title: The effect of anesthesia type on major lower extremity amputation in functionally impaired elderly patients.
abstract: OBJECTIVE
  Patients undergoing major lower extremity amputations are at risk for a wide variety of perioperative complications. Elderly patients with any functional impairment have been shown to be at high risk for these adverse events. Our goal was to determine the association between the type of anesthesia-general anesthesia (GA) and regional/spinal anesthesia (RA)-on perioperative outcomes after lower extremity amputation in these elderly and functionally impaired patients.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data set (2005-2012) was queried to identify all patients aged ≥75 years with partial or total functional impairment who underwent major lower extremity amputations. Propensity matching and multivariate analysis were performed to isolate the effect of anesthesia type.
  
  
  RESULTS
  We identified 3260 patients (50% male), 2558 GA patients and 702 RA patients, who were a mean age of 82 years. Anatomic distribution was 59% above-the-knee and 41% below-the-knee amputations. Patients undergoing GA were more likely to have impaired sensorium (9% vs 6%; P = .035), be on anticoagulation or have a bleeding disorder (33% vs 17%; P < .001), have had a previous operation ≤30 days (16% vs 10%; P < .001), and be operated on by a nonvascular surgeon (16% vs 12%; P = .033). GA was associated with shorter anesthesia time to surgery (36 ± 48 vs 42 ± 49 minutes; P < .001) but a similar operative time (66 ± 33 vs 64 ± 33 minutes; P = .292) compared with RA. After propensity matching, rates of 30-day mortality (14% vs 12%; P = .135), postoperative myocardial infarction/cardiac arrest (2.9% vs 3.1%; P = .756), pulmonary complications (7.3% vs 6.7%; P = .632), stroke (0.7% vs 0.9%; P = .694), urinary tract infections (6.7% vs 6.5%; P = .887), and wound complications (7.6% vs 7.6%; P = .999) were similar in patients undergoing GA and RA, respectively. Median length of stay was similar in both groups (5 vs 5.5 days; P = .309). Multivariable analyses confirmed that anesthesia type did not significantly affect morbidity and mortality.
  
  
  CONCLUSIONS
  The mode of anesthesia, GA vs RA, did not have significant effect on perioperative outcomes after major lower extremity amputation in the functionally impaired geriatric population. These findings provide an evidence base that will allow surgeons, anesthesiologists, and patients to make an informed decision about anesthesia type for their procedure.
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass. Electronic address: carla.moreira@bmc.org.
authors.forename: Carla C
authors.initials: CC
authors.lastname: Moreira
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kalish
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Eslami
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Didato
authors.affiliation: Department of Biostatistics, Boston University, Boston, Mass.
authors.forename: Denis
authors.initials: D
authors.lastname: Rybin
authors.affiliation: Department of Biostatistics, Boston University, Boston, Mass.
authors.forename: Ghoerghe
authors.initials: G
authors.lastname: Doros
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects / Q000401:mortality; D000765:Anesthesia, Conduction / Q000009:adverse effects / Q000401:mortality; D000768:Anesthesia, General / Q000009:adverse effects / Q000401:mortality; D000775:Anesthesia, Spinal; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D035002:Lower Extremity / Q000601:surgery*; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D011237:Predictive Value of Tests; D057216:Propensity Score; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States