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154]

Original Article

Peripheral nerve blocks for above knee amputation in high‑risk

patients

Rajkumar Chandran, Zhi Yuen Beh, Fung Chen Tsai, Suran Dhanushka Kuruppu, Jia Yin Lim
Department of Anesthesia and Intensive Care, Changi General Hospital, Singapore

Abstract
Background and Aims: Above knee amputation (AKA) is associated with considerable mortality and morbidity. There is paucity
of data describing the use of peripheral nerve blocks (PNB) as the sole anesthetic technique in high-risk patients undergoing
AKA. Our objectives were to evaluate the use of PNB as sole anesthetic technique in the above-mentioned population and its
clinical outcomes.
Material and Methods: This was a retrospective descriptive study conducted in a tertiary hospital. For this study, patients with
American Society of Anesthesiologist [ASA] IV physical status underwent AKA using PNB between January 2010 and December
2016, were identified. The primary outcome measured was the success of the operation. The secondary outcomes were block details,
intraoperative hemodynamics, usage of sedation and analgesia, patients’ comorbidities, mortality rates at 30 days and one year.
Results: Out of fifty-seven patients, the median age (interquartile range) was 74 (57 – 81) years and 60% were males. The
results show 91% successfully underwent surgery with PNB (95% CI 81% to 96%). 95% required intraoperative sedation
and analgesia. 67% received combined femoral, obturator and sciatic nerve blocks, in which nine cases had an additional
lateral femoral cutaneous nerve block. Interestingly, 33% only received combined femoral and sciatic nerve blocks, and they
required higher sedation analgesia (p = 0.013). The 30-day and one-year mortality were 12.3% & 47.4%. Majority had stable
hemodynamics during the surgery.
Conclusion: This study shows that PNB is a viable option for reliable anesthesia for AKA in high‑risk patients. Combined FOS
nerve block would reduce the dose for sedation–analgesia during the operation.

Keywords: Above knee amputation, high‑risk patients, peripheral nerve blocks, regional anesthesia, survival

Introduction prompt infectious source control in overwhelming soft-tissue

or bone infection. Patients at this point of presentation are
Patients undergoing non-traumatic major lower extremity in severe sepsis with multi-organ dysfunction confounded by
amputation (MLEA) such as above knee amputation (AKA) poor comorbidities translating to high risk of perioperative
commonly have multiple comorbidities like diabetes mellitus, complications. In one study[2], a patient with ASA grade
cardiovascular and renal disorders[1,2] and they are at risk of ≥4 undergoing MLEA was associated with a greater than
significant postoperative morbidity and mortality. fourfold increase in 30-day mortality, and a twofold increase
in long-term mortality. The long-term survival for those
AKA is often the last resort following failed limb salvage undergoing AKA is dismal.[4]
treatment.[3] When performed as an emergency, it is for
Peripheral nerve block (PNB) is the preferred choice of
Address for correspondence: Dr. Zhi Yuen Beh, anesthetic technique for high-risk patients undergoing MLEA
Department of Anesthesia and Intensive Care, Changi General
Hospital, 2 Simei Street 3, Singapore 529889, Singapore.
E‑mail: michaelbzy@gmail.com This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercial-
Access this article online ShareAlike 4.0 License, which allows others to remix, tweak, and
Quick Response Code: build upon the work non-commercially, as long as appropriate credit
Website: is given and the new creations are licensed under the identical terms.
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Chandran R, Beh ZY, Tsai FC, Kuruppu SD, Lim JY.
10.4103/joacp.JOACP_346_17 Peripheral nerve blocks for above knee amputation in high-risk patients.
J Anaesthesiol Clin Pharmacol 2018;34:458-64.

