Comparison of the effects of remifentanil-based general anesthesia and popliteal nerve block on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation: A retrospective observational study

Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.

Pain management in the postoperative period of amputation surgeries: A scoping review

BACKGROUND

Pain in the postoperative period of amputation surgeries, when not managed correctly, can have consequences for the patient.

PURPOSES AND OBJECTIVES

The aim of this study was to map the scientific evidence on pain management in patients in the postoperative period of amputation surgeries.

DESIGN

Scoping review with elaboration based on the recommendations of the Joanna Briggs Institute, supported by The PAGER framework and guided by the PRISMA-ScR Checklist.

METHODS

The survey was conducted in August 2022 in 10 data sources. The 3300 publications found were analysed by two independent reviewers, after applying inclusion and exclusion criteria, 16 studies were selected.

RESULTS

Publications occurred between the years 1997 and 2022 and mainly dealt with the management of residual pain and phantom limb through pharmacological measures with pain assessment made by numerical scales.

CONCLUSIONS

The literature pointed out strategic uses of analgesics and highlighted technologies for neurostimulation through catheters. The need for new studies with non-pharmacological measures and with designs that can prove their effectiveness is reinforced.

RELEVANCE TO CLINICAL PRACTICE

The knowledge of these strategies by health professionals allows adequate pain management and patient follow-up for a less traumatic recovery.

PATIENT OR PUBLIC CONTRIBUTION

To patient or public involvement in this scoping review.

General Anesthesia With Remimazolam and Peripheral Nerve Blocks Is Useful for Femoral Surgery in Patients With Severe Aortic Stenosis: A Case Report

Traditional intravenous anesthetics and opioid analgesics are susceptible to inducing hemodynamic instability. Herein, we describe a case of open reduction and internal fixation of a femoral neck fracture in a patient with severe aortic stenosis. General anesthesia was accomplished using remimazolam, an intravenous anesthetic devoid of hemodynamic instability properties, in combination with a peripheral nerve block. During the surgical procedure, the need for circulatory agonist was reduced to a single dose, and satisfactory pain management was achieved. This approach represents an alternative method for patients with circulatory risk undergoing femoral surgery.

Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide

BACKGROUND

Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear.

METHODS

To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved.

RESULTS

A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future.

CONCLUSION

This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.

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

OBJECTIVE

Postoperative morbidity in patients undergoing lower extremity amputation (LEA) has remained high. Studies investigating the influence of the anesthetic modality on the postoperative outcomes have yielded conflicting results. The aim of our study was to assess the effects of regional anesthesia vs general anesthesia on postoperative complications for patients undergoing LEA.

METHODS

We systematically searched PubMed, Embase, MEDLINE, Web of Science, and Google Scholar from 1990 to 2022 for studies investigating the effect of the anesthetic modality on the postoperative outcomes after LEA. Regional anesthesia (RA) included neuraxial anesthesia and peripheral nerve blocks. The outcomes included 30-day mortality, respiratory failure (unplanned postoperative intubation, failure to wean, mechanical ventilation >24 hours), surgical site infection, cardiac complications, urinary tract infection, renal failure, sepsis, venous thrombosis, pneumonia, and myocardial infarction.

RESULTS

Of the 25 studies identified, we included 10 retrospective observational studies with 81,736 patients, of whom 69,754 (85.3%) had received general anesthesia (GA) and 11,980 (14.7%) had received RA. In the GA group, 50,468 patients were men (63.8%), and in the RA group, 7813 patients were men (62.3%). The results of the meta-analyses revealed that GA was associated with a higher rate of respiratory failure (odds ratio, 1.38; 95% confidence interval, 1.06-1.80; P = .02) and sepsis (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; P < .0001) compared with RA. No differences were found in postoperative 30-day mortality, surgical site infection, cardiac complications, urinary tract infection, renal failure, venous thrombosis, pneumonia, and myocardial infarction between the GA and RA groups.

CONCLUSIONS

The results of our meta-analysis have shown that GA could be associated with a higher rate of respiratory failure and sepsis compared with RA for LEA.

