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6562
Comparison of 3 Perioperative Analgesic Approaches for Patients Undergoing Major Lower Extremity Amputation
Session: MP-02b
Thur, April 11, 10:00am-12:00pm
Tribune

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years

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Comparison of 3 Perioperative Analgesic Approaches for Patients Undergoing Major Lower Extremity Amputation

Authors: Catalina I. Dumitrascu MD1, Nafisseh S. Warner MD1,2, Thomas M. Stewart MD1, Adam W. Amundson MD1, Danette L. Bruns RRT, LRT3, Andrew C. Hanson4, Phillip J. Schulte PhD4, Mark M. Smith MD1, Michael J. Brown MD1, Adam D. Niesen MD1, Carlos B. Mantilla MD, PhD1, Matthew A. Warner MD1,5

INTRODUCTION

Pain control for patients undergoing major lower extremity amputation (MLEA) is challenging and optimal analgesic strategies remain incompletely defined.[1-3] We report perioperative analgesic outcomes following MLEA comparing 3 unique analgesic strategies: no regional anesthesia, peripheral nerve blockade with standard local anesthetic, and peripheral nerve blockade using a mixture of standard and liposomal bupivacaine (Exparel®, non-FDA approved indication).

 

METHODS

  • Retrospective review of adults (> 18 years) undergoing MLEA under general anesthesia at a large academic medical center between 1/1/2012-12/31/2017

  • Three unique analgesic categories:

    • No regional anesthesia

    • Peripheral nerve blockade with standard local anesthetic

    • Peripheral nerve blockade with a mixture of standard and liposomal bupivacaine

  • Primary outcome: oral morphine equivalent (OME) at 72 hours

  • Secondary outcomes: numeric rating scale (NRS) pain scores, NRS pain score > 7/10, and postoperative opioid-related respiratory depression

  • Multivariable regression analyses adjusted for age, sex, BMI, history of chronic pain, preoperative opioid use, baseline NRS scores, Charlson Comorbidity Index, surgery length, and emergency surgery

RESULTS

  • 631 unique general anesthetics for MLEA

    • No regional anesthesia (416)

    • Regional with standard local anesthetic (84)

    • Regional with liposomal bupivacaine (131)

  • Multivariable analyses

    • OME requirements 1.50x greater in no regional group compared to regional with combined standard and liposomal bupivacaine (95% CI 1.12 - 2.01; p = 0.007)

    • OME requirements 1.34x greater in no regional group compared to regional anesthesia with standard local anesthetic (95% CI 0.96 – 1.87; p = 0.085)

    • No difference between regional anesthesia with or without liposomal bupivacaine (p = 0.586)

       

DISCUSSION

Numerous modalities to prevent perioperative pain in amputations have been studied with mixed results.[1-3]  The use of peripheral nerve blockade with combined standard and liposomal bupivacaine is a novel analgesic strategy. In this study, peripheral nerve blockade with standard and liposomal bupivacaine was associated with lower OMEs when compared to those not receiving regional anesthesia.  However, analgesic outcomes were not statistically different when comparing this novel strategy with peripheral nerve blockade with standard local anesthetic alone. Prospective investigations are warranted to define optimal analgesic strategies in this high-risk population.

 

ACKNOWLEDGEMENTS

We are grateful for funding from the ASRA Resident/Fellow Travel Award as well as the Mayo Clinic Small Grant Program.

 

REFERENCES

1Srivastava, D., Chronic post-amputation pain: peri-operative management - Review. Br J Pain, 2017. 11(4): p. 192-202.

2Karanikolas, M., et al., Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial. Anesthesiology, 2011. 114(5): p. 1144-54.

3Borghi, B., et al., The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesth Analg, 2010. 111(5): p. 1308-15.

 

 

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