Anesthetic management for high-risk patients undergoing foot care surgery requires meticulous planning to minimize perioperative complications and enhance recovery [1]. High-risk patients often present with comorbidities such as diabetes mellitus, cardiovascular diseases, and peripheral vascular disorders, which can complicate both the surgical procedure and anesthesia [2]. A comprehensive preoperative evaluation is essential to identify and optimize existing medical conditions, including   assessing      cardiovascular     and    respiratory function, renal status, and glycemic control. Tight glycemic control is crucial for diabetic patients, as hyperglycemia can impair wound healing and increase infection risk [3]. Managing cardiovascular risk factors and ensuring adequate nutritional status are also critical for improving surgical outcomes [4]. The choice of anesthesia regional, general, or a combination depends on the patient’s medical history, the surgical procedure, and the anticipated postoperative course. Regional anesthesia techniques, such as ankle blocks or popliteal sciatic nerve blocks, are often preferred due to  their  effectiveness  and  reduced systemic effects, particularly for patients with cardiovascular comorbidities [5]. Studies have demonstrated that regional anesthesia is a safe and effective alternative to general anesthesia for high-risk patients undergoing foot surgery [6]. However, when regional anesthesia is contraindicated or the procedure necessitates it, general anesthesia may be used, with total intravenous anesthesia (TIVA) being a preferred option due to its improved postoperative recovery profile and reduced nausea and vomiting compared to inhalational agents [7].  During surgery, continuous monitoring of vital signs, including heart rate, blood pressure, oxygen saturation, and end-tidal CO₂ is essential to maintain hemodynamic stability, particularly in patients with cardiovascular conditions. A tourniquet should be used cautiously to control bleeding, ensuring that its duration and monitoring for signs of ischemia are carefully managed [8]. Postoperative care focuses on effective pain management to facilitate early mobilization and recovery. Multimodal analgesia, combining regional blocks with systemic analgesics, can provide significant pain relief while reducing opioid consumption [9].  Furthermore, monitoring for complications like infection, deep vein thrombosis, and pressure ulcers is necessary, with early mobilization being critical in preventing these issues. Anesthetic management for high-risk patients requires a tailored approach that considers the patient’s comorbidities, the nature of the surgery, and postoperative expectations, ultimately enhancing patient safety and improving outcomes [10]. The study aimed to evaluate the anesthetic management for high-risk patients of foot care surgery.

This cross-sectional observational study was conducted at the Department of Anesthesiology, BIHS General Hospital, Darussalam, Dhaka, Bangladesh. The study duration was 02 years, from January 2023 to December 2024. A total of 36 high-risk patients requiring foot care surgery were selected through a purposive sampling method, following specific inclusion and exclusion criteria. Ethical clearance for the study was obtained from the institutional ethical committee, and necessary permissions were secured from the concerned departments. Informed written consent was taken from each participant, ensuring confidentiality and the protection of their rights and health. Participants were assured of their right to withdraw from the study at any stage. Relevant clinical data, including preoperative evaluations, anesthetic techniques, intraoperative monitoring, and postoperative outcomes, were systematically recorded in a predesigned data sheet. The anesthetic management approach was tailored to the individual risk profiles of the patients, incorporating regional and general anesthesia techniques as appropriate. Hemodynamic parameters, perioperative complications, and recovery profiles were documented and analyzed using        SPSS,        applying     appropriate       statistical tests     to         evaluate       outcomes            and associations.

Inclusion Criteria:

• High-risk patients (ASA III & IV) undergoing foot care surgery.

• Patients aged 18 years or older with relevant comorbidities.

• Patients who provided informed written consent.

Exclusion Criteria:

• Low-risk patients (ASA I & II).

• Patients with severe medical conditions preventing surgery.

• Patients who refused to participate or withdrew consent.

This table presents the age distribution of the study participants. The majority of participants were between 41-50 years, 51-60 years, and 61-70 years, with each age group representing 11 participants (30.6% each). Only 3 participants (8.3%) were in the 31-40 age group.

This table shows the prevalence of various comorbidities among the study participants. The most common comorbidity was Diabetes Mellitus (DM) in 37 participants (33.9%), followed by Hypertension (HTN) in 27 participants (24.8%). Other comorbidities included Ischemic Heart Disease (IHD), Chronic Kidney Disease (CKD), and Peripheral Vascular Disease (PVD).

This table provides the preoperative clinical parameters of the study participants, including Pulse, SpO₂, and other measurements. The mean pulse was 90.18, with a standard deviation of 15.94, and the mean SpO₂ was 96.78, with a standard deviation of 16.20.

This table shows the prevalence of various comorbidities among the study participants. The most common comorbidity was Diabetes Mellitus (DM) in 37 participants (33.9%), followed by Hypertension (HTN) in 27 participants (24.8%). Other comorbidities included Ischemic Heart Disease (IHD), Chronic Kidney Disease (CKD), and Peripheral Vascular Disease (PVD).

This table summarizes the distribution of various physiological parameters among the participants.

Table 1: Age Distribution of the Study Participants (n = 36)

Table 2: Comorbidities Distribution of the Study Participants (n = 36)

Table 3: Preoperative Clinical Parameters of the Study Participants (n = 36)

Table 4: Distribution of Physiological Parameters of the Study Participants (n = 36)

Table 5: General Condition and Postoperative Complications Distribution of the Study Participants (n = 36)

Table 6: Diagnosis Distribution of the Study Participants (n = 36)

It shows that 82.1% of participants had a normal pulse, while 17.9% had a high pulse. 61.5% had high blood pressure, and 52% had low SpO₂ levels.

