The decision to proceed to amputation ususally follows several discussions with the patient and/or family. Sometimes, in acute ischameia, there is a need to proceed fairly rapidly to amputation. The decison should be documented in the chart along with the side (written in full) and the level. This is important even where there has been a previous contralateral amputation.
- Consider preoperative Physiotherapy, occupational therapy and social work assessment.
- Alert anaesthesia as early as possible to ensure early review.
- Where the decision is purely elective for rest pain with unreconstructable disease etc., then it may be appropriate to seek a preoperative visit with the rehabilitation service in Dun Laoghaire or Balnchardstown
- Speak to the relatives etc with the patients permission and offer the opportunity preoperatively to meet with Consultant/SpR if they wish
- Ask the patient if they would like their own arrangements for limb disposal or whether this will be dealt with by the hospital (incineration) and record this in the notes.
- Record informed consent for the procedure in the notes. This must include the limb (leg or arm), the side (right or left in letters - even if the other has been previously amputated), and the level. If there has been a decision to decide on the level at the time of surgery record this in the notes
- Check that the correct side is written in the notes and recorded on the consent form - check with the operating surgeon and Consultant if in any doubt.
- Make and initial and date a mark on the limb.
- If there are any erroneous entries in the chart citing the other limb, record this and note that there was an error and confirm the correct side.
- Ensure medical problems optimised
- Check Hb, Coag, U&E (esp. Potassium), send Gr & Hold (or crossmatch if Hb less than 10)
- Fast from midnight or minimum six hours in emergency
In Theatre
- Confirm that the correct side is known, recorded and marked. if possible, speak to the patient and confirm it with them preoperatively in reception or the anaesthetic room.
- Complete the operation note correctly identifying side and level
- Give clear postoperative instructions regarding dressings/wounds, sutures (which stay longer than would normally be the case for the level of the incision), drains etc.
- Ensure arrangements are in place for post operative analgesia and that this is written up before the patient returns to the ward.
- Do not suture the drain in place if used - this allows it to be pulled out without disturbing the dressings.
Postoperatively
- Remove the drain on the first postoperative day if drainage is less than 20mls.
- Inspect the wound on the second postoperative day.
- Check that the patient has adequate analgesia - if an epidural is used for perioperative analgesia, make sure a suitable alternative is in place when the epidural is removed after 48-72 hours
- If there is an epidural in place, check that the coagulation is sent four hours prior to planned removal - this will also require withholding heparin and/or Clopidogrel.
- Check Hb 24 hours postoperatively and U&E etc as required.
- Patients with Hb greater than 8g/dl do not normally require transfusion unless symptomatic or obvious cardiac disease. In this ace aim for HB 9-10g/dl.
- Consult early (in the first 24 hours) with physiotherapy (for chest and limb exercises and later mobilisation), occupational therapy (early mobility and rehab), social worker ( earl support structures and expedited discharge, rehabilitation)
- Download and complete referral form for rehab - usually Dun Laoghaire for <65y and Blanchardstown for >65y.
- Ensure this is passed on to therapists and completed form faxed or posted for OPD assessment.
- Referral to Psychiatry/medical Gerontology only if required.
- Stump shrinkers should not be applied within the first week after surgery but at that stage, if wound is clean and dry, these should be used.