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Chandran, et al.: Peripheral nerve blocks for above knee amputation

in our center. However, the effects of peripheral nerve blocks higher dose with a single agent would be considered as
(PNB) as the sole anesthetic technique in high-risk patients moderate to deep sedation-analgesia. For the purpose of
undergoing AKA have not been fully evaluated and only a the study, hypotension was defined as a decreased in mean
few case series were reported.[5-7] We aimed to evaluate the arterial pressure (MAP) of >20% from the baseline value
use PNB as sole anesthetic technique for the above-mentioned and required vasopressors. The intraoperative hemodynamics
population and its clinical outcomes. status for the first 120 minutes after administering the
PNB was evaluated and the usage of vasopressors, such
Material and Methods as ephedrine and phenylephrine, during the surgery was
determined.
This retrospective descriptive study (January 1, 2010
to December 31, 2016) was conducted with a waiver of Statistical analysis
informed consent approved by SingHealth Centralized Descriptive statistics for categorical data were presented as
Institutional Review Board (CIRB Ref: 2018/2010), frequency and percentage. Numerical data were presented
https://research.singhealth.com.sg. All patients categorized as median [(interquartile range) IQR] unless otherwise
as high risk [American Society of Anesthesiologist (ASA) specified. The differences in characteristics were examined
IV and V] who underwent nontraumatic transfemoral, AKA using Mann–Whitney U‑test for numerical variables;
using PNB in the above‑mentioned period were included. Chi‑square test or Fisher’s exact test were adopted for
Major amputations secondary to trauma were excluded. categorical variables. A two‑tailed, P value <0.05 was
considered statistically significant. Statistical data analysis was
Data collection source included patients’ hospital electronic performed with SPSS statistical software, version 19.0 (IBM
medical records, anesthesia files, and departmental nerve Corp. Armonk, NY).
block audit database. Patients’ demographic profiles, ASA
status, comorbidities, and investigation results were retrieved Results
from the hospital electronic records. Details of the PNB,
intraoperative hemodynamic status, usage of sedation and Patient characteristics
analgesia were obtained from the nerve block audit database During the study period, 57 ASA IV patients underwent
and anesthesia records. AKA using PNB [Table 1]. None of the patients with
ASA V status were identified. The demographic data and
We evaluated the success of the operation using PNB, nerve the duration of surgery are given in Table 1.
blocks details, intraoperative hemodynamic status, and usage
of sedation and analgesia, plus postoperative monitoring Major comorbidities
destination. Patients’ survival at 30 days and 1 year were Table 2 shows that the patients were generally very sick.
determined. We defined block success[8] in this study as the Each of them had at least four major comorbidities. The
ability to proceed with the surgery without conversion to
general anesthesia or spinal anesthesia. Table 1: Above knee amputation on high‑risk patients ‑
characteristics and association with mortality
Patients’ various comorbidities were further evaluated using Characteristics Association with
the Charlson comorbidity index, a validated scoring system mortality (P)
Age (years)
which contains 19 categories of comorbidities, and predicts
Median (IQR) 74 (57‑81) 0.538*
the one-year mortality.[9] The mortality rate increased with Gender, n (%)
increasing Charlson Score: none (0), 7%; low (1 – 2), 22%; Male 34 (59.6) 0.629*
moderate (3 – 4), 31%; and high (≥5), 40%.[9] Female 23 (30.4)
BMI (kg/m2)
Additional sedation and analgesia are commonly required to Median (IQR) 21.5 (20.5‑26.4) 0.542*
facilitate AKA.[5-7] The commonly used drugs for sedation Discipline, n (%)
and analgesia included fentanyl, midazolam, ketamine, and Vascular surgery 33 (57.9) 0.843*
propofol. As for the intraoperative usage of sedation and Orthopedic 24 (42.1)
analgesia, we considered mild sedation-analgesia if only one Charlson comorbidity index
Median (IQR) 8.0 (7.0 – 10.0) 0.048
or two agents in low dose were used, such as fentanyl (<1mcg/
Duration of surgery, minute
kg), midazolam (<0.05mg/kg), ketamine (<0.5mg/kg),
Median (IQR) 85 (50‑120) N/A
propofol (< 25mcg/kg/min or target controlled infusion < *Pearson’s Chi‑square test; N/A=Not applicable, IQR=Interquartile range,
0.5mcg/ml). Any usage of more than two agents or using BMI=Body mass index

