Perioperative care for lower limb
amputation in vascular disease
Helen Melsom MBBS FRCA
Gerard Danjoux MBBS FRCA
Key points
Lower limb amputation
(LLA) secondary to vascular
disease is associated with a
30 day mortality as high as
17%.
Patients presenting for LLA
have significant co-morbidity
and are high risk for
perioperative complications.
Time is often limited for
pre-assessment and
optimization; however, it is
important to optimize
remediable factors in
advance of surgery.
Phantom limb pain is a
significant complication of
LLA with up to 70% of the
patients experiencing
phantom pain at some
stage.
There is ongoing
development of a national
Quality Improvement
Framework to reduce
mortality.
Helen Melsom MBBS FRCA
Specialist Registrar in Anaesthesia
James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW
UK
Gerard Danjoux MBBS FRCA
Consultant Anaesthetist
James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW
UK
Tel: 44 1642 854 600
Fax: 44 1642 282 818
E-mail: gerard.danjoux@stees.nhs.uk
(for correspondence)
162
Matrix reference 2A07, 3A05
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Lower limb amputations (LLAs) are widely Preoperative assessment
performed. Rates for LLA have remained rela-
Patients undergoing LLA should be recognized
tively constant over the last decade, with
as high risk and as a clinical priority.
5000 procedures performed per year in the
Communication between vascular surgeons and
UK. The indications are predominantly vascu-
anaesthetic services should facilitate early
lar occlusive disease and diabetes mellitus,
involvement of a consultant anaesthetist for
with both conditions present concurrently in a
preoperative assessment and to arrange appro-
substantial proportion of patients. The pro-
priate additional investigations, intervention,
portion of above knee amputations (AKAs) in
and plan postoperative care. There is often
comparison with below knee amputations
limited time in the preoperative period, particu-
(BKAs) has decreased over recent years. A
larly if surgery is urgent due to infection or
recent UK series showed a BKA:AKA ratio of
severe pain. It is, however, important to address
just greater than 1:1.1
those factors that can be improved in the avail-
Patients presenting for LLA due to vascular
able time and identify those patients at particu-
disease are predominantly elderly and have a
larly high risk. The balance must be made
high prevalence of co-morbid pathology includ-
between optimizing medical conditions before
ing coronary artery disease, hypertension, cer-
operation and the need for surgery.
ebrovascular disease, diabetes mellitus, chronic
An expedited and targeted assessment is
kidney disease, and smoking-related lung
therefore indicated with the aim of preparing
disease [e.g. chronic obstructive pulmonary
individuals for surgery at the earliest
disease (COPD)]. Post-mortem studies report
opportunity.
diffuse and severe coronary artery atherosclero-
A detailed history of the medical and func-
sis in up to 92% of the patients requiring LLA
tional status of the patient should be ascer-
for peripheral vascular disease.2 Perioperative
tained. Cardiac symptoms may often be masked
cardiac events are common and the leading
due to limited mobility related to claudication,
cause of morbidity and mortality. Patients
limb ulceration, and general poor functional
requiring LLA have 30 day mortality rates as
capacity. A clinical examination should be per-
high as 17%.3 AKA is associated with an
formed, with particular attention to the cardio-
increased risk compared with BKA, with mor-
respiratory systems and findings used to guide
tality rates of 1017% and 5 10%, respect-
targeted investigations.
ively.3 In addition, patients undergoing LLA
Recommended baseline investigations for
have a high incidence of complications with
individuals being considered for surgery are
respiratory and wound infections, poor mobi-
outlined below:
lity, and persistent postoperative pain.
Surgery is frequently undertaken on emer- Full blood count. Identification of
gency lists and out of hours. This situation anaemia which may require correction
creates challenges for perioperative planning (see below). An elevated white cell count
and reduces the time available for medical should prompt a septic screen. Infection in
optimization in the preoperative period. Using the ischaemic limb may be the cause but
the available evidence base and concentrating other sources, in particular respiratory
on anaesthetic aspects, this review will describe infection, should be identified.
a focused, best practice approach to the peri- Urea and electrolytes. Electrolyte abnorm-
operative care for patients undergoing LLA. alities (e.g. hypo/hyperkalaemia) and pre-
doi:10.1093/bjaceaccp/mkr024 Advance Access publication 12 July, 2011
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 11 Number 5 2011
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
 Perioperative care for lower limb amputation in vascular disease
renal impairment are common in this patient group and can
be optimized in the preoperative period.
