What is the best course of action for a patient with a perforated abdominal viscus and severe incisional pain unrelieved by Oxycodone (oxycodone) 5mg?

Management of Severe Incisional Pain After Oxycodone Administration in a Post-Abdominal Surgery Patient

For a patient with perforated abdominal viscus experiencing severe incisional pain unrelieved by 5mg oxycodone, the most appropriate next step is to administer intravenous morphine at a dose of 1-5mg and reassess in 15 minutes. 1

Assessment and Initial Management

• For patients with severe pain (rating 7-10) that is unrelieved by initial opioid dose, a change in route of administration from oral to intravenous should be considered after 2-3 cycles of unsuccessful oral dosing 1
• The presence of a wound vacuum on a surgical incision following perforated viscus repair indicates recent major abdominal surgery, which typically requires stronger analgesia than low-dose oral oxycodone 1
• Intravenous morphine (1-5mg) or equivalent is recommended for severe pain with assessment of efficacy every 15 minutes for IV administration 1

Dosing Considerations

• If pain remains unchanged or increases after initial IV dose assessment, administer 50-100% of the previous rescue dose 1
• If pain decreases to moderate level (4-6), repeat the same dose and reassess in 15 minutes 1
• If pain decreases to mild level (0-3), maintain the effective dose as needed over 24 hours before adjusting management strategy 1

Alternative Approaches

• Consider IV lidocaine infusion (bolus: 1-2 mg/kg followed by 1-2 mg/kg/h) if regional analgesia is not being used, as this is particularly beneficial for abdominal surgery patients 1
• For patients with wound vacs and surgical incisions, multimodal analgesia may be necessary - consider adding adjuvant medications such as NSAIDs if not contraindicated 1
• If the patient has been receiving multiple doses of opioids during hospitalization, they may have developed tolerance requiring higher doses for adequate pain control 1

Important Considerations for Perforated Viscus Patients

• Patients with recent abdominal perforation may have significant inflammation and peritoneal irritation contributing to severe pain 1, 2
• Constipation is a common adverse effect of opioids that requires prophylactic management, especially important in patients with recent abdominal surgery 1, 3
• Stercoral perforation can occur as a complication of severe opioid-induced constipation, making proper pain management and bowel regimen essential 2

Monitoring and Follow-up

• Closely monitor respiratory status, especially within the first 24-72 hours of initiating therapy or following dosage increases 4
• Reassess pain level, vital signs, and sedation at regular intervals (every 15 minutes for IV administration) 1
• If multiple IV rescue doses are required, consider converting to extended-release formulations once pain is controlled and 24-hour opioid requirement is stable 1

Common Pitfalls to Avoid

• Inadequate dosing of rescue medication is a common error - for severe breakthrough pain, the rescue dose should be 10-20% of the total 24-hour opioid requirement 1
• Failing to switch routes of administration when oral medications are ineffective delays adequate pain control 1, 5
• Overlooking the need for a prophylactic bowel regimen when administering opioids, especially in patients with abdominal surgery 1, 3