Successful Management of above Knee Amputation with Combined and Modified Nerve Blocks

The Perioperative Challenges of Major Lower Extremity Amputation and the Impact of Regional Anesthesia on Morbidity, Mortality, and Pain Management: A Narrative Review

Limb amputation can impose severe burdens on the individual and society. Regardless of the underlying cause of amputation, pain management is challenging and may impact patients' recovery and quality of life. Individuals undergoing major lower extremity amputation (MLEA) face significant perioperative risk. Therefore, anesthesiologists must meticulously customize their anesthetic approach. Regional anesthesia (RA) provides numerous physiological advantages over general anesthesia (GA) and is essential for pain management in orthopedic surgeries, standing as an excellent anesthesia method for high-risk patients and being fundamental in multimodal analgesia. This narrative review is an attempt to enhance understanding of different pain phenomena following limb amputation and to provide a critical synthesis of the existing evidence concerning the efficacy and impact of RA on morbidity, mortality, and pain management following MLEA, aiming to shed light on areas that have not received enough attention within these aspects and subsequently serve as a guide for future research. Despite the persistent controversy regarding the comparative mortality rates associated with RA versus alternative anesthetic methods for MLEA, several studies praise their efficacy in pain management and in mitigating adverse perioperative outcomes. Given that much of this data originates from retrospective studies, randomized multicenter prospective trials remain essential to validate their actual efficacy. A comprehensive analysis of the impact of RA on healthcare costs and resources related to MLEA is necessary to determine its correlation with cost reduction, decreased hospital stays, improved resource allocation, and increased patient satisfaction.

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.

Ultrasound-Guided peripheral nerve blocks for major amputation in critically ill patients with peripheral artery disease

OBJECTIVE

The aim of this study was to assess the safety and efficacy of major amputation under ultrasound-guided peripheral nerve blocks in critical peripheral artery disease (PAD) patients.

METHODS

We reviewed the medical records of consecutive patients who underwent major amputation at our center between December 2012 and December 2020. The patients' baseline demographics and comorbidities were collected. The primary outcomes were 30-day and 12-month mortality. The secondary outcomes were intraoperative events, complications and intensive care unit (ICU) admission.

RESULTS

Fifteen patients classified as American Society of Anesthesiologist (ASA) III and 13 ASA IV (mean age: 76.07 ± 11.78 years) were included in the study. These patients were critically ill and had many comorbidities, such as coronary artery disease. All amputations were successfully performed under ultrasound-guided PNB without conversion to GA, but intravenous analgesia was given in 7 patients during the operation. The majority of the patients had stable hemodynamics except for 2 patients who had hypoxia, so none of the patients were transferred to the ICU postoperatively. None of the patients suffered from acute cardio-cerebral events. However, 5 patients had wound infections, and 4 of 5 patients had to receive reamputation. None of the patients died within 48 h after amputation. However, the 30-day mortality was 3.57%, and the 12-month mortality was up to 35.71%.

CONCLUSION

This study demonstrates that major amputation could be safely and effectively performed under ultrasound-guided peripheral nerve blocks for critically ill patients, and ultrasound-guided peripheral nerve blocks could be an alternative for patients at high risk of general anesthesia or spinal anesthesia.

Ultrasound-guided femoral and sciatic nerve block as an option for below-knee amputation in an elderly patient: A case report

Peripheral nerve blocks can be a very safe option in elderlypatients with multiple comorbidities where spinal or general anesthesia may be associated with increased risks. We present a 67 years male taking antiplatelet drugs with deranged coagulation profile with bilateral pneumonia with diabetic foot with wet gangrene planned for emergency below knee amputation under ultrasound guided femoral and sciatic nerve block.