Coagulation screen. Coagulopathy related to anticoagulants or
sepsis can be corrected before surgery. Knowledge of the
coagulation status may guide anaesthetic technique.
Blood glucose. Avoidance of persistent hyperglycaemia is
important in both diabetics and non-diabetics (see below).
Twelve-lead ECG. In addition to providing a baseline test, the
ECG may identify a recent acute coronary syndrome or sig-
nificant arrhythmia which may require intervention before
operation.
Chest X-ray. Indicated in patients with abnormal respiratory
clinical examination. Findings of consolidation or fluid over-
load are amenable to preoperative treatment.
Further investigations
Echocardiography should be performed in those patients with clini-
cal findings of a murmur or cardiac failure. The presence of signifi-
cant valvular disease or severe left ventricular dysfunction should
prompt consideration of invasive monitoring and guide postopera-
tive care.
Respiratory system assessment
Patients with COPD have a three-fold increase in risk for pulmonary
complications in unselected surgery. It is therefore paramount to ident-
ify individuals with potential respiratory insufficiency as this will
influence anaesthetic management and postoperative care.
Recommended investigations to guide such assessment are as follows:
Arterial blood gases, in particular to identify the presence of
respiratory failure.
Pulmonary function tests. A forced expiratory volume in 1 s
(FEV1) ,70% of the predicted value or an FEV1/forced vital
capacity ratio ,0.65 indicates a high risk of perioperative
complications.
Assessment of exercise tolerance in patients listed for amputation
is problematic and patients may be relatively immobile due to limb
pain. Pharmacological stress testing, for example, dobutamine
stress echo, is unlikely to be feasible in the short preoperative
period.
The focused assessment allows timely evaluation of relevant
information to inform discussions regarding risk between clini-
cians, the patient, and relatives. In some instances, the risks of the
procedure and anaesthesia may outweigh any benefit of lower limb
amputation and the patient may not progress to surgery.
Preoperative optimization
A focused preoperative assessment allows identification of those
factors that can be optimized in an appropriate timescale. Input
from specialist teams, in particular cardiology, respiratory, diabetic,
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
and pain teams, with an emphasis on short-term improvements can
assist this process. Patients may also warrant postoperative input
from medical specialties.
Pharmacological optimization
Opportunities for pharmacological methods of risk reduction are
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limited in the preoperative setting in patients undergoing LLA, due
to the often emergent need for surgery.
Statins
The utility of perioperative statin therapy in reducing cardiovascu-
lar events in vascular patients has been strongly suggested by
meta-analyses. The majority of studies available are retrospective
and heterogeneity is great, leading to the conclusion that the evi-
dence base is currently inadequate to recommend the acute admin-
istration of statin therapy before emergent surgery.4 The majority
of vascular surgical patients would, however, benefit from statin
administration for secondary prevention. For those patients already
established on statin therapy, discontinuation in the perioperative
period is associated with increased risk for adverse cardiac events.
In an observational study of 298 statin users who underwent major
vascular surgery, discontinuation of statin therapy for a median of
72 h in the perioperative period was associated with a 7.5-fold
increase in risk for myocardial infarction and death.5
b-Blockers
Recent evidence suggests the benefit of b-blockers titrated to heart
rate in the perioperative period, but acutely commencing high-dose
regimes cannot be recommended due to increased risk of stroke
and death seen in large clinical trials.6
Established cardiac medication [including b-blockers, statins,
aspirin, angiotensin-converting enzyme (ACE) inhibitors, and
diuretics] should be managed perioperatively in keeping with
recent guidelines (Table 1).
Specific medical conditions
Active cardiac conditions
The majority of individuals require medical optimization alone as
outlined above. However, specific conditions (Table 2) warrant
urgent referral and assessment before consideration of surgery. In a
proportion of patients, irremediable factors will be present which
place the patient at high risk for perioperative mortality, for
example, severe aortic stenosis. In these situations, surgery may
need to continue in the knowledge of this increased risk when felt
to be in the best interests of the patient.
Minor cardiac arrhythmias
Those arrhythmias not requiring a specialist assessment, for
example, atrial fibrillation, should be rate controlled before oper-
ation with appropriate medication. In the acute setting, the target
ventricular rate should usually be 80 100 bpm.7
163
Perioperative care for lower limb amputation in vascular disease

