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

Abstract

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. 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. 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. 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.