Patients’ reported experiences and outcomes following surgical excision of lower limb osteomyelitis and microvascular free tissue reconstruction under ‘awake’ epidural anaesthesia and sedation

Abstract

Background: Orthoplastic operations for lower limb osteomyelitis (LLOM) involving microvascular free tissue reconstructions ("free-flaps") are usually performed under general anaesthesia (GA), with or without epidural anaesthesia (EA) due to concerns about the discomfort associated with prolonged surgery. However, our clinical experience supports "awake" epidural anaesthesia with sedation (EA þ Sed) rather than EA þ GA as a technique of choice for this type of surgery.Methods: We used a standardised postoperative questionnaire to formally assess the experiences and outcomes for 50 patients who underwent free-flaps for LLOM under EA þ Sed. Findings:The mean duration of surgery was 522 min (8.7 h), range 240e875 min. There were no ITU admissions or flap failures. Postoperatively, fifty patients completed a standardised questionnaire about their experiences before the operation, in the anaesthetic room and theatre. 80% were aware of the procedure at least "some of the time". 72.5% patients and 75% respectively, did not have any concerns in the anaesthetic room and theatre. Concerns expressed by the remaining patients were manageable. 97.5% of those patients who recalled their operation reported their overall experience as "comfortable" or "very comfortable". 92% of respondents had undergone previous lower limb surgery under GA ± EA. In this subgroup, 91.3% reported the recovery after EA þ Sed as "quicker" than GA, and 89.4% reported their experience with EA þ Sed as "better". All fifty patients (100%) were "satisfied" or "very satisfied" with their experience and all but one (98%) would recommend this technique to others.Conclusions: Our study showed that despite prolonged duration, the patients' reported experiences and outcomes were excellent when EA þ Sed was used for orthoplastic operations involving free-flaps for LLOM. We recommend EA þ Sed as the anaesthetic technique of choice for such patients.

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

“…Since prolonged general anaesthesia increases perioperative complications, 45 we are considering the introduction of a free flap technique that is safe for systemic hemodynamics using spinal/epidural anaesthesia without general anaesthesia. 46 , 47 In performing a stable free flap technique, it is necessary to consider not only the technical acquisition of the free flap but also the reduction of complications. 48 …”

The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes

“…When considering the option of awake surgery for the different specialties and for spine surgery specifically, much emphasis is given to cost-effectiveness, 21 , 22 , 23 , 24 , 25 , 26 , 27 lesser postoperative hospital stay, 24 , 26 , 28 patient reported outcome, 24 , 26 , 29 , 30 , 31 , 32 peri- and postoperative complications. 24 , 26 , 27 , 28 , 30 , 32 , 33 Spinal awake surgery is relatively new, having been known in the neurosurgical and orthopedic practice for 20 years.…”

Patients’ caring experience during procedures under regional anesthesia in Mainland China: A phenomenology study

“…In such procedures, a stable physiological support of applying anesthetic drugs to the central nervous system is not required [ 2 ]. The significant benefits of procedures under regional anesthesia include low risk of anesthesia [ 3 ], short surgery time [ 4 ], reduced incidence of adverse reactions [ 3 , 4 ], low incidence of complications [ 2 , 4 , 5 ], improved surgical outcomes [ 2 , 6 ], shortened hospital stays [ 3 , 4 , 7 , 8 ], and reduced healthcare costs [ 4 , [9] , [10] , [11] ]. More importantly, in the context of the global COVID-19 pandemic, medical teams are more inclined to perform procedures under regional anesthesia if conditions permit.…”

“…However, reported weaknesses of procedures performed under regional anesthesia include increased surgery-related anxiety [ 15 , 16 ], aggravated pain [ 17 ], worse discomfort [ 3 ], and lower patient satisfaction compared to general anesthesia surgeries [ 7 ]. Despite their low risk, procedures under regional anesthesia still have uncertainties and risks, like all surgeries.…”