Pisansky Andrew J B, Brovman Ethan Y, Kuo Christine, Kaye Alan D, Urman Richard D
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA.
Ann Vasc Surg. 2018 Apr;48:53-66. doi: 10.1016/j.avsg.2017.10.014. Epub 2017 Dec 5.
Nontraumatic lower extremity amputation (LEA) remains a common procedure among patients who frequently have significant comorbidities. Patients undergoing above knee amputation (AKA) have the highest rates of mortality in this cohort, yet there is little evidence to support selection between peripheral nerve block or neuraxial regional anesthesia (RA) versus general anesthesia (GA) techniques. The objective of this study was to determine whether RA (neuraxial or peripheral nerve block) techniques were associated with more favorable outcomes versus general anesthesia among patients undergoing AKA.
This is a retrospective cohort study using propensity-matched groups. Patients undergoing AKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data set and grouped according to anesthetic type as either RA or GA. Patients undergoing AKA with RA were propensity matched to similar patients who had GA. Primary outcome was 30-day mortality. Secondary outcomes were numerous and included cardiac, pulmonary, infectious, and bleeding complications, as well as length of stay. Among a subset of patients for whom readmission data were available, rate of readmission was compared as a secondary outcome.
Nine thousand nine hundred ninety-nine patients were identified in the ACS-NSQIP database. One thousand three hundred twelve received a regional anesthetic, and the remainder had a general anesthetic. Factors significantly associated with GA included younger age (70 vs. 75 years; P < 0.001), higher body mass index (26.5 vs. 25.4; P < 0.001), and ethnically white (62.4% vs. 57%; P < 0.001). Before matching, patients receiving RA were less likely to be smokers (22% vs. 29%; P < 0.001), have a bleeding disorder (15% vs 30%; P < 0.001), or have a diagnosis of sepsis (26% vs 34%; P < 0.001). Propensity score matching produced a cohort composed of 1,916 patients equally divided between RA and GA. We found no difference with respect to the primary end point of 30-day mortality (11.7% vs 11.7%; odds ratio [OR] 1.01; P = 0.943) nor was there any difference with respect to secondary outcomes. Among patients for whom readmission data were available, there was no statistically significant difference between rates of readmission between the groups (15.6% for RA vs. 12.7% for GA; OR 1.26, confidence interval 0.87-1.828, P = 0.221).
The present investigation did not detect any difference between regional and general anesthetic with respect to morbidity or mortality among patients undergoing AKA. This data set did not allow us to address other relevant markers including pain control or phantom limb syndrome.
非创伤性下肢截肢（LEA）在常伴有严重合并症的患者中仍是一种常见手术。在这一队列中，接受膝上截肢（AKA）的患者死亡率最高，但几乎没有证据支持在周围神经阻滞或神经轴区域麻醉（RA）与全身麻醉（GA）技术之间进行选择。本研究的目的是确定在接受AKA的患者中，RA（神经轴或周围神经阻滞）技术与全身麻醉相比是否能带来更有利的结果。
这是一项使用倾向匹配组的回顾性队列研究。在美国外科医师学会国家外科质量改进计划（ACS - NSQIP）数据集中识别出接受AKA的患者，并根据麻醉类型分为RA组或GA组。接受RA的AKA患者与接受GA的类似患者进行倾向匹配。主要结局是30天死亡率。次要结局众多，包括心脏、肺部、感染和出血并发症以及住院时间。在有再入院数据的患者子集中，将再入院率作为次要结局进行比较。
在ACS - NSQIP数据库中识别出9999例患者。1312例接受区域麻醉，其余接受全身麻醉。与GA显著相关的因素包括年龄较小（70岁对75岁；P < 0.001）、体重指数较高（26.5对25.4；P < 0.001）以及白人种族（62.4%对57%；P < 0.001）。在匹配前，接受RA的患者吸烟可能性较小（22%对29%；P < 0.001）、有出血性疾病的可能性较小（15%对30%；P < 0.001）或诊断为脓毒症的可能性较小（26%对34%；P < 0.001）。倾向得分匹配产生了一个由1916例患者组成的队列，RA组和GA组各占一半。我们发现30天死亡率的主要终点没有差异（11.7%对11.7%；优势比[OR] 1.01；P = 0.943），次要结局也没有差异。在有再入院数据的患者中两组之间的再入院率没有统计学显著差异（RA组为15.6%，GA组为12.7%；OR 1.26，置信区间0.87 - 1.828，P = 0.221）。
本研究未发现接受AKA的患者在区域麻醉和全身麻醉之间的发病率或死亡率存在任何差异。该数据集不允许我们探讨其他相关指标，包括疼痛控制或幻肢综合征。