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Chandran, et al.: Peripheral nerve blocks for above knee amputation

Table 2: Major comorbidities and its association with mortality

Major comorbidities Cases (%) Association with
mortality (P)
Hypertension 55 (96.5) 0.172
Diabetes mellitus with end organ damage (retinopathy, neuropathy, nephropathy) 55 (96.5) 0.940
Cardiovascular problem
Known IHD 49 (86) 0.872
Recent* ACS (STEMI, NSTEMI, troponin leak due to sepsis) 9 (15.8) 0.848
Cardiac arrhythmia with or without pacemaker 4 (7) 0.913
CHF 32 (56.1) 0.129
PVD 35 (61.4) 0.439
Neurological problem
Old CVA 12 (21.1) 0.139
Acute CVA† 5 (8.8)
Others ‑ dementia, parkinsonism, meningioma 11 (19.3)
Renal problem
CKD 1‑3 25 (43.8) 0.064
CKD 4‑5 6 (10.5)
Sepsis
Sepsis‡ 53 (93) 0.55
Septic shock (at clinical presentation) 4 (7)
Bleeding potential
Mild coagulopathy (requires FFP transfusion) 2 (3.5) 0.36
Antiplatelet and anticoagulation therapy 43 (75.4)
Other significant comorbidities
Lung disorders (pleural effusion, asthma, chronic obstructive pulmonary disease, superimposed pneumonia) 4 (7) N/A
Previous lower limb deep vein thrombosis (with or without caval filter) 3 (5.3)
Clinical hypothyroidism 1 (1.7)
Chronic liver disease 2 (3.5)
All values are expressed in numbers and percentages; Pearson’s Chi‑square test or Fisher’s exact test were adopted for categorical variables, where appropriate. *Recent ACS
defined as diagnosis within 3 months prior to surgery or during current hospital admission; One of them had STEMI, 3 had NSTEMI and 3 had raised troponin level likely
secondary to sepsis as diagnosed by cardiologists, †Two unilateral MCA territory infarct, 1 unilateral PCA infarct, and 1 bilateral cerebellar infarct; ‡Evidenced by clinical
signs, raised total white cell counts, raised inflammatory markers, i.e., CRP bacteremia from blood cultures. CRP=C‑reactive protein, N/A=Not applicable, FFP=Fresh frozen
plasma, IHD=Ischemic heart disease, CHF=Congestive heart failure, PVD=Peripheral vascular disease, CVA=Cerebrovascular accident, STEMI=ST elevation myocardial
infarction, NSTEMI=Non‑ST elevation myocardial infarction, MCA=Middle cerebral artery, PCA=Posterior cerebral artery, CKD=Chronic kidney disease

median Charlson comorbidity index was 8.0 (IQR 7.0 Peripheral nerve blocks and patient survival
– 10.0, p value 0.048) which indicates high one-year Ninety‑one percent (52 patients) successfully underwent
mortality. Forty nine (86%) patients had recent transthoracic surgery with PNB [Table 3]. Only 5% of the operations
echocardiography (performed within the last 6 months) or were performed under PNB without the usage of sedation
during the current hospital admission; 14 cases (24.6%) had or analgesia in the intraoperative period. Sixty‑seven percent
preserved left ventricular function (ejection fraction ≥50%); received combined femoral, obturator, and sciatic (FOS)
35 cases had impaired left ventricular function (mean nerve blocks, in which nine cases had an additional
ejection fraction 38 ± 15%) and the lowest ejection fraction lateral femoral cutaneous nerve (LFCN) block (lateral
was 10%; 2 patients had poor heart function with left FOS). The rest of the patient had combined femoral and
ventricular apical clot. Four cases had a history of cardiac sciatic nerve (FS) blocks. The FS group required higher
arrhythmias such as sick sinus syndrome, complete heart sedation and analgesia compared to the FOS and FOSL
block, and chronic atrial fibrillation. One of them had groups (P‑value = 0.013).
pacemakers inserted.
Two patients had bilateral AKA in the same operative setting,
All patients had evidence of sepsis from the affected lower in which blocks were performed in stages. PNB was given to
extremity. Of the four patients presented with septic shock one side first. Another round of PNB was delivered at the
on admission, three had been successfully weaned from contralateral limb after completion of the first amputation. All
vasopressor before operative procedure. Various comorbidities received FOSL and both cases were successfully operated
are listed in Table 2. using PNB.

