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

Abstract

Background: Anesthetic management of lower extremity amputation in chronic hemodialysis (HD) patients can be challenging because of their poor cardiovascular status. As previously reported, peripheral nerve block (PNB) may be beneficial in these complicated cases. We report the effects of PNB combined with general anesthesia on hemodynamic stability in HD patients undergoing elective lower extremity amputation. Methods: We retrospectively analyzed 13 HD patients who underwent lower extremity amputation. Patients received general anesthesia (GA group, n = 7) or general anesthesia combined with PNB (GA with PNB group, n = 6), as decided by the anesthesiologists. Mean blood pressure (MBP), systolic blood pressure (SBP), lowest BP, heart rate (HR), blood loss, fluid and blood infusion volumes, and doses of vasopressors required were compared for hemodynamic assessment. The coefficient of variation (CV ¼ σ= X) of MBP (CV MBP) and SBP (CV SBP) was calculated to compare hemodynamic stability. Intraoperative opioid use and postoperative pain scores at rest using a numerical rating scale (NRS) on postoperative days 0 and 1 were compared for pain assessment. We also assessed 30-day mortality. Results: CV MBP in the GA group was significantly higher than that in the GA with PNB group (0.15 ± 0.05 and 0.08 ± 0.04, respectively, p = 0.03). The CV SBP in the GA group was also significantly higher than that in the GA with PNB group (0.16 ± 0.02 and 0.09 ± 0.01, respectively, p = 0.03). No significant differences in other hemodynamic parameters were observed. Intraoperative fentanyl doses were significantly lower in the GA with PNB group (GA 210.7 ± 99.9 μg vs. GA with PNB 113.0 ± 75.6 μg, p = 0.04). There were no significant differences in other pain parameters and 30-day mortality between the groups. Conclusion: Our results suggest that PNB combined with general anesthesia contributes to intraoperative hemodynamic stability through better pain control in HD patients undergoing lower extremity amputation.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery

“…However, one could speculate that hemodynamic stability achieved by better pain control may assist in reduced time used for hemostasis. Previous studies have suggested that higher intraoperative blood pressure variability is associated with increased blood loss during surgery [17], and peripheral nerve blocks may contribute to hemodynamic stability when combined with general anesthesia [18,19]. As the administration of additional opioids during surgery in both groups was directed by conventional parameters such as blood pressure and heart rate, reduced consumption in the Block group may reflect stable hemodynamics.…”

Effects of Anesthetic Techniques on the Risk of Postoperative Complications Following Lower Extremity Amputation in Diabetes Patients with Coagulation Abnormalities: A Retrospective Cohort Study Using Propensity Score Analysis

“…In the above study by Kim et al, intraoperative hemodynamic stability was better maintained in the PNB group than in the general anesthesia group [ 28 ]. Moreover, in another single-center retrospective study of chronic hemodialysis patients who underwent LEA in Japan, combined general anesthesia and PNB was associated with lower blood pressure variability than general anesthesia alone [ 16 ]. Furthermore, femoral nerve block with propofol sedation was shown to have higher intraoperative mean blood pressure than general anesthesia in patients with severe cardiac dysfunction [ 31 ].…”

“…Only patients with below-knee or more distal-level amputation were included in this study, as above-knee amputation (AKA) is not performed under PNB alone in our institution. Below-knee amputation (BKA) was regarded as a major amputation, whereas a more distal-level amputation was regarded as a minor amputation [ 14 , 15 , 16 , 17 ]. Amputation of the forefoot, midfoot, and hindfoot were considered minor.…”