Table 1 Pharmacological risk reduction strategies6

Drug Recommendation Class of Level of

recommendation* evidence

b-Blockers Continuation of b-blockers is recommended in patients previously treated for IHD, hypertension, or I C
arrhythmias
Statins It is recommended that statins be continued perioperatively I C
Aspirin Continuation of aspirin in patients previously treated with aspirin should be considered in the IIa B

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perioperative period
ACE inhibitors ACE I should be continued perioperatively in patients treated for LV systolic dysfunction I C
Transient discontinuation of ACE I before non-cardiac surgery in hypertensive patients should be IIa C
considered
Diuretics Hypertensive patients should discontinue low-dose diuretics on the day of surgery and resume orally I C
when possible
Diuretics should be continued in heart failure patients up to the day of surgery, resumed i.v. I C
perioperatively, and continued orally when possible
*Classes of Definition
recommendations
Class I Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective
Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure
Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy
Class IIb Usefulness/efficacy is less well established by evidence/opinion
Class III Evidence and general agreement that the treatment or procedure is not useful/effective and in some cases may be harmful

Level of evidence A Data derived from multiple randomized clinical trials or meta-analyses

Level of evidence B Data derived from single randomized clinical trial or large randomized studies

Level of Evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries

Table 2 Active cardiac conditions.6 *MI within 30 days. Canadian Cardiovascular
Society Classification of angina pectoris, angina on minimal exertion (Class III) or at
rest (Class IV)
Unstable coronary syndromes (recent myocardial infarction,* CCS III or IV angina)
Decompensated cardiac failure
Severe valve disease, e.g. aortic stenosis
Significant cardiac arrhythmias, e.g. sustained ventricular tachycardia
Respiratory disease
The presence of an acute respiratory tract infection should prompt
initiation of treatment with appropriate antibiotics, oxygen therapy,
and physiotherapy before operation. Patients with COPD with
infective symptoms should receive corticosteroids in addition, for
example, prednisolone at a dose of 30 mg for 7 days. All regular
bronchodilator therapy should be continued.
Diabetes mellitus
There are currently no studies in general surgical patients to indi-
cate whether blood glucose control improves outcome. A recent
consensus statement recommends that blood glucose should be
,10 mmol litre21 in non-critically ill patients.8 These limits apply
to both diabetic and non-diabetic patients. Locally agreed insulin
regimes should be in place to achieve this; involvement of diabetic
teams may be required.
Anaemia
Evidence suggests a haemoglobin level of 810 g dl21 to be safe
even in patients with severe cardiorespiratory disease.9
Perioperative blood transfusion should aim to maintain haemo-
globin concentrations in this range.
Other factors
Anticoagulation
Low-molecular-weight heparin should be withheld for an appropri-
ate duration where central neuraxial block is being considered. The
suggested guidelines are that full therapeutic anticoagulation
should be omitted for 24 h before operation and prophylactic anti-
coagulation omitted for 12 h before operation.10
Current recommendations suggest that clopidogrel should be
omitted for 7 days before central neuraxial block.10 The risks and
benefits of these techniques should be considered on an individual
basis for those patients taking clopidogrel.
Nutrition and fluid balance
Adequate nutrition should be maintained and prolonged preopera-
tive fasting avoided. An appropriate i.v. fluid regime should be
commenced to correct preoperative dehydration and electrolyte
imbalances. Regular monitoring of instituted treatment is essential.
Preoperative pain control
A large number of patients undergoing LLA will have longstanding
and often severe ischaemic pain, with many requiring preoperative
opioid analgesia. This pain may have increased in severity in the
immediate preoperative period and be a driving force for surgery.
In addition, LLA is a surgical procedure that carries one of the
highest incidences of persistent post-surgical pain.11
Phantom limb pain (PLP) is a significant complication of lower
limb amputation with up to 70% of the patients experiencing
phantom pain at some stage.12 Peripheral nerve transection results
in an afferent nociceptive stimulus that initiates spinal cord hyper-
excitability. These neuroplastic changes are thought to be

