Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Ki Hyuk Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Woon Seok Roh
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
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Gunawardena M, Salami M, Howard A, Awupetu A. Does the Mode of Anaesthesia (General or Regional) Affect Survival and Complications Following Femoropopliteal and Femorodistal Bypass? Cureus 2022; 14:e32104. [DOI: 10.7759/cureus.32104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 12/04/2022] Open
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Ke JXC, Flexman AM, Schwarz SKW, MacDonald S, Prabhakar C. OUP accepted manuscript. BJS Open 2022; 6:6601280. [PMID: 35657135 PMCID: PMC9164863 DOI: 10.1093/bjsopen/zrac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background The relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)). Methods Patients who underwent elective infrainguinal bypass in the 2014–2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 109/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression. Results Included were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378). Conclusion There was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.
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Affiliation(s)
- Janny Xue Chen Ke
- Correspondence to: Janny Xue Chen Ke, 1081 Burrard Street, Vancouver, British Columbia V6Z1Y6, Canada (e-mail: ; @jannyke
| | - Alana M. Flexman
- Department of Anesthesia, St. Paul’s Hospital, Providence Health Care, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephan K. W. Schwarz
- Department of Anesthesia, St. Paul’s Hospital, Providence Health Care, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shaun MacDonald
- Division of Vascular Surgery, St. Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
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Roberts DJ, Dreksler H, Nagpal SK, Li A, Parsons Leigh J, Brandys T, Jetty P, Dubois L, Stelfox HT, McIsaac DI. Outcomes After Receipt of Neuraxial or Regional Anesthesia Instead of General Anesthesia for Lower Limb Revascularization Surgery: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2021; 10:e32170. [PMID: 34507273 PMCID: PMC8665382 DOI: 10.2196/32170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients. OBJECTIVE The aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization. METHODS We will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia-related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates. RESULTS The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022. CONCLUSIONS This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial. TRIAL REGISTRATION Prospero CRD42021237060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=237060. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/32170.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
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Boyd S, Dittman JM, Tse W, Lavingia KS, Amendola MF. Modern Lower Extremity Bypass Outcomes by Anesthesia Type in the Veteran Population. Ann Vasc Surg 2021; 80:187-195. [PMID: 34673178 DOI: 10.1016/j.avsg.2021.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lower extremity bypass (LEB) revascularization can be performed under general (GA) or neuraxial anesthesia (NA). Studies show that the use of NA may decrease morbidity, 30-day mortality, and hospital length-of-stay (LOS). The goal of our analysis is to examine the differences in postsurgical outcomes following LEB between patients who undergo GA compared to NA in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database. METHODS After IRB approval, the VASQIP database was assessed for patients who underwent LEB between 1998-2018. Only infrainguinal bypass procedures and anesthesia type classified as "general," "epidural," or "spinal" were included. The neuraxial cohort includes both spinal and epidural anesthesia patients. The Risk Analysis Index (RAI), a validated measure of frailty, was additionally calculated for each patient. Chi squared, paired t-test, and binary logistic regression were used to compare the cohorts. RESULTS During this period, 22,960 veterans underwent LEB recorded in VASQIP. Compared to those who underwent surgery under GA, patients with procedures performed using NA were older (66.4 ± 9.6 years vs. 65.3 ± 9 years respectively; P <0.001) and more frail (average RAI score 25.7 ± 7.0 vs. 24.9 ± 6.7; P < 0.001). Operative time was shorter in the NA group (4.1 ± 1.7 hrs vs. 4.7 ± 3.0 hrs; P < 0.001) and fewer cases were emergent (1.55% vs. 4.13%; P <0.001). Patients in the GA group had higher rates of postoperative prolonged ileus (0.31% vs. 0.00%; P = 0.03), pneumonia (1.60% vs. 1.06%; P = 0.025), deep wound infection (2.67% vs. 2.61%; P = 0.01), sepsis (1.68% vs. 0.79%; P < 0.001), reintubation (1.80% vs. 1.30%) (P = 0.04),and number of packed red blood cell (pRBC) transfused intraoperatively (0.39 ± 1.21 units vs. 0.22 ± 0.79 units; P <0.001). There was no significant difference in rate of graft failure, return to the OR, myocardial infarction, death, or LOS. In regression analysis, those undergoing NA were less likely to require pRBC transfusion intraoperatively (OR: 0.43; 95% CI: 0.31-0.61; P < 0.001), however no other outcomes reached statistical significance. CONCLUSION Although younger and less frail, veteran patients undergoing GA for lower extremity revascularization had higher rates of postoperative ileus, pneumonia, deep wound infection, sepsis, and need for transfusion as compared to those undergoing NA. There was no significant difference in the rate of other major complications, myocardial infarction, death or LOS. After adjustment, only intraoperative transfusion remained statistically significant, likely reflecting longer and more complex cases for those that undergo general anesthesia rather than the effect of anesthetic choice itself.
