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Anesthesia type for major lower extremity amputation in frail elderly patients does not affect outcomes
Carla C. Moreira, M.D., Denis Rybin, Alik Farber, M.D., Jeffrey A. Kalish, M.D., Mohammad H. Eslami, M.D., Sebastian Didato, M.D., Jeffrey J. Siracuse, M.D..
Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.
Objective:
The purpose of this study was to determine the impact of anesthesia type; general anesthesia (GA) and regional/spinal (RA), on outcomes after lower extremity amputation in frail elderly patients.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2005-2012) was queried to identify all patients ages greater than 75 years-old with partial or total functional impairment who underwent major lower extremity amputations with use of GA or RA. To ensure comparability of the groups we used 2:1 propensity matching based on clinically important and significantly different at 0.2 level factors and multivariable analyses adjusting for the same factors.
Results:
There were 3260 patients identified - 702 RA and 2558 GA. The mean age was 82 and 50% were male. Anatomical distribution was 59% above the knee (AKA) and 41% below the knee (BKA). Patients undergoing GA were more likely to have impaired sensorium (9% vs. 6%, P=.035), be on anticoagulation or have a bleeding disorder (33% vs. 17%, P<.01), have had a previous operation within 30 days (16% vs. 10%, P<.01), and were more likely to be operated on by a general surgeon (16% vs. 12%, P=.03). Age and other comorbidities were similar. Propensity matching showed that RA was associated with longer anesthesia time to surgery (41±31 min vs. 36 ±34 min, P<.01), however there was no difference in operative time (63.2±31 min vs. 64.8±33 min). There was no difference in complications between GA and RA - specifically 30-day mortality (14.4% vs. 11.7%, P=0.14), postoperative myocardial infarction (MI) (2.9% vs. 3.1%, P=08), pulmonary complications (7.3% vs. 6.7%, P=0.6), stroke (0.7% vs. 0.9%, P=0.7), UTI (6.7% vs. 6.5%, P=.9), and wound complications (7.6% vs. 7.6%, P=0.75). Median length of stay for both groups was 5 days. Multivariate analysis of complications and 30-day mortality confirmed that anesthesia type was not an independent risk factor.
Conclusions:
The mode of anesthesia, general vs. regional/spinal, was not found to be associated with perioperative outcomes following major lower extremity amputation in the frail geriatric population. GA can safely be used in this high risk patient population.
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