164 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
 Perioperative care for lower limb amputation in vascular disease
responsible for the development of post-surgical chronic pain syn-
dromes, including PLP.
Pre-emptive analgesia with epidural infusions, intrathecal, and i.v.
ketamine has not consistently shown reductions in chronic PLP.
Studies have been underpowered and suffered from significant loss to
follow-up due to the high mortality rate seen in this patient popu-
lation. However, pre-amputation pain intensity has been identified as
a significant predictor of chronic PLP intensity. Aside from the poten-
tial to modulate pain pathways and reduce chronic pain, good pre-
operative analgesia should be ensured in all patients to reduce the
sympathetic stress response and improve perioperative cardiovascular
stability. Input from the acute pain service at this stage should
develop a multimodal analgesic regime with regular simple analge-
sics in addition to consideration of oral opioids and agents for neuro-
pathic pain (gabapentin and amitriptyline) where appropriate.
Opioid-based patient-controlled analgesia (PCA) may be required in
the immediate preoperative period to control severe ischaemic pain
where surgery is imminent. The use of epidural infusions, while not
demonstrating a reduction in chronic postoperative pain, may provide
superior preoperative pain control and their use should be considered.
Perioperative care
Timing of surgery
Where possible, surgery should be undertaken within 48 h of the team
decision to operate and recurrent cancellations avoided. Undertaking
LLA on planned lists during daytime, working hours should facilitate
this. Unpublished prospectively collected data on 271 patients under-
going LLA in our institution over the past 5 yr suggest that patients
who are operated on for major amputation out of hours have a three-
fold increase in mortality compared with those operated on in hours.
The reasons for this are likely to be multifactorial. The operation
should be performed by a senior surgeon, experienced in lower limb
amputation procedures. Owing to the high prevalence of cardiac
co-morbidity in this patient population, a consultant anaesthetist or
senior trainee with appropriate consultant supervision should be
responsible for the anaesthetic care of the patient.
Aims of anaesthesia
The aims of anaesthesia should be to maintain cardiovascular stab-
ility, normovolaemia, normothermia, avoid anaemia, and to
provide good analgesia into the postoperative period. Antibiotic
prophylaxis, guided by local policy, should be given within 60 min
before start of surgery. Consideration should be given to invasive
monitoring in those patients with significant cardiac disease or in
those acutely unwell due to sepsis.
Anaesthetic technique
Regional anaesthesia
Anaesthetic options include central neuraxial block or general
anaesthesia, both of which may be complemented by peripheral
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
regional techniques. The surgical time required for lower limb
amputation allows single-shot spinal techniques to be used.
Regional anaesthesia has several theoretical benefits in this popu-
lation including improved postoperative respiratory function13 and
attenuation of the stress response to the surgery. Postoperative cog-
nitive dysfunction is a recognized complication of major surgery
in the elderly. Available evidence shows that in patients random-
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ized to receive either general or regional anaesthesia, the incidence
of cognitive impairment in the first week after surgery is reduced
in those receiving regional anaesthesia. This difference does not
persist at 3 months.14 Reduction in early postoperative cognitive
dysfunction or delirium with the use of regional anaesthesia may
have important implications for compliance with medical therapy,
functional recovery, and length of stay.
Spinal or epidural anaesthesia is relatively contraindicated in
patients with systemic manifestations of sepsis and those who are
anticoagulated. General anaesthesia may be more appropriate in
these patients.
General anaesthesia
Controlled or spontaneous ventilation is appropriate. A stable
induction and attenuation of the cardiovascular response to tracheal
intubation are primary considerations due to the high prevalence of
ischaemic heart disease. The particular anaesthetic technique
chosen is probably less important than attention to cardiovascular
