Regional Anaesthesia Alone is Reasonable for Major Lower Extremity Amputation in High Risk Patients and May Initiate a More Efficacious Enhanced Recovery Programme

Major limb amputations are physiologically stressful and subject patients to peri-operative cardiovascular risk. Up to 90% of major lower extremity amputations (LEAMP) are being performed under general anaesthesia, despite regional anaesthesia being an acceptable option in most cases. Obtaining a better understanding of who would benefit from regional vs. general anaesthesia could reduce complications and help establish best evidence based practice. It was hypothesised that patients undergoing LEAMP with regional anaesthesia would have better post-operative outcomes than patients receiving general anaesthesia.

This retrospective cohort study used the U.S. Vascular Quality Initiative lower extremity amputation module to identify patients (≥18 years) who underwent LEAMP from 2013 to 2018. Outcomes included 30 day incidence of major adverse cardiac events (MACE) and all cause mortality. Multivariable logistic regression models were used to compute odds ratios (OR) and 95% confidence intervals (CI). Time to death was analysed using standard survival analysis.

The final sample included 5 567 patients (median age: 65 years, 67% white, 65% male). Only 719 (13%) of patients received regional anaesthesia. Compared with patients undergoing general anaesthesia, patients in the regional group were older (67 vs. 65 years, p < .001) and more likely to have diabetes (78% vs. 69%; p < .001), end stage renal disease (26% vs. 18%; p < .001), congestive heart failure (33% vs. 27%; p < .01) and coronary artery disease (35% vs. 30%; p < .01). The overall incidence of MACE, death, and MACE or death was 5%, 6%, and 9%, respectively. There was no statistically significant difference by anaesthesia groups for MACE (OR 0.98, 95% CI 0.69-1.39) or mortality (HR 1.03, 95% CI 0.90-1.17).

There was no difference in outcomes between regional or general anaesthesia techniques in patients undergoing LEAMP, despite the regional group having more comorbidities. Regional anaesthesia may be under used for high risk patients undergoing LEAMP. Further studies are needed to establish best practices in LEAMP procedures.