Amputation pain (Raigmore in-patient) (Guidelines)

Audience

• Argyll & Bute HSCP and Highland HSCP
• Secondary Care.

NB: For patients who are admitted with a pre-existing opiate/neuropathic regime: Contact Acute Pain Team (#1003) if this requires optimisation. 

Pre-operative management 

• Contact Acute Pain Team (Bleep 1003) once patient identified for amputation.
• Consider neuropathic agent pre-operatively after discussion with Acute Pain Team.
  First Line: Pregabalin
  Second Line: Nortriptyline

Intra-operative management

1. Anaesthetic: Neuraxial Blockade with opiates or general anaesthesia.
   • Preferably on elective operative list with Consultant Surgeon/Anaesthetist present.
2. Ketamine: Bolus 0.3mg/kg, if no contraindications.
3. Perineural LA Catheter:
   
   • Below knee amputaton: Sciatic perineural catheter to be inserted by Surgeon with Ropivacaine 0.2% or Levobupivacaine 0.125% at a rate of 10mL/hr.
     
     • Each pump lasts 40 hours so a change in pump will be required.
     • Please place sticker on pump with date and time of required pump change.
       One refill maximum (i.e.: two consecutive pumps).
     • If pump change needed out of hours then contact Anaesthetics #5000
   • Above knee amputation: Femoral perineural catheter to be inserted by Surgeon with Ropivacaine 0.2% or Levobupivacaine 0.125% at a rate of 10mL/hr
4. Opioids: Oral Morphine 10mg four times daily plus 10mg once hourly when required.
   Consider Oxycodone immediate release 2mg four times daily PLUS once hourly when required in renal failure or frail/elderly patient
   • Consider PCA if not controlling analgesia

Post-operative management

• Neuropathic agent to be titrated to effect/tolerated.
• Aim to continue neuropathic agent post-operatively for 2 weeks duration before weaning dose if no evidence of neuropathic pain.
• Continue if evidence of neuropathic pain.
• Opioids should ideally be weaned prior to discharge as acute stump pain should be improving by 72 hours.
• Contact Acute Pain Team (#1003)/Anaesthetics (#5000) if pain management becomes complex.
• Consider SHDU post-operatively for patients if there is a clinical need.

Patients at risk for severe post-operative pain 

1. Severe pre-operative pain
2. Pre-operative strong opioid use in excess of 120mg oral morphine equivalent
3. Long history of critical ischaemia related pain
4. Psychological vulnerability
5. Drug dependency
6. Psychiatric history

Standard

100% of these patients to be referred to the Acute Pain Team (#1003)/Anaesthetics (#5000) during admission

Neuropathic agent dosing information

Loading regime

• First Line: Pregabalin
  • Initiate Pregabalin at 50mg twice daily pre-operatively.
  • First dose ideally night before surgery.
  • If required, then titrate slowly up to a maximum of 300mg twice daily, if well tolerated.
• Second Line: Nortriptyline
  
  • Initiate Nortriptyline at 10mg at night pre-operatively.
  • If required, then titrate slowly up to a maximum of 50mg at night, if well tolerated.

High risk groups

• Consider Pregabalin dose reduction to 25mg twice daily in high risk patients: Elderly, Renal Failure (eGFR less than 30mL/min).
• Specific advice about prescribing pregabalin for patients on dialysis should be sought as timing doses will depend on their dialysis sessions.
• Contact Acute Pain Team (#1003)/Anaethetics (#5000) if any concerns about dosing.

Weaning regime

• Continue established therapy for 2 weeks post-operatively.
• If no symptoms of neuropathic pain then consider weaning neuropathic agent by reducing dose every 4 to 7 days.
• If neuropathic pain persists, then consider continuing established dose.
  Please mention on IDL for GP to review in the community.