Amputation pain (Raigmore in-patient)


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  • 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

Self-management information 

Last reviewed: 11 November 2022

Next review: 30 November 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

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