Above/Below Knee Amputation Perioperative Pain Management Best Practices — SolvingPain

Above/Below Knee Amputation

All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.

Preoperative	Intraoperative	Postoperative (Inpatient)	Discharge Strategies
•Acetaminophen 1g •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) •+/- Hydromorphon Contin 3mg PO OR •+/- oxycodone (IR): 5-to-10mg PO •Regional-prolonged analgesia via continuous perineural blockade for stump and phantom pain •Femoral nerve block •Sciatic nerve block	•Spinal anesthesia •Consider intrathecal morphine in select patients	•Hydromorphone 0.2mg IV q5-10min then as needed •Hydromorphone 2-4mg PO q3h then as needed •Celecoxib 100mg PO BID •Acetaminophenl q6h regularly (up to maximum daily dose) •Ketamine •Clonidine	MANAGEMENT OF PAIN W/O MEDICATION: •Physiotherapy •Deep vein thrombosis prophylaxis CO-ANALGESICS: •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) OPIOID PRESCRIPTION*: Recommend: 30 tabs Range: 30-50 tabs For higher numbers, consider a part-fill prescription

*All tabs for discharge are oxycodone, 5mg. To convert this dosage to a different opioid drug, please visit this page. For conversions involving oxycodone, please note that it is 50% more potent than morphine. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration. Please note that current guidelines give a range of tabs. While we suggest prescribing the lowest effective dose possible, where clinical judgment indicates prescribing toward the higher range, we recommend using a part-fill prescription.

Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.

Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.

See our full disclaimer here.

Amundson AW, Johnson RL, Abdel MP, Mantilla CB, Panchamia JK, Taunton MJ, et al. A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty. Anesthesiology. 2017 06;126(6):1139-50.

Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty. 2015 Oct;30(10):1705-9.
Biswas A, Perlas A, Ghosh M, Chin K, Niazi A, Pandher B, et al. Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty: A Randomized Controlled Trial. Reg Anesth Pain Med. 2018 Feb;43(2):154-60.
Christiansen CL, Fields T, Lev G, Stephenson RO, Stevens-Lapsley JE. Functional Outcomes After the Prosthetic Training Phase of Rehabilitation After Dysvascular Lower Extremity Amputation. PM R. 2015 Nov;7(11):1118-26.
Do DA., Pozek JJ. How I do it: Perioperative Analgesia For Lower Limb Amputations. ASRA News. 2021;46. https://doi.org/10.52211/asra050121.031.
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation Therapy with Guided Imagery for Postoperative Pain Management: An Integrative Review. Pain Manag Nurs. 2019 02;20(1):3-9.
Prospect. Prospect Total Knee Arthroplasty Subgroup [Internet]. Switzerland: ESRA; 2020 [cited 2020 Jul 27]. Available from: https://archive.postoppain.org/sections/?root_id=47232&section=8.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.

Treatment Altering Factors

Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.

Organ Dysfunction


•In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine


•In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine

Patient Specific Factors

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•Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities

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•Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia
•Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated
•Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated
•Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities


•In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible

•In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it

•Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia
•Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance
•Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated
•Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible


•Consider regional anesthetic techniques, if feasible for specific surgical procedure


•Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge

•Preoperative: Consider anxiolytics prior to administration of anesthetic
•Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms

Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge

System Disorders


•Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines


•Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing

References for Treatment Altering Factors

Patient Resources

Best Practices

Above/Below Knee Amputation

Treatment Altering Factors

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