A Systematic Review and Meta-analysis of General versus Regional Anesthesia for Lower Extremity Amputation

The impact of anesthesia methods on postoperative outcomes of lower limb surgeries in elderly patients over 90 years old: A multicenter propensity-matched study

PURPOSE

This study aimed to assess the impact of different anesthesia methods on postoperative outcomes of lower limb surgeries in elderly patients over 90 years old.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of elderly patients over 90 years old who underwent lower limb surgeries at Chongqing University Center Hospital, the Affiliated Hospital of Southwest Medical University, and Chongqing General Hospital from January 2012 to December 2022. The patients were categorized into two groups based on the anesthesia method employed: the general anesthesia (GA) group and the regional anesthesia (RA) group. To minimize potential confounding, propensity score matching (PSM) was conducted in a 1:1 ratio with the caliper value set as 0.1; additionally, further univariable logistic regression was employed to compare the risk of postoperative complications and mortality between the GA and RA groups.

RESULTS

A total of 560 patients were included in our analysis, with 363 cases receiving general anesthesia (GA) and 197 cases receiving regional anesthesia (RA). After conducting propensity score matching (PSM), 139 pairs of data were successfully matched. Compared with the RA group, the GA group had a higher risk of postoperative complications (32.4% vs. 19.4%;OR,1.99; 95% CI, 1.15-3.44; p = 0.015), a higher risk of postoperative ICU admission (44.6% vs. 20.9%;OR,3.05; 95% CI,1.80-5.18;p < 0.001), but a lower risk of intraoperative blood transfusion (46% vs. 59%;OR,0.59; 95% CI,0.37-0.95;P = 0.031).No statistically significant differences were observed in other perioperative indices between the two groups.

CONCLUSION

In elderly patients over 90 years old undergoing lower limb fracture surgeries, GA is associated with a higher risk of postoperative complications and ICU admission compared to RA. Furthermore, compared with RA, GA is associated with a decreased need for intraoperative blood transfusion.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2400083103, principal investigator: Hong Fu, 14/04/2024).

Use of natural language processing method to identify regional anesthesia from clinical notes

INTRODUCTION

Accurate data capture is integral for research and quality improvement efforts. Unfortunately, limited guidance for defining and documenting regional anesthesia has resulted in wide variation in documentation practices, even within individual hospitals, which can lead to missing and inaccurate data. This cross-sectional study sought to evaluate the performance of a natural language processing (NLP)-based algorithm developed to identify regional anesthesia within unstructured clinical notes.

METHODS

We obtained postoperative clinical notes for all patients undergoing elective non-cardiac surgery with general anesthesia at one of six Veterans Health Administration hospitals in California between January 1, 2017, and December 31, 2022. After developing and executing our algorithm, we compared our results to a frequently used referent, the Corporate Data Warehouse structured data, to assess the completeness and accuracy of the currently available data. Measures of agreement included sensitivity, positive predictive value, false negative rate, and accuracy.

RESULTS

We identified 27,713 procedures, of which 9310 (33.6%) received regional anesthesia. 96.6% of all referent regional anesthesia cases were identified in the clinic notes with a very low false negative rate and good accuracy (false negative rate=0.8%, accuracy=82.5%). Surprisingly, the clinic notes documented more than two times the number of regional anesthesia cases that were documented in the referent (algorithm n=9154 vs referent n=4606).

DISCUSSION

While our algorithm identified nearly all regional anesthesia cases from the referent, it also identified more than two times as many regional anesthesia cases as the referent, raising concerns about the accuracy and completeness of regional anesthesia documentation in administrative and clinical databases. We found that NLP was a promising alternative for identifying clinical information when existing databases lack complete documentation.

