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. 2025 Dec 17.
doi: 10.1111/anae.70107. Online ahead of print.

Peri-operative pain management in major lower extremity amputation in vascular Surgery: a UK anaesthetic and vascular surgery Delphi consensus study

Thanapon Ekkunagul  1 , Caitlin Sara MacLeod  2   3 , Anna Celnik  4 , John Chalmers  4 , Ross Thomson  4 , Alan J R Macfarlane  5   6 , David Bosanquet  7   8 , John Nagy  2 , Patrice Forget  1   9 ; Delphi expert panel
Collaborators, Affiliations

Peri-operative pain management in major lower extremity amputation in vascular Surgery: a UK anaesthetic and vascular surgery Delphi consensus study

Thanapon Ekkunagul et al. Anaesthesia. .

Abstract

Introduction: Major lower extremity amputations occurring secondary to vascular disease remain prevalent worldwide. Pain surrounding these procedures is complex, multifactorial and associated with poor functional and psychosocial outcomes. The evidence base informing pain management approaches in major lower extremity amputations remain largely heterogeneous and limited. This study aimed to establish procedure-specific, multispeciality consensus on the ideal principles and practices required to optimise pain management for vascular surgical patients undergoing major lower extremity amputations.

Methods: A three-round online modified Delphi consensus process was undertaken, with consultant anaesthetists and consultant vascular surgeons across the UK forming the expert panel. Structured statements were assessed on a 5-point Likert scale against a strong consensus threshold of ≥ 75% ratings in agreement or disagreement, and a rating stability criterion of < 10% change between rounds. Free-text responses were thematically analysed at each round to iteratively modify or generate new statements.

Results: Seventy-two panellists participated in the study. Of the 44 consensus statements assessed, 32 reached strong consensus agreement. These included: shared cross-speciality responsibility for pain management; the mainstay role of locoregional analgesia; use of perineural catheters; opioid-sparing approaches; and protocolised decision aids with individualisation of analgesia. Barriers to practices identified included resource constraints and the paucity of direct evidence. There was non-consensus in 12 statements, notably on pre-amputation initiation of locoregional analgesia; ultrasound-guided nerve catheter placement; and surgeon-delivered regional analgesia. No statement reached strong consensus disagreement.

Discussion: This study provides the first procedure-specific consensus, delineating agreed principles and preferred pharmacological and locoregional analgesic approaches to peri-operative pain management in patients undergoing major lower extremity amputations. The areas of non-consensus expose key uncertainties that may inform future research, service organisation and guideline development agendas.

Keywords: amputation, surgical; pain management; vascular surgery.

Plain language summary

What we did: Groups of expert doctors from across the UK worked together online to agree on the best ways to manage pain for patients who need to have their leg removed. They answered questions over three rounds and rated how much they agreed with different statements. The goal was to see which ideas most experts supported.

Why we did it: Some people need to have part of their leg removed because of problems with their blood vessels. These operations can cause different kinds of pain, which can make it harder for patients to move, heal and recover emotionally. Doctors use many methods to help with pain, but the research about the best ways to do this is mixed and not always clear.

What we found: Seventy‐two doctors took part. They looked at 44 statements and strongly agreed on 32 of them. They agreed that doctors from different specialities should share responsibility for pain care, that numbing certain nerves is very helpful, that small tubes can be placed near nerves to give pain medicine and that treatment should try to reduce the need for strong opioid drugs. They also agreed that pain plans should be guided by clear rules but still be flexible for each patient. Some things did not reach agreement, such as starting nerve‐numbing treatments before surgery and which doctors should place nerve catheters. This study is the first to create clear, shared guidance on how to manage pain for people having major leg amputations. The areas where the experts did not agree show where more research and clearer rules are still needed.

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References

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