Comparison of the effects of remifentanil-based general anesthesia and popliteal nerve block on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation

Abstract

Diabetic foot ulcer is the most common cause of diabetes-associated nontraumatic lower extremity amputation. Most patients who undergo lower extremity amputation for a diabetic foot have had diabetes for a long time and suffer from multiorgan disorder; thus, it can be a challenge to ensure sufficient anesthetic and analgesic effects while maintaining stable hemodynamics. Recently, peripheral nerve block has gained popularity owing to its attenuating effects of systemic concerns. This retrospective observational study aimed to compare the effects of remifentanil-based general anesthesia (GEA) and popliteal nerve block (PNB) on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation.A total of 59 consecutive patients with a diabetic foot who underwent distal foot amputation between January 2012 and May 2014 were retrospectively reviewed. Patients received remifentanil-based GEA (GEA group, n = 32) or PNB (PNB group, n = 27). The primary outcomes were to evaluate postoperative analgesic effects and perioperative hemodynamics. Also, postoperative pulmonary complications and 6-month mortality were assessed as secondary outcomes.Significant differences in pain scores using numeric rating scale were observed between the groups in a linear mixed model analysis (PGroup×Time = 0.044). Even after post hoc analysis with the Bonferroni correction, the numeric rating scale scores were significantly lower in the PNB group. Furthermore, patients in the PNB group required less pethidine during the first 6 hours after surgery (27 ± 28 vs 9 ± 18 mg; P = 0.013). The GEA group had a lower mean blood pressure (Bonferroni-corrected P < 0.01), despite receiving more ephedrine (P < 0.001). Significantly more patients in the GEA group suffered from postoperative pneumonia and required the management in intensive care unit (P = 0.030 and 0.038, respectively). However, the groups did not differ in terms of 6-month mortality.This study demonstrated that compared with remifentanil-based GEA, PNB might be a favorable option for diabetic patients undergoing distal foot amputation, despite the lack of significant mortality benefits, as PNB was associated with improved postoperative analgesia, hemodynamic stability, and a low incidence of pulmonary complications during the immediate postoperative period, especially in high-risk patients.

Infrainguinal bypass under triple nerve block in patients with severely compromised left ventricular ejection fraction and chronic limb-threatening ischemia

“…The procedure time in our study ranged from 150 to 300 min, which was substantially longer than the duration of, e.g., minor foot amputations performed under RA 30 . Still, the PNB allowed to complete the intervention successfully.…”

Peripheral nerve block combined with general anesthesia for lower extremity amputation in hemodialysis patients: case series

“…We could not investigate the effect of larger doses of remifentanil on hemodynamic stability since remifentanil doses were similar between the GA and GA with PNB groups. A previous study found lower mean blood pressures despite larger doses of ephedrine in patients who received remifentanil-based analgesia compared to GA with PNB [11].…”

“…Some authors have reported the successful use of PNB for lower extremity amputation patients, in order to avoid the systemic adverse effects of general anesthesia [2,3]. Favorable aspects of PNB, such as better pain control and functional recovery, have been emphasized, although the impact of anesthesia methods on postoperative mortality remains controversial [10][11][12].…”

Exploration of the Clinical Effect of Modified Peroneal Nerve Block in Foot Operation Under the Plane of the Ankle joint: A Non-Randomized Clinical Feasibility Observational Study.

“…First, some experts suggest that the anesthesia effect of deep peroneal nerve innervation can be solved by skin infiltration anesthesia, which can not only reduce the risk of acupuncture but also make anesthesia simpler. However, our literature review suggested that this is not feasible for the following reasons: (1) skin infiltration anesthesia cannot guarantee an ideal anesthesia effect and anesthesia time, while injection of the drug solution into the peripheral nerve can ensure an ideal anesthesia effect [7] .…”