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Affiliation(s)
- Sally Boyd
- Division of Vascular and Endovascular Surgery, Virginia Commonwealth University Health System, Richmond, VA; Division of Vascular and Endovascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA
| | - James M Dittman
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Wayne Tse
- Division of Vascular and Endovascular Surgery, Virginia Commonwealth University Health System, Richmond, VA; Division of Vascular and Endovascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA
| | - Kedar S Lavingia
- Division of Vascular and Endovascular Surgery, Virginia Commonwealth University Health System, Richmond, VA; Division of Vascular and Endovascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA; Virginia Commonwealth University School of Medicine, Richmond, VA.
| | - Michael F Amendola
- Division of Vascular and Endovascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA; Virginia Commonwealth University School of Medicine, Richmond, VA
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Bisgaard J, Torp-Pedersen C, Rasmussen BS, Houlind KC, Riddersholm SJ. Editor's Choice - Regional Versus General Anaesthesia in Peripheral Vascular Surgery: a Propensity Score Matched Nationwide Cohort Study of 17 359 Procedures in Denmark. Eur J Vasc Endovasc Surg 2021; 61:430-438. [PMID: 33358100 DOI: 10.1016/j.ejvs.2020.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 11/03/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Cardiopulmonary comorbidity is common in vascular surgery. General anaesthesia (GA) may impair perfusion and induce respiratory depression. Regional anaesthesia (RA), including neuraxial or peripheral nerve blocks, may therefore be associated with a better outcome. METHODS This was a nationwide retrospective cohort study. All open inguinal and infra-inguinal arterial surgical reconstructions from 2005 to 2017 were included. Data were extracted from national registries. Multivariable linear and logistic regression models and propensity score matching were used. The propensity score was derived by developing a model that predicted the probability that a given patient would receive GA based on age, comorbidity, anticoagulant medication, procedure type, and the urgency of surgery. Matching was performed in four groups based on American Society of Anesthesiologists' score I - II, score III - V, and gender. Outcome parameters included surgical and general complications (bleeding, thrombosis/embolus, cardiac, pulmonary, renal, cerebral, and >3 days intensive care therapy), length of stay, and 30 day mortality, hypothesising a better outcome after RA. RESULTS There were 10 509 procedures in the GA group and 6 850 in the RA group. After propensity score matching, 6 267 procedures were included in each group. Surgical and general complications were significantly more common after GA in both matched (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001) and unmatched analyses (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001). The 30 day mortality rate was significantly higher after GA, in matched and un matched analyses (3.1 vs. 2.4%, p = .019 and 4.1 vs. 2.4%, p < .001). There was no difference in length of stay. CONCLUSION RA may be associated with a better outcome, compared with GA, after open inguinal and infra-inguinal peripheral vascular surgery. In the clinical context when RA is not feasible, GA can still be considered safe.