stability, intravascular volume, normothermia, and analgesia.
Perioperative measures to reduce chronic
post-surgical pain
The use of local anaesthetic infusions via surgically placed sciatic
nerve catheters has been shown to provide improved pain relief
and reduce opioid requirements in the immediate postoperative
period, while not demonstrating a lasting effect on postoperative
chronic pain.15 Despite a lack of evidence for the efficacy of per-
ipheral nerve block in reducing phantom pain, the reduction in
acute postoperative pain and opioid-sparing effect make these tech-
niques important to consider in this patient group.
Postoperative care
Owing to the high incidence of postoperative morbidity and mor-
tality, utilization of critical care services should be given early
consideration. These decisions should be made, where possible,
before surgery. Avoidance of hypoxia, tachycardia, hypotension,
and anaemia is of importance in patients at risk of postoperative
myocardial ischaemia. Patients should receive supplemental
oxygen for the first 72 h after operation.
Postoperative pain relief
Attention to good pain control is essential for patient comfort and to
reduce sympathetic catecholamine surges with their resultant
effects. A balanced analgesic regime should be established. Acute
165
Perioperative care for lower limb amputation in vascular disease
pain service management in the postoperative period is desirable,
with patients usually requiring PCA or regional catheter techniques.
All patients should, in addition, receive regular simple analgesia in
the form of oral or i.v. paracetamol. The routine use of non-steroidal
anti-inflammatory drugs is not recommended due to increased risk
of gastrointestinal and renal toxicity in this population.
The onset of phantom pain is usually within the first 7 days
after amputation. As previously mentioned, a convincing reduction
has not been demonstrated using pre-emptive regional analgesia or
regional techniques used intraoperatively. A trial examining the
effect of gabapentin started on the first post-amputation day did
not find a reduction in incidence or intensity of phantom pain.16
PLP remains common and difficult to prevent and treat.
Rehabilitation
Once through the immediate postoperative period, there should be
prompt referral to a local amputee rehabilitation team for early
mobilization and physiotherapy. This period provides an opportu-
nity to aggressively institute measures for secondary prevention,
both for cardiovascular and peripheral vascular disease.
Optimization of medical treatment, with institution of statins and
anti-platelet agents, smoking cessation advice, and optimization of
diabetic control are important considerations for reducing the risk
of subsequent loss of a second limb.
The future
Lower limb amputation surgery is an area of current national inter-
est. The significant and persistent mortality associated with lower
limb amputation has prompted action from the Vascular Society
and Vascular Anaesthesia Society of Great Britain and Ireland
(VASGBI) with the ongoing development of a Quality
Improvement Framework. Owing to the underlying disease states
that lead to the need for amputation and the associated
co-morbidity, this patient group is likely to remain at high risk for
perioperative complications. To reduce mortality, systematic,
co-ordinated, multidisciplinary input is required. The care path-
ways put in place for the management of patients admitted with
fractured neck of femur, with best evidence guidelines and a colla-
borative approach would seem an appropriate parallel to draw with
patients requiring lower limb amputation. Both represent an elderly
group of patients with multiple and complex morbidities, present-
ing with a surgical condition that requires prompt treatment. A
focused approach to optimizing medical conditions while minimiz-
ing surgical delay is an underlying key concept. To this end, the
development of regular, dedicated daytime trauma lists for vascu-
lar patients may be a valuable addition to the management of
major lower limb amputation. With the development of a Quality
Improvement Framework, there will be a change in the national
strategy, which will hopefully lead to a reduction in the significant
mortality associated with lower limb amputation surgery.
166 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
Conflict of interest
None declared.
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Please see multiple choice questions 9 12.