Ghanami Racheed J, Hurie Justin, Andrews Jeanette S, Harrington Robert N, Corriere Matthew A, Goodney Philip P, Hansen Kimberley J, Edwards Matthew S
Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
Ann Vasc Surg. 2013 Feb;27(2):199-207. doi: 10.1016/j.avsg.2012.04.006. Epub 2012 Sep 1.
This report examines the effects of regional versus general anesthesia for infrainguinal bypass procedures performed in the treatment of critical limb ischemia (CLI).
Nonemergent infrainguinal bypass procedures for CLI (defined as rest pain or tissue loss) were identified using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program database using International Classification of Disease, ninth edition, and Current Procedure Terminology codes. Patients were classified according to National Surgical Quality Improvement Program data as receiving either general anesthesia or regional anesthesia. The regional anesthesia group included those specified as having regional, spinal, or epidural anesthesia. Demographic, medical, risk factor, operative, and outcomes data were abstracted for the study sample. Individual outcomes were evaluated according to the following morbidity categories: wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, and operative. Length of stay, total morbidity, and mortality were also evaluated. Associations between anesthesia types and outcomes were evaluated using linear or logistic regression.
A total of 5,462 inpatient hospital visits involving infrainguinal bypasses for CLI were identified. Mean patient age was 69 ± 12 years; 69% were Caucasian; and 39% were female. In all, 4,768 procedures were performed using general anesthesia and 694 with regional anesthesia. Patients receiving general anesthesia were younger and significantly more likely to have a history of smoking, previous lower-extremity bypass, previous amputation, previous stroke, and a history of a bleeding diathesis including the use of warfarin. Patients receiving regional anesthesia had a higher prevalence of chronic obstructive pulmonary disease. Tibial-level bypasses were performed in 51% of procedures, whereas 49% of procedures were popliteal-level bypasses. Cases performed using general anesthesia demonstrated a higher rate of resident involvement, need for blood transfusion, and operative time. There was no difference in the rate of popliteal-level and infrapopliteal-level bypasses between groups. Infrapopliteal bypass procedures performed using general anesthesia were more likely to involve prosthetic grafts and composite vein. Mortality occurred in 157 patients (3%). The overall morbidity rate was 37%. Mean and median lengths of stay were 7.5 days (± 8.1) and 6.0 days (Q1: 4.0, Q3: 8.0), respectively. Multivariate analyses demonstrated no significant differences by anesthesia type in the incidence of morbidity, mortality, or length of stay.
These results provide no evidence to support the systematic avoidance of general anesthesia for lower-extremity bypass procedures. These data suggest that anesthetic choice should be governed by local expertise and practice patterns.
本报告探讨了区域麻醉与全身麻醉对治疗严重肢体缺血（CLI）的腹股沟下旁路手术的影响。
利用2005年至2008年美国外科医师学会国家外科质量改进计划数据库，通过国际疾病分类第九版和当前手术操作术语编码，确定非急诊CLI腹股沟下旁路手术（定义为静息痛或组织缺失）。根据国家外科质量改进计划数据，将患者分类为接受全身麻醉或区域麻醉。区域麻醉组包括指定接受区域、脊髓或硬膜外麻醉的患者。提取研究样本的人口统计学、医学、风险因素、手术和结局数据。根据以下发病类别评估个体结局：伤口、肺部、静脉血栓栓塞、泌尿生殖系统、心血管和手术相关。还评估了住院时间、总发病率和死亡率。使用线性或逻辑回归评估麻醉类型与结局之间的关联。
共确定了5462例涉及CLI腹股沟下旁路手术的住院病例。患者平均年龄为69±12岁；69%为白种人；39%为女性。总共4768例手术采用全身麻醉，694例采用区域麻醉。接受全身麻醉的患者更年轻，且更有可能有吸烟史、既往下肢旁路手术史、既往截肢史、既往中风史以及包括使用华法林在内的出血性疾病史。接受区域麻醉的患者慢性阻塞性肺疾病患病率更高。51%的手术为胫部旁路手术，49%为腘部旁路手术。采用全身麻醉的病例住院医师参与率、输血需求和手术时间更高。两组之间腘部和腘以下旁路手术的发生率没有差异。采用全身麻醉进行的腘以下旁路手术更有可能使用人工血管和复合静脉。157例患者（3%）死亡。总体发病率为37%。平均住院时间和中位数住院时间分别为7.5天（±8.1）和6.0天（第一四分位数：4.0，第三四分位数：8.0）。多变量分析表明，麻醉类型在发病率、死亡率或住院时间方面无显著差异。
这些结果没有提供证据支持在下肢旁路手术中系统性地避免全身麻醉。这些数据表明，麻醉选择应由当地专业知识和实践模式决定。
