Pain Management in Four‐Limb Amputation: A Case Report

Abstract

Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four-limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four-limb amputation.

Peri‐operative management and analgesic strategy for a patient undergoing quadruple limb amputation

“…A pre‐operative review of the literature demonstrated very few case reports of quadruple amputation [ 2 ] and those we found reported more limited amputations. Given the extent of the surgery planned and pre‐operative pain, we felt that nerve blockade would be important in minimising postoperative discomfort and the potential for development of chronic pain as well as maximising the potential for early rehabilitation.…”

A Surgeon’s Perspective on Lower Extremity Amputation and Rehabilitation

“…Amputees are known to have various type of pain with different mechanisms of action, thus it is important to differentiate them, as they require distinctive modalities for management. Phantom Limb Pain (PLP), the sensation of pain in the amputated limb, and Residual Limb Pain (RLP), sensation of pain in the residual limb, are the two common clinical presentations of Post-operative pain [29]. Controlling pre-operative pain has been shown to decrease the likelihood of developing chronic pain [30].…”