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Sixty‑five percent of the blocks were performed with ultrasound, Table 3: Characteristics of peripheral nerve block (PNB)
and the rest used dual guidance (ultrasound and peripheral Type of PNB FS† FOS† FOSL*,† P
nerve stimulator). Variable local anesthetic (LA) concentrations (n=19) (n=29) (n=9)
and volumes [Table 4] were used by specialists experienced Block success, n (success 16 27 9 0.339
rate=91%)
in performing PNB. All subjects received standard ASA Nerve localization technique, n
monitoring. For hemodynamic monitoring, 40% of the Ultrasound 10 20 7 0.346
patients had an arterial line. Majority of the patients were US + peripheral nerve stimulator 9 9 2
hemodynamically stable during operation [Figure 1] except Intraoperative
for 10 patients which required vasopressor during operation. Sedation and analgesia
Patients in our study had a 1‑year survival of 53% [Table 5]. Not required 0 1 2 0.013**
Mild 6 17 9
The 30‑day mortality was noted at 12%. The intraoperative
Moderate‑deep 9 9 0
mortality and within 48 h after surgery was observed to be zero.
Hemodynamic
The earliest recorded death was on the sixth postoperative day. Stable 16 22 9 0.243
Required vasopressor 3 7‡ 0
Discussion All values are expressed in numbers; Pearson Chi‑square test and Fisher’s exact
test were used where appropriate. *Two cases had bilateral AKA in the same
operative setting in which blocks were performed in stages, one after another
Our study has confirmed that PNB could be used as the sole amputation: all received FOSL. **Comparison made between type of PNB and
anesthetic technique in high-risk patients having AKA with group with moderate‑deep sedation plus group with mild or no sedation. †Sciatic
nerve block ‑ 82% proximal approach (parasacral, transgluteal, subgluteal),
high success rate. We present a relatively large number of 15% mid‑thigh level, 3% popliteal approach. ‡One case had dopamine infusion
ASA IV patients underwent AKA with PNB. The existing preoperatively and no further escalation of dose during operation. N/A=Not
applicable, FS=Femoral plus sciatic nerve block, FOS=Femoral, obturator, and
literatures were just a small case series of four patients[5] and sciatic nerve block, FOSL=Femoral, obturator, sciatic nerve, and lateral femoral
two individual case reports.[6,7] cutaneous nerve block, AKA=Above knee amputation, US=Ultrasound

The neuraxial anesthesia in the form of a subarachnoid block Table 4: Characteristics of local anesthetic
has always been considered as the gold standard technique Type of local Concentration (%) Total Additive
for lower extremity surgeries.[10-13] However, it is unsafe to anesthetic* volume (ml)
perform neuraxial blocks on high-risk patients with deranged Ropivacaine 0.4, 0.5, 0.6, 0.7, 0.75 20‑40 23% used
Bupivacaine 0.25, 0.375, 0.5 20‑25 epinephrine
coagulation secondary to sepsis or the use of anticoagulant/ 5 µg/ml
Levo‑bupivacaine 0.25, 0.5 20‑25
antiplatelet medications.[14,15] Further, anesthesiologists Lignocaine 1‑1.5 20‑30
may choose to avoid subarachnoid blocks in patients with *53% used admixture of long‑acting and short‑acting LA (bupivacaine or
limited cardiovascular reserve due to the risk of significant levo‑bupivacaine mixed with lignocaine). LA=Local anesthetic

