What is the recommended post-operative pain management regimen for a patient with peritonitis after a laparoscopic appendectomy at home?

Post-Operative Pain Management for Laparoscopic Appendectomy with Peritonitis at Home

For patients discharged home after laparoscopic appendectomy with peritonitis, prescribe scheduled oral acetaminophen (1g every 6 hours) combined with an NSAID (ibuprofen 400mg three times daily), with a short course of oral opioids (oxycodone 5-10mg every 4-6 hours as needed) reserved strictly for breakthrough pain. 1, 2, 3

Multimodal Oral Analgesia Regimen

First-line therapy should consist of:

• Acetaminophen 1g orally every 6 hours (maximum 4g/24 hours) as the cornerstone of your multimodal regimen 1, 2, 4
• NSAIDs (ibuprofen 400mg three times daily or equivalent) unless contraindicated by renal impairment or GI bleeding history 1, 2, 4
• This combination provides superior analgesia without increasing side effects compared to either agent alone 2, 4

Oral administration is strongly preferred over other routes once the patient can tolerate oral intake, as absorption is reliable in the post-discharge setting 1, 2

Opioid Management for Breakthrough Pain

Reserve opioids exclusively for moderate-to-severe pain unresponsive to the acetaminophen-NSAID combination:

• Prescribe a limited supply of short-acting oral opioids (oxycodone 5-10mg every 4-6 hours as needed, typically 10-15 tablets maximum) 1, 3
• Patients with peritonitis experience more pain and consume more opioids than those with uncomplicated appendicitis, so anticipate higher analgesic requirements 3, 5
• Critical caveat: Use opioids cautiously in peritonitis cases, as these patients may have intestinal overdistension and impaired motility—opiates can significantly exacerbate postoperative ileus 1

Special Considerations for Peritonitis Cases

Patients with peritonitis require enhanced monitoring and expectations:

• Expect longer recovery times (mean hospital stay 5.6 days for complicated vs 4 days for uncomplicated cases) and proportionally longer pain duration at home 6, 5
• Warn patients about opioid-induced constipation, which is particularly problematic in peritonitis cases with already compromised bowel function 2
• Consider prescribing a stool softener (docusate) prophylactically if opioids are needed 2

Practical Prescribing Algorithm

Day 1-3 post-discharge:

• Scheduled acetaminophen 1g every 6 hours + ibuprofen 400mg three times daily 2, 4
• Oxycodone 5-10mg every 4-6 hours only if pain remains moderate-severe (NRS >4/10) despite scheduled non-opioids 1, 3

Day 4-7:

• Continue scheduled acetaminophen and ibuprofen 2, 4
• Transition to as-needed dosing for both agents if pain improves 4
• Opioids should be discontinued by this point in most cases 1

After day 7:

• Most patients require only occasional acetaminophen or ibuprofen 4

Critical Pitfalls to Avoid

Do not prescribe intramuscular analgesics for home use—this route should be avoided entirely in postoperative pain management 1

Monitor for inadequate pain control that may signal complications: patients with intra-abdominal abscess (7% incidence in complicated cases) will have persistent or worsening pain requiring re-evaluation 5

Avoid prolonged opioid courses beyond 5-7 days to prevent dependency, which is a significant concern given the current opioid crisis 1

Consider patient-specific factors: elderly patients require lower opioid doses due to increased sensitivity and side effect risk 2, 4

When to Seek Re-evaluation

Instruct patients to return if:

• Pain worsens or fails to improve after 48-72 hours despite adequate analgesia 5
• New fever develops (may indicate abscess formation, seen in 7% of complicated cases) 5
• Inability to tolerate oral medications due to persistent nausea/vomiting 1