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Affiliation(s)
- Jannie Bisgaard
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Bodil S Rasmussen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kim C Houlind
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
| | - Signe J Riddersholm
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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Roberts DJ, Nagpal SK, Kubelik D, Brandys T, Stelfox HT, Lalu MM, Forster AJ, McCartney CJ, McIsaac DI. Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study. BMJ 2020; 371:m4104. [PMID: 33239330 PMCID: PMC7687020 DOI: 10.1136/bmj.m4104] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery. DESIGN Comparative effectiveness study using linked, validated, population based databases. SETTING Ontario, Canada, 1 April 2002 to 31 March 2015. PARTICIPANTS 20 988 patients Ontario residents aged 18 years or older who underwent their first lower limb revascularisation surgery in hospitals performing 50 or more of these surgeries annually. MAIN OUTCOME MEASURES Primary outcome was 30 day all cause mortality. Secondary outcomes were in-hospital cardiopulmonary and renal complications, length of hospital stay, and 30 day readmissions. Multivariable, mixed effects regression models, adjusting for patient, procedural, and hospital characteristics, were used to estimate associations between anaesthetic technique and outcomes. Robustness of analyses were evaluated by conducting instrumental variable, propensity score matched, and survival sensitivity analyses. RESULTS Of 20 988 patients who underwent lower limb revascularisation surgery, 6453 (30.7%) received neuraxial anaesthesia and 14 535 (69.3%) received general anaesthesia. The percentage of neuraxial anaesthesia use ranged from 0.6% to 90.6% across included hospitals. Furthermore, use of neuraxial anaesthesia declined by 17% over the study period. Death within 30 days occurred in 204 (3.2%) patients who received neuraxial anaesthesia and 646 (4.4%) patients who received general anaesthesia. After multivariable, multilevel adjustment, use of neuraxial anaesthesia compared with use of general anaesthesia was associated with decreased 30 day mortality (absolute risk reduction 0.72%, 95% confidence interval 0.65% to 0.79%; odds ratio 0.68, 95% confidence interval 0.57 to 0.83; number needed to treat to prevent one death=139). A similar direction and magnitude of association was found in instrumental variable, propensity score matched, and survival analyses. Use of neuraxial anaesthesia compared with use of general anaesthesia was also associated with decreased in-hospital cardiopulmonary and renal complications (odds ratio 0.73, 0.63 to 0.85) and a reduced length of hospital stay (-0.5 days, -0.3 to-0.6 days). CONCLUSIONS Use of neuraxial anaesthesia compared with general anaesthesia for lower limb revascularisation surgery was associated with decreased 30 day mortality and hospital length of stay. These findings might have been related to reduced cardiopulmonary and renal complications after neuraxial anaesthesia and support the increased use of neuraxial anaesthesia in patients undergoing these surgeries until the results of a large, confirmatory randomised trial become available.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Dalibor Kubelik
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine and O'Brien Institute for Public Health University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Alan J Forster
- Department of Medicine, Ottawa Hospital, Ottawa, ON, Canada
| | - Colin Jl McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Effects of adding a combined femoral and sciatic nerve block with levobupivacaine and clonidine to general anaesthesia in femoropopliteal bypass surgery: A randomised, double-blind, controlled trial. Eur J Anaesthesiol 2020; 37:787-795. [PMID: 32769505 DOI: 10.1097/eja.0000000000001263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Adding a regional block to general anaesthesia can prevent postoperative pain and improve peripheral circulation. OBJECTIVE To seek improved postoperative analgesia and care due to a long-acting combined femoral and sciatic nerve block in patients undergoing femoropopliteal bypass surgery. DESIGN A randomised, double-blind, controlled trial. SETTING Vascular surgery unit of a French university hospital. PATIENTS Forty-four adults scheduled for bypass surgery under general anaesthesia. INTERVENTION Patients were allocated to receive either an active nerve block with 20 ml of 0.375% levobupivacaine and clonidine 0.5 μg kg, or a simulated (sham) block only, but with local anaesthesia of the skin, before general anaesthesia. General anaesthesia was standardised with propofol, then sevoflurane and sufentanil adjusted according to clinical need. Postoperative analgesia was standardised with paracetamol 1 g every 6 h, and intravenous morphine, initially titrated in the postanaesthesia care unit and then patient-controlled. Oral analgesics were repeated up to day 3. MAIN OUTCOME MEASURES The primary outcome was morphine consumption during the first 24 postoperative hours. In a subgroup of postoperative patients distal tissue oxygen saturation was recorded at the lateral side of the blocked calf. RESULTS Patients in the active group received less intra-operative sufentanil (median dose 25 vs. 41 μg), needed less morphine during the first 24 h (15 vs. 27 mg) and 72 (20 vs. 35 mg) postoperative hours, than in the control group. They also had less pain on movement, but pain at rest, the tissue oxygen saturation and other rehabilitation outcomes were unaffected by the treatment. Tolerance outcomes were also similar between groups. CONCLUSION Combining the two regional blocks improves the quality of postoperative care in this frail population, probably by reducing the amount of peri-operative opioid. TRIAL REGISTRATION ClinicalTrials.gov (ref. NCT01785693).
