What is the best approach to manage right hip pain in a post-abdominal surgery patient who cannot take ibuprofen (Nonsteroidal Anti-Inflammatory Drug, NSAID)?

Management of Right Hip Pain in Post-Abdominal Surgery Patient Unable to Take NSAIDs

Start with acetaminophen (paracetamol) 1 gram every 6-8 hours as your foundational analgesic, and add opioids for rescue analgesia when acetaminophen alone is insufficient. 1

Primary Analgesic Strategy

First-Line: Acetaminophen

• Acetaminophen 1 gram IV or oral every 6-8 hours should be your cornerstone therapy when NSAIDs are contraindicated due to recent major abdominal surgery 2, 1
• This provides effective pain control with lower pain intensity scores and reduced opioid consumption compared to placebo 2
• The oral and IV routes are equally effective for postoperative pain outcomes, so use oral when feasible to reduce costs 2
• Critical caveat: Exercise caution if the patient has underlying liver disease, as acetaminophen can elevate liver enzymes 1

Why NSAIDs Are Contraindicated Post-Abdominal Surgery

• NSAIDs significantly increase the risk of anastomotic dehiscence in patients with bowel anastomoses from abdominal surgery 1
• This is a serious complication that can lead to peritonitis, sepsis, and death—making NSAID avoidance essential in your patient's case 1
• Even COX-2 selective inhibitors carry this risk and should be avoided 1

Second-Line: Add Adjunctive Agents

Gabapentinoids for Inadequate Pain Control

• If acetaminophen alone is insufficient, add pregabalin 75-150 mg every 12 hours orally OR gabapentin 300-600 mg every 8 hours orally 3
• These agents provide additional analgesia without the gastrointestinal risks of NSAIDs 3
• Monitor closely for sedation and dizziness, especially in the first 24-48 hours, as these are common side effects 3
• Taper gradually when discontinuing rather than stopping abruptly 3

Corticosteroids as Adjunct

• Consider dexamethasone 8-10 mg IV as a single dose to reduce pain and opioid requirements 2
• This provides significant pain reduction (>20 mm on VAS), reduces opioid consumption, and shortens hospital stay 2
• Safe even in diabetic patients, though monitor blood glucose levels as there may be a small increase 2
• No increased risk of postoperative infection has been demonstrated 2

Third-Line: Opioid Rescue Therapy

When to Use Opioids

• Opioids remain first-line for moderate-to-severe pain unresponsive to non-opioid medications 1
• Use as rescue medication rather than scheduled dosing when possible 2

Patient-Controlled Analgesia (PCA) Protocol

• PCA is superior to continuous IV infusion for pain control and patient satisfaction 1
• Recommended parameters: loading dose 0.1-0.2 mg/kg morphine IV, demand dose 1-2 mg, lockout interval 5-10 minutes 1
• Never start with continuous infusion in opioid-naïve patients—use bolus dosing only 1
• Prophylactically manage constipation, as this is the most frequent opioid side effect 1

Alternative Considerations

Regional Anesthesia Techniques

• If pain remains severe despite the above measures, consider fascia iliaca block or local infiltration analgesia 2
• These techniques are effective for hip pain without systemic side effects 2
• Can be performed as single-shot procedures for acute pain management 2

Route of Administration Hierarchy

• Prefer oral administration over IV when feasible and drug absorption is assured 1
• Never use intramuscular route for postoperative pain management 1

Clinical Algorithm Summary

1. Start: Acetaminophen 1g every 6-8 hours (oral or IV) 2, 1
2. If inadequate at 24 hours: Add pregabalin 75 mg every 12 hours OR gabapentin 300 mg every 8 hours 3
3. Consider early: Dexamethasone 8-10 mg IV single dose 2
4. For breakthrough pain: Opioid rescue (morphine 1-2 mg IV PRN or oral opioid equivalent) 2, 1
5. If severe persistent pain: Consider regional anesthesia consultation for nerve block 2

Critical Pitfalls to Avoid

• Do not use NSAIDs or COX-2 inhibitors in patients with recent abdominal surgery involving bowel anastomoses—the risk of anastomotic dehiscence is too high 1
• Do not combine different NSAIDs or add COX-2 inhibitors to NSAIDs—this increases cardiovascular and renal toxicity without additional benefit 1
• Do not start PCA with continuous infusion in opioid-naïve patients—use demand dosing only 1
• Do not forget to monitor and prophylactically treat opioid-induced constipation 1