What is the best approach to manage ongoing pain in a 45-year-old female with a history of prolapse bladder, appendicitis, claw toes, recent umbilical hernia surgery with complications, and visceral pseudo-aneurysm of the Pancreaticoduodental (PDA) artery repair?

Management of Ongoing Pain in a Complex Surgical Patient

This patient requires a multimodal pain management strategy prioritizing non-opioid analgesics as first-line therapy, with acetaminophen and NSAIDs (if no contraindications exist) forming the foundation, supplemented by gabapentinoids, and reserving opioids only as a last resort given her multiple surgical complications suggesting possible connective tissue disorder. 1

Immediate Assessment Priorities

Rule Out Surgical Complications First

• Any sudden increase in pain, especially with tachycardia, hypotension, or fever, mandates urgent comprehensive evaluation for postoperative complications including bleeding, anastomotic leaks, or deep vein thrombosis before attributing pain to chronic causes 1
• Her recent umbilical hernia repair with healing complications and history of visceral pseudo-aneurysm requiring surgery places her at higher risk for ongoing surgical issues 1

Pain Characterization

• Assess pain using validated multidimensional tools rather than simple VAS scores, as VAS alone fails to capture the complexity of her pain presentation 1
• Document pain location, quality, duration, functional impact, and relationship to surgical sites 2
• Evaluate for chronic pain history, as preoperative chronic pain predicts worse acute postoperative pain outcomes 1

Pharmacologic Management Algorithm

First-Line: Non-Opioid Multimodal Analgesia

Acetaminophen should be initiated first as it is safer than other analgesics when contraindications are absent 1

• Scheduled acetaminophen (not PRN) provides baseline analgesia 1
• Add NSAIDs if no contraindications exist (no renal impairment, bleeding risk, or cardiovascular disease) 1
• Opioid usage must be minimized in postoperative pain management strategies 1

Second-Line: Gabapentinoids

• Consider gabapentin or pregabalin as adjunctive therapy, particularly if neuropathic pain components exist 1
• Gabapentinoids carry moderate recommendation with moderate quality evidence for multimodal analgesia 1

Third-Line: Opioids (Only When Necessary)

• Reserve opioids for breakthrough pain uncontrolled by non-opioid regimens 1
• If opioids are required, use the smallest appropriate quantity with intensive monitoring 3
• Assess addiction risk before prescribing, as patients with chronic pain and multiple surgeries face increased risk 3
• Implement universal precautions including abuse risk assessment and patient-prescriber agreements 3

Special Considerations for This Patient

Possible Underlying Connective Tissue Disorder

Her constellation of conditions—bladder prolapse, claw toes requiring osteotomies, umbilical hernia with poor healing, and visceral pseudo-aneurysm—suggests possible Ehlers-Danlos syndrome or similar connective tissue disorder 4

• These patients often have chronic pain that is difficult to treat and may not respond predictably to standard approaches 4, 5
• Recognize and address psychosocial aspects of pain, as chronic pain patients require comprehensive biopsychosocial management 4

Pain Monitoring Protocol

• Establish regular assessment intervals (24-hour monitoring with documentation improves outcomes) 1
• Reassess after each intervention at appropriate intervals based on anticipated effect 1
• Combined nurse service with clinician supervision provides better outcomes 1

Non-Pharmacologic Interventions

Physical Medicine Approaches

• Consider physical therapy focused on functional restoration 6
• Evaluate for orthotic needs given her claw toe history 6

Psychological Support

• Address catastrophizing thoughts and maladaptive coping strategies, as these worsen pain outcomes 1
• Screen for depression and anxiety, which are common in chronic pain patients 4
• Consider referral to pain psychology or behavioral health specialists 1

Red Flags Requiring Urgent Re-evaluation

• New or worsening abdominal pain (consider anastomotic complications, bleeding, or recurrent pseudo-aneurysm) 1
• Fever or signs of infection 1
• Hemodynamic instability 1
• Signs of bowel obstruction or perforation 1

Long-Term Management Strategy

Establish Continuity of Care

• Avoid chronic repeat visits to non-continuity providers through care plans with primary care physicians 1
• Consider pain management specialist referral if pain persists beyond expected postoperative recovery period 1

Opioid Tapering (If Currently Prescribed)

• If patient is on opioids, taper by no more than 10-25% of total daily dose every 2-4 weeks to avoid withdrawal 3
• Monitor for withdrawal symptoms: restlessness, lacrimation, rhinorrhea, myalgia, anxiety, insomnia 3
• Ensure multimodal approach to pain management including mental health support is in place before initiating taper 3

Common Pitfalls to Avoid

• Do not delay analgesic administration waiting for definitive diagnosis when pain is clearly present 1
• Avoid assuming aberrant behaviors indicate addiction—they may represent under-treatment of pain (pseudo-addiction) 1
• Do not rely solely on opioids; this approach fails to address underlying mechanisms and increases addiction risk 1, 3
• Female gender and younger age are risk factors for worse postoperative pain—do not undertreat based on assumptions 1
• Avoid irregular PRN-only dosing schedules; scheduled analgesia with breakthrough options is superior 1