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Tsay C, Luo J, Zhang Y, Attaran R, Dardik A, Ochoa Chaar CI. Perioperative Outcomes of Lower Extremity Revascularization for Rest Pain and Tissue Loss. Ann Vasc Surg 2019; 66:493-501. [PMID: 31756416 DOI: 10.1016/j.avsg.2019.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the clinical manifestation of severe peripheral artery disease presenting as rest pain (RP) and tissue loss (TL). Most studies compare CLI as a homogenous group with claudication with limited database studies specifically studying these differences. We hypothesize that CLI should be stratified into RP and TL because of significant differences in disease severity, comorbidities, and outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 was reviewed. All patients with a postoperative diagnosis of CLI undergoing femoral to popliteal bypass (FPB) with vein or graft were identified. Patients were stratified into cohorts based on International Classification of Disease (ICD)-9 or ICD-10 codes for RP or TL (gangrene or ulcer). Univariate and multivariate analyses were performed to examine 30-day mortality, morbidity, major amputation, and readmission adjusting for demographics, comorbidities, and procedural details. RESULTS There were 5,304 patients. Compared to RP, patients with TL were older (P < 0.0001) and more likely to be dependent (P < 0.0001). TL patients were also more likely to have diabetes (P < 0.0001), congestive heart failure (P < 0.0001), renal failure (P = 0.004), dialysis (P < 0.0001), history of wound infection (P < 0.0001), and sepsis (P < 0.0001). TL patients had higher American Society of Anesthesiologists class (P < 0.0001), were less likely to be transferred from home (P < 0.0001), and more likely to receive an FPB with vein (P = 0.03). Patients with TL had worse perioperative outcomes compared with RP in terms of pneumonia (P = 0.004), unplanned intubation (P = 0.009), cardiac arrest requiring cardiopulmonary resuscitation (P = 0.003), bleeding requiring transfusions (P < 0.0001), sepsis (P < 0.0001), septic shock (P = 0.02), and reoperation (P < 0.0001). TL was associated with significantly higher 30-day morbidity (P < 0.0001), 30-day mortality (P < 0.0001), major amputation (P = 0.0004), and readmission rates (P = 0.005). Patients with TL compared with those with RP also had longer hospital stays (P < 0.0001) and days between operation to discharge (P < 0.0001). TL was independently associated with increased 30-day morbidity (OR: 1.16 [1.00-1.35]) and major amputation (OR: 2.48 [1.29-4.76]) compared with RP. CONCLUSIONS Patients with RP and TL have drastic differences that impact perioperative mortality and readmissions. TL is an independent predictor of 30-day morbidity and major amputation. The stratification of CLI into RP and TL can provide insight into variations in outcomes and provide a means to quantify the risks associated with the 2 manifestations of the disease.
