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Amputation pain (Raigmore in-patient) (Guidelines)



  • 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


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.


Abbreviation  Meaning 
IDL Incremental Discharge Letter
PCA Patient controlled analgesia

Last reviewed: 11/11/2022

Next review date: 30/11/2025

Author(s): Acute Pain Team.

Version: 1

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Claire Wright, Acute Pain Nurse Specialist, Louise Reid, Clinical Nurse Specialist Anaesthetics .

Document Id: TAM518

Internal URL:


Self-management information