hemodynamic instability.
Table 5: Patients’ survival after AKA
PNB give greater hemodynamic stability than any other Survival after operation Number (%)
anesthetic techniques. [16-18] Figure 1 showed stable Survived >1 year 30 (53)
hemodynamic trend over 120 minutes after receiving PNB. Died within 30 days 7 (12)
Only 18% of the cases required some amount of vasopressor 1 month <died ≤3 months 7 (12)
during operation, and that could be due to the usage of higher 3 months <died ≤6 months 4 (7)
6 months <died ≤1 year 9 (16)
sedation-analgesia, and patients had limited cardiovascular
reserve and bleeding during operation. PNB has also proven
to provide excellent anesthesia and analgesia[17-19] for a variety and hematoma. The presence of coagulopathy or the use of
of surgeries, with a particular benefit on those undergoing the anticoagulants or antiplatelet further enhances the risk of
upper and lower extremity surgeries. [7,20] hematoma. In addition, most literature[23] described lumbar
plexus block as a technique for intra-operative and post-
In the textbook, the recommended PNB of choice for AKA operative analgesia following lower limb surgeries. The quality
surgery would be lumbar plexus block combined with sciatic of anesthesia is inconsistent for it to be used as a sole anesthetic
nerve block.[19,21,22] A lumbar plexus block should block the for any surgical procedure (even when combined with sciatic
femoral, obturator, lateral femoral cutaneous and genitofemoral nerve block). Therefore, the anesthesiologists selectively
nerves. However, it is a deeply seated block in a highly vascular block the main components of lumbar plexus – femoral and
area requiring a high volume of LA. The anatomy poses an obturator nerves in 67% of the patients, lateral femoral
increased risk of local anesthetic systemic toxicity (LAST) cutaneous nerve (LFCN) is also blocked for some patients.[7]

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Chandran, et al.: Peripheral nerve blocks for above knee amputation

Figure 1: Changes of MAP and heart rate from baseline and 2 h after peripheral nerve block

Some anesthesiologists did not block the obturator and lateral anesthetic technique used. Scott et al.[2], found no association
femoral cutaneous nerve, which is essential to achieve complete between the choices of anesthetic technique (neuraxial regional
anesthesia for AKA. Owing to poor documentation, we anesthesia or general anesthesia) with survival after MLEA
could not determine the reason for blocking only femoral and when corrected for other variables. However, patients in their
sciatic nerve. Our assumptions – patients were mostly very study did not receive PNB. The overall 30-day mortality in
sick and small size hence limiting the LA dose and volume, their study[2] was 12.4%, but in patients with ASA grade
the sonoanatomy might not be clearly visualized due to tissue 4 or 5 was 23.2%. Our study showed 30-day mortality of
edema and not every operator was familiar with obturator 12.3% and 1-year mortality of 47.4%. Our study had no
nerve or LFCN block. The operators probably believed, control group. The perceived mortality benefits from this
the medial and lateral aspect incision discomfort could be study need to be supported by randomized control study
overcome with sedation analgesia and local infiltration by the (RCT). Various factors that can affect in-hospital mortality
surgeon. Therefore, we are not surprised that the FS group apart from the anesthetic technique are cardiac complications,
required higher sedation analgesia. nosocomial infection, venous thromboembolism and poor
wound healing.[27] Nevertheless, our study showed that PNB
Sixty-five percent of the blocks were performed with ultrasound, could reliably provide stable hemodynamic throughout the
and the rest used dual guidance (ultrasound plus peripheral operation without any reported case of intraoperative mortality.
nerve stimulator). The use of ultrasound in lower extremity
block had shown to decrease block performance time, reduce Limitations
block onset time, increase the rate of sensory block and Our study only involved a single center with a relatively
improve the efficacy of analgesia.[24,25] Dual guidance is useful small cohort number to determine the mortality benefit. This
in cases involving deep and challenging blocks whereby the study is also based on the analysis of retrospective data.
visualization of sonographic images of the needle and neural Poor documentation such as the need for LA infiltration
structure is poor. by surgeon precludes our further evaluation of failed block
cases. We had no standardized LA type, concentration,
Mortality or volume [Table 4]. LA dosages used in PNB are based
Several studies on MLEA which include AKA and below on the principle of maximal allowable dose. A maximal
knee amputation (BKA)[1,26,27], have quoted high mortality allowable dose may be calculated and diluted into a large,
rates of 13.5 – 22% at 30 days and 44 – 48.3% at one year. convenient to administer volume (usually 30–40 ml). In this
The above-mentioned studies did not evaluate the choice of study, the attending anesthesiologist determined the volume

