Four-Limb Amputation Pain Management

In the United States, around 185,000 lower and upper amputations are performed each year, with the cost for unilateral lower extremity amputation patients exceeding $500,000. Amputation causes a great deal of pain since intra-operative and postoperative pain control is inadequate and the pain is caused by both neuropathic and somatic pain. Pain can only be managed utilizing a multimodal approach within patient-controlled analgesia (PCA). Postoperative and intraoperative pain management is a significant problem for individuals receiving all four extremities. Despite this difficulty, analgesics have been used successfully to reduce pain in individuals undergoing quadruple amputation. Based on the article Pain Management in Four-Limb Amputation: A Case Report by Warner, Warner, Moeschler, & Hoelzer (2015), the paper presents the case of a patient brought to an institution and her successful control of the pain using analgesics regime.

The patient

The patient was a 58 year old woman admitted to an outside hospital with various complications including type 2 diabetes mellitus and hypertension. She was also experiencing nausea, diarrhea, vomiting, and chest discomfort. She was treated with antibiotics and insulin, but her condition only deteriorated and was later discovered to be suffering from Escherichia coli sepsis, which progressed, quickly to multiple organ failures and septic shock among other complications. Due to prolonged vasopressor treatment, she developed ischemia in her four extremities and progressed to her hands and legs. In efforts to save her from amputation, she was subjected to 40 sessions of hyperbaric oxygen therapy but to no success (Warner et al., 2015).

Treatment at our institution

On arriving at our institution, evaluations revealed extensive dry gangrene on her feet and hands that required amputation in a single procedure. Before admission in our institution, the patient had been opioid naïve, which played a role in preoperative analgesia. By the time of her arrival in the institution, she was receiving oral controlled morphine every 12 hours, 15mg of immediate release morphine every four hours and had been recently started on gabapentin 100mg taken thrice daily. The aching pain was 6 of ten severity in all affected extremities as measured by numeric pain scale. The morning of her amputation, she was administered 10mg of immediate release oxycodone, 600mg of gabapentin and 10mg of sustained release morphine. A lumbar epidural using the loss of resistance technique placed L4-5 interspace. Bupivacaine and hydromorphone without preservatives were also used (Warner et al., 2015).

During operation and postoperative period

According to Warner et al. (2015), during operation, she received intravenous hydromorphone, fentanyl, and ketamine. Besides, she received lidocaine for extremity pain bilaterally on the lower part. Later her preoperative analgesia was resumed for the first two weeks postoperatively together with peripheral nerve catheter, epidural and ketamine infusions. Moreover, doses were altered accordingly. The pain scores were 4 to 6 of ten in her postoperative course. At eight months after amputation, she experiences no phantom limb pain or pain limb sensation. The success in pain management for the patient can be attributed the good postoperative active pain control. Hence chronic post-amputation pain control should be emphasized through perioperative period.



Warner, N. S., Warner, M. A., Moeschler, S. M., & Hoelzer, B. C. (2015). Pain Management in Four‐Limb Amputation: A Case Report. Pain Practice, 15(7), E76-E80.

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