AMPUTATION - ABOVE AND BELOW THE KNEE (AKA & BKA)

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Below-the-knee amputation (BKA), also known as transtibial amputation, is a surgical procedure in which the lower leg is removed due to various reasons, such as trauma, infection, severe peripheral vascular disease, or cancer. The goal of the procedure is to remove the affected part of the limb and create a healthy residual limb that can be fitted with a prosthetic.

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Above-the-knee amputation (AKA), also known as transfemoral amputation, is a surgical procedure that involves the removal of the lower limb above the knee joint.

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                                                                Anesthetic Implications for AKA & BKA

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Anesthesia type: General ETT or LMA, peripheral nerve block or neuraxial anesthesia

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Airway: Endotracheal tube or LMA

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Preoperative:

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• Common significant coexisting diseases include diabetes, peripheral vascular, and cardiovascular disease.

• Diabetic patients may have peripheral and autonomic neuropathy​​

• Limb ischemia can result in myoglobinemia due to rhabdomyolysis

• Regional anesthesia from T12 (T8 with tourniquet) is adequate

• Long-standing insulin-dependent diabetics may be difficult airways

• Diabetic patients with coronary artery disease are at high risk for perioperative myocardial ischemia

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Intraoperative:

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• Tourniquet may be used

• Maximum safe tourniquet time is less than 2 hours

• Tourniquet deflation and limb reperfusion 

• Reperfusion can cause the release of toxic metabolic byproducts and inflammatory mediators

• ​Position: Supine with arms out

• EBL: Expect 100-300 ml

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Postoperative:

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• Multimodal analgesia.

• Epidural placement can help with phantom pain postoperatively.

• A fibers transmit pain described as “sharp”

• C fibers are not myelinated and pain may be described as “dull” or “aching”

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Complications:

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• Phantom pain

• Stump pain

• Central sensitization

• Femoral/sciatic nerve damage

• Infection

• Hematoma

• Deep vein thrombosis

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Sources:

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Elisha, S. (2010). Case Studies in Nurse Anesthesia.

 

Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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