Chan D, Y. Liu C. Effects of regional anaesthesia on mortality in patients undergoing lower extremity amputation: A retrospective pooled analysis

Background and Aims:

Lower extremity amputation (LEA) is a commonly performed surgery and is associated with significant mortality and morbidity. This review compares the impact of anaesthetic technique on 30-day mortality and other perioperative outcomes in patients undergoing LEA.

Methods:

A systematic search of databases including PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials, from January 2010 to March 2021, was performed. Studies were eligible if they compared 30-day mortality following either general anaesthesia (GA) or regional anaesthesia (RA), in adult patients undergoing LEA.

Results:

Ten retrospective observational studies were identified. Four of these studies utilised a propensity-score matching technique. Based on these four studies, RA when compared to GA, is not associated with a reduction in the 30-day mortality (Odds ratio 0.83, 95% confidence interval (CI): 0.65, 1.05, I² 20%, P = 0.12). Also there is a very low level of evidence that RA may result in a decrease in the hospital length-of-stay and intensive care unit admissions of patients undergoing LEA.

Conclusion:

RA does not decrease the 30-day postoperative mortality in patients undergoing LEA when compared to GA.

Effects of Anesthetic Techniques on the Risk of Postoperative Complications Following Lower Extremity Amputation in Diabetes Patients with Coagulation Abnormalities: A Retrospective Cohort Study Using Propensity Score Analysis

Diabetic foot amputation is associated with high morbidity and mortality rates. To prevent cardiovascular complications along with vasculopathy in the course of diabetes mellitus, a high number of patients receive anticoagulant therapy. However, anticoagulants are contraindicated in neuraxial anesthesia limiting available anesthetic modalities. Therefore, in this retrospective study, we aimed to compare between general anesthesia and peripheral nerve block (PNB) with respect to postoperative complications following lower extremity amputation (LEA) in patients with coagulation abnormalities. In total, 320 adult patients who underwent LEA for diabetic foot were divided into two groups according to the anesthetic type (general anesthesia vs. PNB). The inverse probability of treatment weighting was performed to balance the baseline patient characteristics and surgical risk between the two groups. The adjusted analysis showed that compared with the general anesthesia group, the PNB group had lower risks of pneumonia (odds ratio: 0.091, 95% confidence interval [CI]: 0.010-0.850, p = 0.0355), acute kidney injury (odds ratio: 0.078, 95% CI: 0.007-0.871, p = 0.0382), and total major complications (odds ratio: 0.603, 95% CI: 0.400-0.910, p = 0.0161). Additionally, general anesthesia was associated with a higher amount of intraoperative crystalloid administration and a requirement for more frequent vasopressors. In conclusion, PNB appears to be protective against complications following LEA in diabetes patients with coagulopathy.

Successful use of ultrasound-guided peripheral nerve block for lower limb surgery in a patient with heart failure with reduced ejection fraction: a case report

The number of patients with heart failure with reduced ejection fraction (HFrEF) is increasing. These patients have a reduced cardiorespiratory reserve. Therefore, preoperative evaluation is essential to determine the best type of anaesthesia to use in patients with HFrEF. A 70-year-old man with HFrEF was scheduled to undergo debridement of skin necrosis due to thrombotic occlusion of the right common iliac artery. He had undergone wound dressing changes under local anaesthesia every other day for several months, and treatment for heart failure was on-going. A sciatic nerve and fascia iliaca compartment block was performed under ultrasound guidance because of the patient’s cardiopulmonary function. After confirming adequate sensory blockage, surgery was performed without any haemodynamic instability or complications. Thereafter, debridement was performed twice more using the same block technique, and a skin autograft was also successfully performed. We successfully performed an ultrasound-guided sciatic nerve and fascia iliaca compartment block in a patient with HFrEF who was scheduled to undergo lower limb surgery. Peripheral nerve block is an alternative option for patients with HFrEF.

Infrainguinal bypass under triple nerve block in patients with severely compromised left ventricular ejection fraction and chronic limb-threatening ischemia

A severely compromised left ventricular ejection fraction (LVEF) is a major limitation for lower extremity bypass reconstruction both under general anesthesia or neuraxial anesthesia (NA). A series of eight infrainguinal bypass procedures were performed under peripheral nerve block in five patients (three males and two females; median age, 67 years) with chronic limb-threatening ischemia and a preoperative LVEF of 35% or less (median, 27%; range, 20%-35%). There were no conversions to neuraxial anesthesia/general anesthesia or early postoperative complications. This study showed that open infrainguinal reconstructions can be performed safely under peripheral nerve blockade in this vulnerable category of patients.

Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation

BACKGROUND

Despite progress in perioperative care standards, there has not been a significant risk reduction in morbidity and mortality rates of lower extremity amputations, an intermediate risk surgery performed on high risk patients. The single-shot peripheral nerve block has shown equivocal impact on postoperative course following lower extremity amputation. Hence, we assessed the potential of preemptive use of continuous catheter-based peripheral nerve block in lower extremity amputations for reduction in pulmonary complications, acute post-operative pain scores, and opioid use in post-operative period.

METHODS

A retrospective review of a quality improvement project initiated in 2018 was conducted to compare outcomes amongst general anesthesia in combination with a catheter-based peripheral nerve block (catheter group) and general anesthesia alone in patients receiving lower extremity amputation. The rate of postoperative pulmonary complications was identified as a primary endpoint. The secondary outcomes assessed were acute post-operative pain scores and opioid consumption up to 48 hours. Our analysis was adjusted for potential confounding variables inclusive of demographics, medical comorbidities, type of surgical procedure and smoking status.

RESULTS

Ninety-six patients were included in the study (61 in the general anesthesia group, 35 in the catheter group). After adjusting for baseline demographics, comorbidities, surgical technique and smoking status, the odds of postoperative pulmonary complications were significantly lower with catheter-based peripheral nerve block in comparison to general anesthesia alone, OR 0.11 [95% CI, 0.01- 0.88] (P = 0.048). The decrease in acute pain scores was also observed in the catheter group when compared to general anesthesia alone, OR 0.72 [95% CI, 0.56 - 0.93] (P = 0.012). Similarly, the opioid consumption was also lower in the catheter group in comparison to general anesthesia alone, OR 0.97 [95% CI, 0.95 - 0.99] (P = 0.025).

CONCLUSION

Preemptive use of continuous peripheral nerve block in patients undergoing lower extremity amputation reduces the incidence of pulmonary complications, acute postoperative pain scores and narcotic use in post-operative period.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Peripheral nerve block combined with general anesthesia for lower extremity amputation in hemodialysis patients: case series

Background

Anesthetic management of lower extremity amputation in chronic hemodialysis (HD) patients can be challenging because of their poor cardiovascular status. As previously reported, peripheral nerve block (PNB) may be beneficial in these complicated cases. We report the effects of PNB combined with general anesthesia on hemodynamic stability in HD patients undergoing elective lower extremity amputation.

Methods

We retrospectively analyzed 13 HD patients who underwent lower extremity amputation. Patients received general anesthesia (GA group, n = 7) or general anesthesia combined with PNB (GA with PNB group, n = 6), as decided by the anesthesiologists. Mean blood pressure (MBP), systolic blood pressure (SBP), lowest BP, heart rate (HR), blood loss, fluid and blood infusion volumes, and doses of vasopressors required were compared for hemodynamic assessment. The coefficient of variation (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \mathrm{CV}=\upsigma /\overline{\mathcal{X}} $$\end{document}CV=σ/X¯) of MBP (CV_MBP) and SBP (CV_SBP) was calculated to compare hemodynamic stability. Intraoperative opioid use and postoperative pain scores at rest using a numerical rating scale (NRS) on postoperative days 0 and 1 were compared for pain assessment. We also assessed 30-day mortality.

Results

CV_MBP in the GA group was significantly higher than that in the GA with PNB group (0.15 ± 0.05 and 0.08 ± 0.04, respectively, p = 0.03). The CV_SBP in the GA group was also significantly higher than that in the GA with PNB group (0.16 ± 0.02 and 0.09 ± 0.01, respectively, p = 0.03). No significant differences in other hemodynamic parameters were observed. Intraoperative fentanyl doses were significantly lower in the GA with PNB group (GA 210.7 ± 99.9 μg vs. GA with PNB 113.0 ± 75.6 μg, p = 0.04). There were no significant differences in other pain parameters and 30-day mortality between the groups.

Conclusion

Our results suggest that PNB combined with general anesthesia contributes to intraoperative hemodynamic stability through better pain control in HD patients undergoing lower extremity amputation.