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Affiliation(s)
- Cynthia Tsay
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jiajun Luo
- Department of Statistics, Yale School of Public Health, New Haven, CT
| | - Yawei Zhang
- Department of Statistics, Yale School of Public Health, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Robert Attaran
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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Fereydooni A, O'Meara T, Popescu WM, Dardik A, Ochoa Chaar CI. Use of neuraxial anesthesia for hybrid lower extremity revascularization is associated with reduced perioperative morbidity. J Vasc Surg 2019; 71:1296-1304.e7. [PMID: 31708304 DOI: 10.1016/j.jvs.2019.07.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/15/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recent advances in endovascular technology have allowed complex peripheral arterial disease (PAD) to be treated with less invasive hybrid procedures under neuraxial anesthesia. This study investigates the perioperative outcomes of hybrid lower extremity revascularization (LER) performed under neuraxial anesthesia (NAA) vs general anesthesia (GA). We hypothesize that the use of NAA is associated with improved outcomes. METHODS The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program dataset was used to identify patients who underwent hybrid LER for PAD. Based on the primary anesthetic technique, patients were divided into two groups: GA and NAA, which included spinal or epidural anesthesia. Baseline characteristics of the two groups were compared. A group of patients treated under GA were matched (2:1) to patients in the NAA group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease, wound infection, American Society of Anesthesiologists classification, emergent surgery, preoperative sepsis, indication, and type of hybrid procedure. Patient characteristics and 30-day outcomes were compared. RESULTS Of 9430 patients who underwent hybrid LER, only 452 (4.8%) received NAA. Patients who received NAA were older (mean age, 68 ± 8.4 vs 72.3 ± 9.2; P = .004) and were more likely to be white (70.9% vs 85.6%; P < .0001), have dependent functional status (7.6% vs 13.1%; P < .0001), chronic obstructive pulmonary disease (24.3% vs 17.5%; P = .001), and a diagnosis of wound infection (15% vs 23.5%; P < .0001). After propensity matching, 904 patients in the GA group were compared with 452 patients in the NAA group with no difference in baseline characteristics. NAA was associated with reduced rate of more than 48 hours' ventilator requirement (2.4% vs 0.2%; P = .0014), bleeding requiring transfusion (17.5% vs 8%; P < .0001), and overall morbidity (29.3% vs 19%; P < .0001), as well as shorter length of hospital stay (6.8 ± 9.3 vs 5.3 ± 6.1 days; P = .0026) and total operating time (237.8 ± 109 vs 202.4 ± 113 minutes; P < .0001) compared with GA. CONCLUSIONS NAA is an infrequently used anesthesia technique during hybrid LER and is primarily used for older patients with chronic obstructive pulmonary disease. NAA is associated with decreased perioperative morbidity and length of hospital stay compared with GA and may be considered in this sicker patient population.
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Affiliation(s)
| | | | - Wanda M Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
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Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:206-213. [DOI: 10.1016/j.ejvs.2019.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 03/09/2019] [Accepted: 03/16/2019] [Indexed: 11/18/2022]
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Utilization of regional versus general anesthesia and its impact on lower extremity bypass outcomes. J Vasc Surg 2019; 69:1874-1879. [PMID: 30792062 DOI: 10.1016/j.jvs.2018.08.190] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
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17
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Is Regional Anaesthesia During Bypass Surgery in High Risk Patients With Chronic Limb Threatening Ischaemia the Columbus Egg? Eur J Vasc Endovasc Surg 2019; 58:214. [PMID: 31085004 DOI: 10.1016/j.ejvs.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 11/24/2022]
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Xu R, Wang Z, Ren Z, Ma T, Jia Z, Fang S, Jin H. Comparative Study of the Effects of Customized 3D printed insole and Prefabricated Insole on Plantar Pressure and Comfort in Patients with Symptomatic Flatfoot. Med Sci Monit 2019; 25:3510-3519. [PMID: 31079137 PMCID: PMC6528551 DOI: 10.12659/msm.916975] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There are many shortcomings in traditional prefabricated rehabilitation insoles for symptomatic flatfoot patients. This study investigated the effects of customized 3-dimensional (3D) printed insoles on pressure and comfort of the plantar foot in symptomatic flatfoot patients. MATERIAL AND METHODS Eighty patients with bilateral flatfoot participated in this study. At week 0, patients were randomly assigned into 1 of 2 groups. In the control group, the patients wore standardize shoes with prefabricated insoles; and in the experimental group the patients wore standardize shoes and customized insoles. The Footscan® system recorded peak pressure, peak force, and peak contact area in 10 areas of the sole at weeks 0 and at week 8. Patients used visual analogue scale scores at week 0 and at week 8 to assess overall comfort of insoles. RESULTS At week 0, compared with the control group, the peak pressure in the metatarsal was significantly lower in the experimental group (P<0.05) while the peak pressure in the mid-foot was significantly higher than the control group (P<0.05). At week 8, in the experimental group, the peak pressures in the mid-foot were significantly higher than the control group (P<0.05). The comfort scores (measured by pain scale) reported by the experimental group were significantly lower than those reported by the control group (P<0.05). CONCLUSIONS Customized 3D printed insoles reduced the pressure on the metatarsals by distributed it over the mid-foot area, thus reduced the damage from symptomatic flatfoot. Customized 3D printed insoles were more effective than prefabricated insoles and offered better comfort for patients with symptomatic flatfoot.