In this table, the most common diagnoses were Gangrene, Abscess, Wound Debridement, and others, each constituting 13.8% of the cases. Amputation and Non-Healing Ulcer (NHU) were observed in 10.3% of participants, while Diabetic Foot, Cellulitis, and Foot Ulcer each accounted for 6.9% of cases. Septic Condition was the least frequent diagnosis, reported in 3.4% of the participants. The findings indicate a diverse range of conditions, with a notable proportion requiring surgical interventions such as wound debridement and amputation.

The anesthetic management of high-risk patients undergoing foot care surgery requires careful consideration of preoperative clinical status, comorbidities, and physiological parameters. Our study evaluated the anesthetic outcomes and perioperative conditions of 36 patients, focusing on their comorbidities, vital signs, and postoperative complications. The findings were compared with existing literature to provide a broader perspective on anesthetic challenges in this patient population. The majority of our participants were between 41-70 years, with each decade group (41-50, 51-60, 61-70) accounting for 30.6% of cases. This distribution aligns with studies indicating that foot-related surgical interventions, particularly for diabetic complications, are more common in middle-aged and elderly patients [11]. Older age groups are often associated with increased comorbidities, necessitating precise anesthetic management to mitigate perioperative risks. Previous research suggests that advanced age contributes to hemodynamic instability and postoperative complications reinforcing the importance of careful anesthetic selection and monitoring [12]. Diabetes Mellitus (DM) was the most prevalent comorbidity in our cohort (33.9%), followed by Hypertension (HTN) (24.8%), ischemic heart disease (11%), and chronic kidney disease (5.5%). These findings are consistent with studies by Elghoneim et al. [13], which reported that DM and HTN are common in patients undergoing foot-related surgeries [13]. Diabetes poses significant anesthetic challenges due to its association with autonomic dysfunction, delayed gastric emptying, and increased risk of perioperative infections [14].  Similarly, HTN and ischemic heart disease necessitate meticulous intraoperative monitoring to prevent hemodynamic instability. Our findings highlight the importance of tailored anesthetic plans to address these risks effectively. The mean pulse rate in our study was 90.18 bpm, with a wide variation (67-140 bpm), while the mean SpO₂ was 96.78%, reflecting a generally stable respiratory status. Compared to research by Ruetzler et al. [15], where similar patient groups demonstrated preoperative tachycardia due to underlying cardiovascular conditions, our study emphasizes the need for preoperative beta-blockade or fluid optimization to stabilize heart rates before surgery [15]. Moreover, lower SpO₂ levels in some patients (as low as 0.98%) indicate the presence of underlying respiratory or cardiovascular dysfunction, which necessitates preoperative oxygen therapy or modified anesthetic techniques, such as regional anesthesia, to avoid respiratory compromise [16]. A high percentage of participants (82.1%) had a normal pulse, but 61.5% presented with hypertension, and 52% had low SpO₂. These findings are in line with a study by Brown et al. (2020), which reported that hypertensive patients undergoing foot surgery frequently experience perioperative blood pressure fluctuations, necessitating the use of short-acting antihypertensive agents during surgery [17]. Additionally, the high prevalence of low SpO₂ levels highlights the need for optimized oxygenation strategies. Literature suggests that regional anesthesia techniques, such as spinal or epidural anesthesia, help maintain better hemodynamic control and reduce respiratory depression compared to general anesthesia [18]. In our study, 74.2% of patients were categorized as “ill-looking” postoperatively, indicating significant physiological stress. Good anesthesia was reported in 28.6% of cases, while blood pressure maintenance was observed in 21.4%. Compared to a study where patients receiving regional anesthesia had lower rates of postoperative morbidity, our results suggest that anesthetic choice plays a crucial role in patient outcomes [19]. Additionally, the presence of disorientation (3.2%) and restlessness (3.2%) in some participants aligns with reports that inadequate pain control or hypoxia can contribute to postoperative agitation [5]. The most common diagnoses in our study included gangrene, abscesses, and wound debridement, each accounting for 13.8% of cases. Similar findings were reported, emphasizing that gangrene and diabetic foot conditions pose significant anesthetic challenges due to poor vascular supply and heightened infection risks [20]. Regional anesthesia has been widely recommended for such cases as it provides superior pain control, reduces systemic complications, and facilitates early mobilization [2]. However, in cases requiring amputation (10.3%), general anesthesia may be preferred due to the duration and extent of surgical intervention.

Limitation of the Study

This study is a relatively small sample size, which may not adequately capture the full diversity of the population under consideration.

Managing anesthesia for high-risk patients undergoing foot care surgery can be quite a journey that requires a personalized approach. This study highlights the prevalence of common conditions such as diabetes and high blood pressure among these patients, which can complicate both the surgery and anesthesia. It is essential to conduct a thorough preoperative evaluation that assesses heart health, respiratory function, and blood sugar levels to ensure the utmost safety during the procedure. Our findings indicate that using regional anesthesia is often a safe and effective option, especially for patients with heart conditions. However, it is crucial to monitor blood pressure closely throughout the surgery and during recovery. Despite these challenges, by developing tailored anesthetic plans and providing attentive postoperative care, many patients experience positive outcomes.

Recommendations

To improve outcomes in high-risk patients undergoing foot care surgery, prioritize thorough preoperative assessments, particularly for managing comorbidities like diabetes and hypertension. Prefer regional anesthesia for effective pain management with fewer systemic effects. Continuous monitoring of vital signs, including blood pressure and oxygen saturation, is crucial postoperatively to catch complications early. A multimodal approach to pain management should be used to reduce opioid reliance and enhance recovery. Regular training for healthcare providers on anesthesia techniques and ongoing research to refine strategies for these patients will boost safety, minimize complications, and optimize recovery.

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