Anesthetic Management With Peripheral Nerve Blocks and Sedation for Popliteal Artery Aneurysm Repair in a Patient With Severe Pulmonary Dysfunction: A Case Report

Postoperative pulmonary complications (PPCs), such as pneumonia, atelectasis, and respiratory failure, pose a significant challenge, particularly in patients with compromised respiratory function. Regional anesthesia is well-known for its numerous advantages, including its effectiveness in mitigating PPCs by circumventing the need for general anesthesia and intubation. A 79-year-old man with no significant medical history other than chronic obstructive pulmonary disease presented with left lower limb swelling, gait disturbance, and cold sensation. Computed tomography revealed a 5 cm left popliteal artery aneurysm, which was diagnosed as the cause of the patient's symptoms. He underwent popliteal artery aneurysm repair using peripheral nerve blocks (PNBs) and sedation. Sciatic, femoral, and obturator nerve blocks with 0.25% levobupivacaine provided effective analgesia. Despite intraoperative challenges, such as elevated partial pressure of carbon dioxide (PaCO2) and prolonged operative time due to vascular reconstruction revisions, the patient remained hemodynamically stable throughout the procedure, and PNBs allowed the preservation of spontaneous respiration. The patient was discharged on postoperative day 15 without pneumonia or respiratory failure. This case underscores the utility of PNBs and sedation in mitigating PPCs like pneumonia.

Regional Anesthesia is Associated with Improved Mortality and Morbidity in Patients with Congestive Heart Failure Undergoing Lower Extremity Amputation

BACKGROUND

While existing literature reports variable results of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing lower extremity amputation (LEA), the effect of RA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this vulnerable population.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program files between 2005 and 2022, all patients receiving LEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. The association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis.

RESULTS

A total of 5,831 patients (4,779 undergoing GA, 1,052 undergoing RA) with a diagnosis of CHF undergoing LEA were identified. On multivariable logistic regression analysis, RA was associated with lower mortality (adjusted odds ratio [aOR] 0.79, 95% CI 0.65-0.97), pneumonia (aOR 0.76, 95% CI 0.58-0.99), septic shock (aOR 0.64, 95% CI 0.47-0.88), post-operative blood transfusion (aOR 0.82, 95% CI 0.70-0.97), and 30-day readmission (aOR 0.79, 95% CI 0.64-0.97).

CONCLUSIONS

This study demonstrates that RA for LEA in patients with CHF is associated with decreased morbidity and mortality compared to GA. While furthermore research is needed to confirm this association, RA should be at least considered in CHF patients undergoing LEA when feasible.

Peripheral nerve blocks for through-knee amputation in a patient on extracorporeal membrane oxygenation

A woman in her 40s with an ischaemic right lower limb, who was on extracorporeal membrane oxygenation (ECMO) following cardiopulmonary failure secondary to bilateral alveolar haemorrhage, was scheduled for through-knee amputation. She was under mechanical ventilation and continuous intravenous medications. Considering her significant comorbidities, peripheral nerve blocks were chosen for anaesthesia. Ultrasound-guided traditional nerve blockade techniques of the femoral and sciatic nerves were not possible because of the presence of an ECMO cannula, altered anatomy following previous surgery on the same side and inability to turn the patient to a lateral position. An ultrasound-guided trans fascia iliaca for femoral and anterior approach for sciatic were rather used to accomplish the nerve blockades. Surgery completed without any complications and with reduced postoperative outcomes such as opioid consumption, other morbidities and mortality. This report is unique as the literature on peripheral nerve block approaches for lower limb amputations in ECMO patients is sparse.

A patient with acute myocardial infarction with acute lower extremity arterial embolization underwent amputation under general anesthesia

INTRODUCTION

Acute peripheral and coronary artery embolism are common complications of diabetes mellitus and greatly affect the clinical outcome of patients with diabetes; however, there are few reports about the symptoms and prognosis of patients with acute myocardial infarction (AMI) and concurrent acute lower extremity arterial embolism (ALEAE).

CASE PRESENTATION

A 44-year-old man with a history of 4 years of type 1 diabetes was admitted to hospital after suddenly experiencing severe pain in his right lower limb and feeling tightness in the left anterior chest area. Ultrasonography revealed distal occlusion of the right superficial femoral artery, and an electrocardiogram showed acute anterior interstitial myocardial infarction. After conservative treatment for 2 days, the patient had severe necrosis of the lower limbs and secondary injury of multiple organs. Haemodialysis and heparin anticoagulant therapy were performed before amputation. Twelve days after the operation, the patient's condition was stable, and he was transferred out of the intensive care unit.

CONCLUSIONS

If patients with ALEAE miss the opportunity for early treatment, even with AMI, emergency amputation under general anaesthesia is the right strategy to save lives.