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Affiliation(s)
- Rui Xu
- Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China (mainland)
| | - Zhonghan Wang
- Department of Orthopedics, The Second Hospital Of Jilin University, Changchun, Jilin, China (mainland)
| | - Zhenxiao Ren
- Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China (mainland)
| | - Tingjian Ma
- Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China (mainland)
| | - Zhe Jia
- Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China (mainland)
| | - Shuyan Fang
- Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China (mainland)
| | - Hui Jin
- Department of Pain, The Second Hospital of Jilin University, Changchun, Jilin, China (mainland)
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Beaulieu RJ, Locham S, Nejim B, Dakour-Aridi H, Woo K, Malas MB. General anesthesia is associated with reduced early failure among patients undergoing hemodialysis access. J Vasc Surg 2019; 69:890-897.e5. [DOI: 10.1016/j.jvs.2018.05.247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/30/2018] [Indexed: 01/19/2023]
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Malik OS, Brovman EY, Urman RD. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications. J Cardiothorac Vasc Anesth 2018; 33:935-942. [PMID: 30243870 DOI: 10.1053/j.jvca.2018.08.195] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Over 150,000 carotid endarterectomy (CEA) procedures are performed each year. Perioperative anesthetic management may be complex due to multiple patient and procedure-related risk factors. The authorsaimed to determine whether the use of general anesthesia (GA), when compared with regional anesthesia (RA), would be associated with reduced perioperative morbidity and mortality in patients undergoing a CEA. DESIGN Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SETTING The authors evaluated patients undergoing a CEA at multiple university- and community-based settings. PARTICIPANTS A total of 43,463 patients were identified; 22,845 patients were propensity matched after excluding for missing data. INTERVENTIONS The study population was divided into 2 groups: patients undergoing RA or GA. The RA group included regional anesthesia performed by the anesthesiologist or surgeon, monitored anesthesia care, and local infiltration. METHODS The primary endpoint was 30-day mortality. Secondary endpoints included surgical site infection, pulmonary complications, return to the operating room, acute kidney injury, cardiac arrest, urinary tract infection, myocardial infarction, thromboembolism, perioperative transfusion, sepsis, and days to discharge. MEASUREMENTS AND MAIN RESULTS Younger age, Hispanic ethnicity, body mass index <18.5, dyspnea, chronic obstructive pulmonary disease, and smoking history were associated with receiving GA. Patients with low hematocrit and low platelets were more likely to get RA. There was no mortality difference. GA was associated with a significantly higher rate of perioperative transfusions (p = 0.037) and perioperative pneumonia (p = 0.027). CONCLUSION The use of RA over GA in CEA is associated with decreased risk of postoperative pneumonia and a reduced need for perioperative blood transfusions.
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Affiliation(s)
- Obaid S Malik
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA.
