title: 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.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Nafisseh S
authors.initials: NS
authors.lastname: Warner
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Warner
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A.|Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Moeschler
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A.|Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Bryan C
authors.initials: BC
authors.lastname: Hoelzer
mesh_terms: D059787:Acute Pain / Q000175:diagnosis / Q000601:surgery / Q000628:therapy; D000671:Amputation, Surgical / Q000009:adverse effects*; D015360:Analgesia, Epidural / Q000379:methods; D000700:Analgesics / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D005260:Female; D006225:Hand / Q000601:surgery*; D006801:Humans; D035002:Lower Extremity / Q000601:surgery*; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement / Q000379:methods; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D010591:Phantom Limb / Q000175:diagnosis / Q000209:etiology / Q000601:surgery / Q000628:therapy
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid
keywords: acute pain; epidural analgesia; extremity amputation; four-limb amputation; ketamine; peripheral nerve catheter; phantom limb pain; quadruple amputation; residual limb pain