PredictionPreanesthetic mortality prediction in diabetics undergoing major lower limb amputation at a tertiary referral hospital: Implications of preoperative echocardiographic and laboratory values☆
Introduction
In diabetes, the prevalence of lower extremity amputation is high at 0.21% to 1.37% and that of foot ulcer is 1.0% to 4.1% [1]. Patients who undergo amputation for diabetic foot ulcer have an exceptionally low 5-year survival rate (up to 23%), and survival in this patient population is highly correlated with previous cardiac comorbidity (hazard ratio, 2.16) [2], [3]. Studies on the topic have reported that advanced age, comorbid cardiovascular disease, absence of revascularization, and renal impairment are major determinants of survival after amputation for a foot ulcer in diabetic patients [2], [4]. However, few studies have addressed prognostic factors other than the aforementioned clinical histories after major lower limb amputation in this population. Considering the fact that cardiovascular mortality is 4.4-fold higher in diabetic patients than in nondiabetic subjects [5], it is somewhat surprising that no prognostic factors that predict mortality and morbidities have been suggested in diabetic patients undergoing major lower limb amputation.
Echocardiographic findings regarding cardiac anatomy and function have been suggested to be good predictors of 30-day and long-term cardiovascular outcome after open vascular surgery in patients with asymptomatic left ventricular (LV) dysfunction [6]. In addition, some perioperative laboratory findings aid the management of diabetic foot amputation [7], [8].
We conducted this retrospective analysis to access the abilities of preanesthetic echocardiographic and laboratory values to predict mortality and cardiovascular morbidity in type II diabetes patients undergoing major lower limb amputation under spinal anesthesia.
Section snippets
Data collection
After obtaining approval from our ethics committee, we retrospectively reviewed the medical records of 310 patients archived at the Gachon University Gil Medical Center, a 1400-bed tertiary referral hospital. Records were searched using the keywords “diabetes mellitus plus amputation.” Of the 310 patients initially identified, 95 subjects were excluded from the analysis due to traumatic amputation, minor amputation, or wound dressing under local anesthesia. Accordingly, the records of 215
Demographic data, preoperative histories, and postoperative outcomes
Patient demographic data are presented in Table 1. Mean duration of diabetes was 186 months, and all 215 patients had at least 1 comorbidity. Of the 79 CAOD patients, 49 were incidentally diagnosed during a preoperative evaluation. Nine patients had a history of myocardial infarction (MI), and 21 patients had a history of angina pectoris. Three patients had experienced an ischemic heart attack within 3 months before operation. Nine patients had been diagnosed with congestive heart disease. One
Discussion
In the present study, we found the mortality rate after major lower limb amputation for a diabetic foot ulcer in a tertiary referral hospital was 5.6% (12/215) and that preoperative hemoglobin and LVEF predicted inhospital mortality. In particular, a hemoglobin level of 9.55 g/dL and an LVEF of 52% were found to be optimal threshold values for predicting mortality after major lower limb amputation in type II diabetes. To the best of our knowledge, this is the first study conducted on the
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2020, Clinical Orthopaedics and Related Research
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No external funding was received for this study, and the authors have no potential conflict of interest to declare.