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Reply to Drs Saxena and Loganathan. Reg Anesth Pain Med 2018; 43:647-648. [PMID: 30036319 DOI: 10.1097/aap.0000000000000841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Anesthesia for Lower Extremity Bypass. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery. Anesth Analg 2017; 125:1931-1945. [DOI: 10.1213/ane.0000000000002069] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Liu FL, Lin CS, Yeh CC, Shih CC, Cherng YG, Wu CH, Chen TL, Liao CC. Risk and outcomes of fracture in peripheral arterial disease patients: two nationwide cohort studies. Osteoporos Int 2017; 28:3123-3133. [PMID: 28821915 DOI: 10.1007/s00198-017-4192-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/07/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Using national insurance claims data of Taiwan, we found that patients with peripheral arterial disease (PAD) had increased risk of fracture during the follow-up period of 2000-2013. History of PAD was also associated with adverse outcomes in hospitalized fracture patients. Prevention strategies were needed in this susceptible population. INTRODUCTION Limited information was available on the association between PAD and fracture. The purpose of this study is to evaluate fracture risk and post-fracture outcomes in patients with PAD. METHODS We identified 6647 adults aged ≥ 20 years with newly diagnosed PAD using the Taiwan National Health Insurance Research Database in 2000-2004. Comparison cohort consisted of 26,588 adults without PAD randomly selected with frequency matching in age and sex. Events of fracture were identified during the follow-up period from January 1, 2000 until December 31, 2013, to evaluate adjusted hazard ratios (HR) and 95% confidence interval (CI) of fracture associated with PAD. Another nested cohort study of 799,463 hospitalized fracture patients analyzed adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture among patients with and without PAD in 2004-2013. RESULTS Incidences of fracture in people with and without PAD were 22.1 and 15.5 per 1000 person-years, respectively (P < .0001). Compared with control, the adjusted HR of fracture was 1.59 (95% CI, 1.48-1.69) for PAD patients. In the nested cohort study, patients with PAD had higher post-fracture mortality (OR = 1.16; 95% CI, 1.09-1.25) and various complications. PAD patients also had comparatively higher medical expenditure (2691 vs. 2232 USD, P < .0001) and longer hospital stay (10.6 vs. 9.0 days, P < 0.0001) during fracture admission. CONCLUSIONS Increased risk of fracture and post-fracture adverse outcomes were associated with PAD. This susceptible population needs care to prevent fracture and to minimize adverse outcomes after it occurs.
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Affiliation(s)
- F-L Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - C-S Lin
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - C-C Yeh
- Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - C-C Shih
- School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Y-G Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - C-H Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - T-L Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - C-C Liao
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei, 110, Taiwan.
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Valentine EA, Ochroch EA. 2016 American College of Cardiology/American Heart Association Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Perioperative Implications. J Cardiothorac Vasc Anesth 2017; 31:1543-1553. [PMID: 28826846 DOI: 10.1053/j.jvca.2017.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Ashrafi M, Salvadi R, Foden P, Thomas S, Baguneid M. Pre-operative predictors of poor outcomes in patients undergoing surgical lower extremity revascularisation - Retrospective cohort study. Int J Surg 2017; 41:91-96. [PMID: 28344160 DOI: 10.1016/j.ijsu.2017.03.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical lower extremity revascularisation (LER) can lead to poor outcomes that include delayed hospital discharge, in-hospital mortality, major amputations and readmissions. The aim of this study was to identify pre-operative predictors associated with these poor clinical outcomes. MATERIALS AND METHODS All patients (n = 635; mean age 69; male 67.4%) who underwent surgical LER over a 5 year period in a single tertiary vascular institution were identified. Patients considered to have suffered a poor outcome (Group A) included all in-hospital mortality and major amputations, delayed discharges with a length of stay (LOS) over one standard deviation above the mean or any readmission under any specialty within 12 months. Group A included 247 patients (38.9%) and the good outcome group included the remaining 388 patients (61.1%) from which a sample of 99 patients were selected as controls (Group B). RESULTS Mean LOS for the entire study group was 14.4 ± 17.5 days, 12 month readmission rate was 29.1% and in-hospital mortality and major amputation rate was 2.7% and 1.4%, respectively. Pre-admission residence other than own home (OR 9.0; 95% CI 1.2-70.1; P = 0.036), atherosclerotic disease burden (OR 2.2; 95% CI 1.3-3.8; P = 0.003) and tissue loss (OR 3.0; 95% CI 1.6-5.3; P < 0.001) were identified as independent, statistically significant pre-operative predictors of poor outcome. Following discharge, group B patients had a significantly higher rate of amputation free survival and graft infection free survival (P < 0.001) compared to group A. CONCLUSION Recognition of pre-operative predictors of poor outcome should inform case selection and identify high risk patients requiring intensive perioperative optimisation and post discharge follow up.
