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Pharmacological pain management of critical limb ischaemia

The pharmacological management of pain secondary to critical limb ischaemia (CLI) is a challenging topic. Although surgical or local interventions, such as reconstructive vascular surgery, amputation, or nerve blocks, may relieve the pain, they are not immediately adaptable to all patients. However, to the best of our knowledge, there are no international or local guidelines on this subject. There also appears to be a paucity of surveys on the management of CLI in daily clinical practice. The authors of a recent systematic review included only six studies in their criteria. Previous studies focused on intravenous lidocaine, gabapentin, ketamine and a buprenorphine patch compared with morphine or placebo. There was substantial heterogeneity in quality and side effect profiles in these studies. Therefore, no recommendations of pharmacological agents could be made, although several approaches have shown positive results to manage pain in patients with CLI. In this study, we describe clinical data and our institutional policy in the pain management of CLI, and especially focus on fentanyl administration. This was a retrospective observational study in a single, community hospital in Osaka, Japan. Patients who require reconstructive vascular surgery for CLI in our hospital are referred to a specialised centre of peripheral vascular surgery. Fortytwo patients were diagnosed with CLI (32 patients (74%) were men; mean age: 78 years) in 3 years (between March 2019 and February 2022). Their characteristics are shown in table 1. Diabetes mellitus and chronic kidney disease (glomerular filtration rate<30 mL/min/1.73 m) were found in 20 (48%) patients and 27 (64%) patients, respectively. Haemodialysis was performed in 20 (48%) patients. In the Rutherford classification, 1 (2.4%) patient was II4 (ischaemic rest pain), 28 (67%) were III5 (minor tissue loss) and 13 (31%) were III6 (major tissue loss). Amputation was performed in 17 (40%) patients, and 1 (2.4%) patient was transported for a reconstructive vascular surgery. Not all of the patients required the regular use of analgesics. Thirteen (31%) patients did not use any analgesics. Eleven (26%) patients took acetaminophen (paracetamol) 400 mg only as required (up to three or four times a day). A nonsteroidal antiinflammatory drug (celecoxib) was prescribed in only one (2.4%) patient. Pregabalin was prescribed in three (7.1%) patients for diabetic peripheral neuropathic pain (two patients received other analgesics in combination with pregabalin). Tramadol with or without acetaminophen was prescribed in 10 (24%) patients. When the ischaemic pain was uncontrollable despite following the analgesic ladder of nonopioid and weak opioids, the palliative care team was consulted. We administered fentanyl in all of the six (14%) patients with severe, endurable ischaemic pain. Because every patient had chronic kidney disease (five patients required haemodialysis), morphine was not preferable. They included two patients in the perioperative period who underwent amputation or vascular surgery and four patients in the endoflife period with a life expectancy of a few weeks. The Table 1 Patients’ demographic and clinical characteristics