Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations.

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.

Ruptured abdominal aortic aneurysms: 15 years of continued experience in a southern West Virginia community.

Factors affecting survival and mortality rate of patients who present with ruptured abdominal aortic aneurysms (AAAs) at our community hospital were established in the late 1980s. During the intervening years, there have been many improvements in medical care. This study was conducted to re-examine factors affecting survival to ascertain whether improvements in care processes have led to corresponding improvements in survival. Outcomes of 73 patients who presented with ruptured AAA from 1983 to 1987 were previously reported. A retrospective chart review was conducted of 84 similar patients from 15 subsequent years. Demographic data, preoperative assessments, treatment timings, intraoperative findings, and subsequent postoperative complications were collected, analyzed, and compared to this institution's previous reported experience. Of 84 patients reviewed, 80% were male. The mean age was 72 years. Overall mortality significantly decreased from past experience (62% compared to 44%, p = 0.03). The mortality rate specifically associated with a free intraperitoneal rupture significantly decreased (97% to 63%, p < 0.001) from our previous report, while mortality for those with retroperitoneal rupture was relatively unchanged. Patients at increased risk in the present series were those aged >70 years and had preoperative hemoglobin of <10, preoperative hematocrit of <28, and an initial emergency department systolic blood pressure of <120 in contrast to patients aged >80 and with hemoglobin of <8 in the previously reported series. Syncope, delays in beginning surgical treatment, and amount of blood loss were not significantly associated with death as had been reported previously. Type of rupture and preoperative hemoglobin were the two factors most significantly associated with death (p < 0.05 by logistic regression). Despite the improvements in patient care and knowledge of the problem, many patients (44%) still die from ruptured AAAs, and 70% of this mortality occurs during the first 24 hr. Type of rupture continues to be an important predictor of mortality, and a large amount of improvement in mortality can be attributed to improvements in treating free intraperitoneal ruptures. Treating physicians have not gained much control over factors significantly affecting mortality, but a refinement of the known factors affecting survival may help target interventions and tailor patient care. Improved prerupture treatments of aneurysms by elective operations are still essential for reducing fatal outcomes.