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Affiliation(s)
- Mohammed Ashrafi
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK
| | - Rohini Salvadi
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK
| | - Philip Foden
- Department of Medical Statistics, University Hospital of South Manchester, Manchester, UK
| | - Stephanie Thomas
- Department of Microbiology, University Hospital of South Manchester, Manchester, UK
| | - Mohamed Baguneid
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK.
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Fraser K, Raju I. Anaesthesia for lower limb revascularization surgery. BJA Educ 2015. [DOI: 10.1093/bjaed/mku042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Patients presenting for lower extremity revascularization often have multiple systemic comorbidities, making them high-risk surgical candidates. Neuraxial anesthesia and general anesthesia are equivocal in their effect on perioperative cardiac morbidity and improved graft patency. Postoperative epidural analgesia may improve perioperative cardiac morbidity. Systemic antithrombotic and anticoagulation therapy is common among this patient population and may affect anesthetic techniques.
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Affiliation(s)
- James M Anton
- St. Luke's Medical Group, CHI St. Luke's Health, 6720 Bertner Avenue, Room 0520, MC 1-226, Houston, TX 77030, USA; Division of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor St. Luke's Medical Center, 6720 Bertner Avenue, Room 0520, MC 1-226, Houston, TX 77030, USA.
| | - Marie LaPenta McHenry
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, USA
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31
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Singh S, Maldonado Y, Taylor MA. Optimal perioperative medical management of the vascular surgery patient. Anesthesiol Clin 2014; 32:615-637. [PMID: 25113724 DOI: 10.1016/j.anclin.2014.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. β-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.
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Affiliation(s)
- Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA.
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
| | - Mark A Taylor
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
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Abstract
Patients presenting for vascular surgery present a challenge to anesthesiologists because of their severe systemic comorbidities. Regional anesthesia has been used as a primary anesthetic technique for many vascular procedures to avoid the cardiovascular and pulmonary perturbations associated with general anesthesia. In this article the use of regional anesthesia for carotid endarterectomy, open and endovascular abdominal aortic aneurysm repair, infrainguinal arterial bypass, lower extremity amputation, and arteriovenous fistula formation is described. A focus is placed on reviewing the literature comparing anesthetic techniques, with brief descriptions of the techniques themselves.
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Affiliation(s)
- James Flaherty
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Jean-Louis Horn
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA
| | - Ryan Derby
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA
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Abstract
Patients undergoing vascular surgery present a myriad of perioperative challenges due to the complex comorbidities affecting them in conjunction with high-risk surgical procedures. Additionally, advances in endovascular technology have enabled surgical procedures to be performed on patients who would not have been considered surgical candidates in the past. This combination of increasing patient morbidity and evolving surgical technique requires a well-planned preoperative assessment and close communication with surgical and perioperative colleagues. This article outlines an appropriate approach by first considering each organ system, followed by review of considerations unique to various surgical procedures, and then an overall assessment of risk.
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O'Brien PJ, Cox MW, Shortell CK, Scarborough JE. Risk Factors for Early Failure of Surgical Amputations: An Analysis of 8,878 Isolated Lower Extremity Amputation Procedures. J Am Coll Surg 2013; 216:836-42; discussion 842-4. [DOI: 10.1016/j.jamcollsurg.2012.12.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
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