Society For Clinical Vascular Surgery

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Impact of Mode of Anesthesia on Lower Extremity Major Amputation
SUNGHO LIM, John Andre, MD, Yaeji Park, MS MPH, Pegge M. Halandras, MD, Carlos Bechara, MD, Bernadette Aulivola, MD, Paul R. Crisostomo, MD.

Objective: General anesthesia (GA) poses numerous deleterious cardiovascular effects including respiratory depression, decreased myocardial contractility, and dysrhythmia. Although regional anesthesia mitigates these disadvantages, numerous meta-analyses fail to demonstrate improved mortality. It remains unknown whether a high risk vascular surgical amputation cohort may benefit from RA. The aim of this study is to investigate postoperative outcomes of regional vs general anesthesia during major limb amputation.Methods: The American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP) between 2005 and 2012 was queried using Current Procedural Terminology (CPT) codes indicating above knee amputation (AKA) and below knee amputation (BKA). Baseline characteristics were reviewed and propensity score matching was used to balance co-morbidities between RA and GA. Operative variables and postoperative complications were compared between the groups. Results: A total of 15,932 major lower extremity amputations were identified from the database. Using baseline characteristics, propensity score matching was performed to minimize patient selection bias. Operative outcomes were similar in both groups. Thirty-day mortality (8.5% vs 8.4%, p=0.86), postoperative myocardial infarction (1.6% vs 1.9%, p=0.50), and postoperative stroke (0.6% vs 0.8%, p=0.55) were comparable. Rate of prolonged ventilator dependency (>48 hours) was higher in GA. Recursive partitioning analysis was performed and identified four variables associated with prolonged intubation after major amputation. Reintubation has the highest importance (41.3) followed by preoperative ventilator dependency (24.0), prolonged hospitalization (11.3), and history of COPD (4.7).Conclusions: GA demonstrated similar postoperative cardiovascular, cerebrovascular, and wound related outcomes compared to RA. However, patients with pre-existing pulmonary comorbidities may benefit from RA.

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