Phantom pain management algorithm how to#

These patients may experience several different types of pain (individually or concomitantly) following LLA (Table 2). The complexity and challenge in managing pain in patients undergoing LLA begins with our limited understanding of the exact pathophysiology and mechanisms underlying the preamputation and postamputation phenomena. Lower limb amputations are commonly performed as a consequence of long-term damage from peripheral vascular disease and diabetes mellitus. The Underlying Complexity of Pain in Lower Limb Amputation Patients

Phantom pain management algorithm how to#

Although the primary goal of this review is to mobilize existing literature to enhance analgesia following LLA, it also serves to illustrate how to combine multiple analgesic modalities in a manner that considers the distinctive needs of a specific patient population. This protocol specifically addresses the unique considerations of the vascular amputation patient relative to their common medical comorbidities together with surgical concerns. This article summarizes the underlying complexity of pain in LLA patients as well as the development and application of a multimodal analgesia protocol for postoperative pain management. Multimodal analgesia has not been described in this patient population as it has been for other surgical procedures. As such, multimodal analgesia may be most valuable as a means by which to treat these multiple and complex pain mechanisms. Postoperative pain for LLA patients is complex and likely involves multiple pain etiologies and pathways. Furthermore, practitioners must consider not only acute postoperative pain but also chronic ischemic pain, residual limb pain, phantom limb sensations, musculoskeletal pain, and the possible development of phantom limb pain. Lower limb amputation (LLA) in vasculopathic patients presents such a unique challenge, since anticoagulation issues are common in the perioperative period as well as the prevalence of significant cardiopulmonary disease. Patients will benefit from multimodal combinations that hold favourable profiles when considering the specific requirements of both their particular surgical procedure and their medical comorbidities. Multimodal analgesia: pharmacological components.

The premise behind multimodal analgesia is the apparent synergy between agents in interfering with pain pathways at multiple anatomic and pharmacologic sites while limiting side effects overall, specifically through opioid-sparing effects. In addition, pharmacologic adjuvants may be added such as gabapentinoids (e.g., gabapentin and pregabalin), N-methyl D-aspartate (NMDA) receptor antagonists (ketamine, memantidine, dextromethorphan, and magnesium), alpha-2 adrenergic agents (clonidine), glucocorticoids (dexamethasone), and others (antidepressants, calcitonin, nicotine, capsaicin, cannabinoids, and lidocaine). Principle pharmacologic elements of multimodal analgesia (Table 1) may include the combination of regional anesthesia (including single-shot or continuous central neuraxial or peripheral nerve blocks and/or local infiltration analgesia), opioid analgesics, and nonopioid systemic analgesics (acetaminophen, and nonsteroidal anti-inflammatories). Multimodal analgesia, a concept first articulated by Kehlet and Dahl, is now the foundation for the management of acute postoperative pain. These pain mechanisms are explored and a proposed protocol for multimodal analgesia is outlined taking into account the common patient comorbidities found in this patient population.

Perioperative pain management in these patients presents a particular challenge considering the multiple sources and pathways for acute and chronic pain that are involved, such as chronic ischemic limb pain, postoperative residual limb pain, coexisting musculoskeletal pain, phantom limb sensations, and chronic phantom limb pain. Multimodal analgesia has been reported for a variety of surgical procedures but not yet for lower limb amputation in vasculopathic patients.

Multimodal analgesia may include pharmacological components such as regional anesthesia, opioid and nonopioid systemic analgesics, nonsteroidal anti-inflammatories, and a variety of adjuvant agents.