Effect of Regional Anesthesia on Diabetic Patients Undergoing Toe Amputations
Abhinav V. Raju1, 2; Ethan Mosley, DO2; John-Paul J. Pozek, MD2
1Kansas City University College of Osteopathic Medicine, Kansas City, Missouri
2Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
BACKGROUND:
• Amputations are associated with chronic postsurgical pain (CPSP) [1].
• There is a lack of literature about the incidence of CPSP after toe amputations unlike more proximal amputation procedures [2].
• There is little study into pain for diabetic patients after toe amputation.
• There is literature that contends diabetics have less phantom limb pain [3].
• There have been studies that show similar rates of phantom pain between diabetics and non-diabetics [4].
PURPOSE/AIMS/HYPOTHESIS:
• Retrospective, single-institution study that evaluates the effect of regional anesthesia (RA) on pain and opioid use in diabetic toe amputations.
• Hypothesis: Regional anesthesia is associated with decreased pain and opioid usage over 72 hours.
METHODS:
•Chart review in EPIC on all patients who had undergone toe amputation surgery at the University of Kansas Health System between 7/1/24 and 12/31/24.
•Inclusion criteria include adult patients 18 years or older and diabetic patients.
•Out of 60 patients, 22 patients received RA, involving a lateral popliteal sciatic nerve block, and 38 did not and formed the control group.
•Multiple local anesthetic concentrations used
•The primary outcome is pain in the immediate postoperative period up to 72 hours after surgery.
•The secondary outcome is milligram morphine equivalent (MME) of opioids from the intraoperative period up to 72 hours after surgery.
RESULTS:
•There was a statistically significant decrease in pain in the immediate postoperative period (2.1 vs 0.36, p = 0.01) in the RA group but not at other time periods (Figure 1).
•While there was a statistically significant decrease in opioid usage intraoperatively (47.6 vs 15.3, p= 0.01) and through 24 hours (32.3 vs 17.1, p = 0.04), this was not sustained to 72 hours (Figure 2).
DISCUSSION:
•The results indicate that RA for diabetic patients undergoing toe amputation leads to reduced pain in the immediate postoperative period.
•The results also show that RA was associated with reduced opioid usage in the intraoperative and 24 hours post-procedure periods.
•Pain control and opioid use were similar after these time periods up to 72 hours
•Unable to account for pre-existing pain or long-term opioid use
•Limited by small sample size and suboptimal RA plan
CONCLUSION:
•Reduced pain and opioid usage only in certain time periods intra- and post-operatively and not over the complete 72 hours.
•Prospective, randomized controlled trials comparing appropriate peripheral nerve catheters with standard therapy are needed.
REFERENCES:
1.Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: risk factors and prevention. The Lancet, 367(9522), 1618-25
2.Fatima H, Chaudhary O, Krumm S, Mufarrih SH, Mahmood F, Pannu A, Sharkey A, Baribeau V, Qureshi N, Polshin V, Bose R, Hamdan AD, Schermerhorn ML, Matyal R. Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation. Ann Vasc Surg. 2021 Oct;76:399-405. doi: 10.1016/j.avsg.2021.03.029. Epub 2021 Apr 23. PMID: 33895258.
3.H. Benzon, R.P. Prithvi, J.P. Rathmell, C.L. Wu, D.C. Turk, C.E. Argoff (Eds.), Practical management of pain (3rd ed.), Mosby, St. Louis, MO (2000), p. 213
4.Clark RL, Bowling FL, Jepson F, Rajbhandari S. Phantom limb pain after amputation in diabetic patients does not differ from that after amputation in nondiabetic patients. Pain. 2013 May;154(5):729- 732. doi: 10.1016/j.pain.2013.01.009. Epub 2013 Jan 26. PMID: 23433944.