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Chandran, et al.: Peripheral nerve blocks for above knee amputation

based on the preference of LA, patient’s body weight, and operation. Majority had stable hemodynamic during the
intended amount to achieve a successful block of each nerve. operation.
The amount of LA used was also dependent on technical
difficulties encountered due to patient, operator, or equipment Acknowledgement
factors, i.e., edematous soft tissue resulting in a bad ultrasound The authors would like to thank Ms Carmen Kam, M.Sc.
image and/or associated with a reduced motor response on the Statistics, Research Officer from the Department of Clinical
use of peripheral nerve stimulator. This information was often Trials and Research Unit, CGH for her assistance with
not documented in the database and hence precluded further statistical analysis.
analysis. Our study revealed that several patients had received
Financial support and sponsorship
LA doses, which had marginally exceeded the upper limit of
Nil.
dosage recommendation based on body weight. There was
no reported incidence of LAST in this study. Bech  et al.[5] Conflicts of interest
had used LA volume of 60–70 ml admixture of bupivacaine There are no conflicts of interest.
0.5% plus carbocaine 2% with epinephrine in four high‑risk
patients that underwent AKA using PNB.
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CONFERENCE CALENDAR October-December 2018

Name of conference Dates Venue Name of organising Secretary with contact details
ASOCON 2019 11th, 12th, 13th Hotel Prasang Dr. Pravin Patel
4th National Conference of the January 2019 Presidency, 3, Sun Residency Bunglow
Anesthesia Society for Obesity RCTI College Road, Opp. Upvan Bunglow, Nr. Bagban party plot
City Homes Ghatlodia, Thaltej Shilaj Road, Thaltej
Ahmedabad -61 Ahmedabad - 380059.
Email: asoconevent2018@gmail.com
Website: www.asocon.in

RACE 2019 25th -27th Department of RACE Secretariat, A6 OR Complex,

Ramachandra Anesthesia January 2019 Anesthesiology, Dept. of Anaesthesiology, Critical Care & Pain Medicine
Continuing Education Sri Ramachandra Sri Ramachandra Medical College & Research Institute
University, Porur, Sri Ramachandra University, Porur, Chennai - 600116.
Chennai Phone: 044 - 23860125, 23860830
Mobile: +91 9176481005 / 9042606596
Web : www.race-elearn.com
E-mail: race.srmc@gmail.com

CRITICARE 2019 30th -31st Renaissance Mumbai Dr. Yatin Mehta

25th Annual Conference of January & Convention Centre Secretariat Address: Unit 13 and 14 ,
Indian Society of Critical Care 1st -3rd February Hotel, Mumbai,  First Floor, Hind Service Industries Premises
Medicine 2019 Maharashtra 400087, Co.operative Society, Near Chaitya Bhoomi,
India Off Veer Savarkar Marg, Dadar, Mumbai - 400028
Contact Person: Prajakta Jadhav
Mob No: +91 7045637444
Email: conferencecoordinator@isccm.org

IAPA 2019 8th-10th February AIIMS, new Delhi Prof Rajeshwari

11th Annaul national 2019 Prof & Head Deptt of Anesthesiology & Critical care
Conference of Association of Conference Secretariat Address : Room no. 5014 A, 5th floor
Pediatric Anaesthesiologists Teaching Block, Ansari Nagar, AIIMS New Delhi – 110029
Dr. Manpreet : +91 9868595487
Dr. Anjolie Chhabra : +91 9810104383
Email : iapaaiims2019@gmail.com

464 Journal of Anaesthesiology Clinical Pharmacology | Volume 34 | Issue 4 | October‑December 2018